I. PURPOSE. To ensure safe evidence based utilization of stress ulcer prophylaxis to prevent upper . ASHP therapeutic guidelines on stress ulcer prophylaxis. ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis. ASHP Commission on Therapeutics and approved by the ASHP Board of Directors on November 14, . Stress Ulcer Prophylaxis in the ICU effects associated with the use of stress ulcer .. ASHP is currently updating their guidelines, with.
|Published (Last):||14 December 2017|
|PDF File Size:||11.61 Mb|
|ePub File Size:||1.42 Mb|
|Price:||Free* [*Free Regsitration Required]|
May 24, ; Accepted date: May 28, ; Published date: May 31, s.
Stepanski M, Palm N. Preventing stress gastropathy has been a mainstay in the management of critically ill patients for decades. A landmark trial in identified the most significant risk factors for stress gastropathy as mechanical ventilation for greater than 48 h and primary coagulopathy. Since this study’s publication more than two decades ago, the incidence of clinically significant gastrointestinal bleeding secondary to stress gastropathy has significantly declined.
We No Longer Need to Stress Ulcer Prophylaxis in the Critically Ill
Stfess addition, the most widely used agents for prophylaxis have been associated with an increasing number of adverse effects, including myocardial infarction, Clostridium difficile infection, osteoporosis and ventilator associated pneumonia.
As the incidence of significant bleeding decreases and the knowledge about prophylaxis-related adverse events increases, it is necessary to revisit current clinical practice. Major practice changes, including early aggressive fluid resuscitation and development of dynamic markers for volume status, have reduced the likelihood for prolonged hypoperfusion strss.
Additionally, the recognition of the important of enteral nutrition early in the ICU stay encourages mesenteric perfusion and reduces risk for development of ischemic damage. Contemporary studies have failed to replicate significant rates of gastrointestinal bleeding, likely in part due to these advances in care.
Recent studies, including a pilot randomized trial, are questioning the necessity of pharmacologic prophylaxis in the modern era, with undetectable rates of gastrointestinal bleeding in stress patients. Patients with risk factors for stress gastropathy who demonstrate no evidence of splanchnic hypoperfusion may not benefit from receiving stress ulcer prophylaxis and tolerance of enteral nutrition may be used as a surrogate marker for adequate perfusion.
Overall there is a ulcef of high quality data supporting stress ulcer prophylaxis in the modern era. Stress ulcer prophylaxis; Gastrointestinal bleeding ; Proton pump inhibitor; Nutrition.
Stress gastropathy occurs when the mucosal barrier of the gastrointestinal GI tract is compromised and can no longer block the detrimental effects of hydrogen ions and free radicals [ 1 ]. The main cause of stress gastropathy in the intensive care unit ICU is mucosal ischemia due to splanchnic hypoperfusion, which may be caused by shock or changes in intra-thoracic pressure i. This bleeding is associated with significant morbidity and mortality; therefore, it is considered standard of care to provide stress ulcer prophylaxis SUP to patients who are risk of stress gastropathy [ 2 ].
In addition, the most widely used agents for SUP, proton pump inhibitors PPIhave been associated with an increasing number of adverse effects, including myocardial infarction, Clostridium difficile infectionosteoporosis and ventilator associated pneumonia [ 5 ]. The decrease in CSGIB in recent years may be attributed to the improved management of critically ill patients.
One of these advancements is early goal directed sgress EGDTwhich promotes aggressive early fluid resuscitation in septic patients. The increase in recognition and early treatment of sepsis has likely impacted a reduction in stress ulcers through avoidance of hypoperfusion [ 6 ]. Neither study evaluated the role of early enteral nutrition.
Another major change in practice over proohylaxis past decades is the promotion of early enteral nutrition in the critically ill. Nutrition has been recognized as not just adjunctive therapy to provide exogenous fuels but as treatment to help attenuate the metabolic response to stress and prevent cellular injury [ 9 ].
Tolerance of enteral nutrition in the ICU is dependent on adequate jlcer perfusion, thereby demonstrating that the patient is not experiencing splanchnic ischemia. Furthermore, enteral nutrition may independently provide prophylaxis against stress gastropathy by increasing intragastric pH, similar to medication therapies, and providing cytotoxin protection [ 145 ].
Prophylactic pantoprazole demonstrated no benefit to mechanically ventilated patients who received enteral nutrition [ 11 ]. Finally, a pilot randomized control trial was recently conducted by Cook and colleagues to evaluate the safety of withholding SUP. Although this study was not powered to determine a difference in CSGIB based on contemporary rates of bleeding, it is hypothesis generating, and larger scales studies are currently enrolling [ 1213 ].
Much of the current literature evaluates patients in whom mechanical ventilation is the primary risk factor for stress gastropathy. Patient selection for minimizing the use of SUP is a very important parameter that has been discerned throughout the years. Patients with neurologic injury or traumatic brain injury have been seen as a risk factor, but the above studies included these patients and did not show a change in the rates of CSGIB. These patients have been evaluated in several studies that have concluded that enteral nutrition was able to decrease overt bleeding and no additional pharmacologic prophylaxis was needed [ 1415 ].
The collection of data does lend credence to the theory that, with advances in clinical practice, there may no longer be benefit to SUP in our highest risk patients admitted to the surgical and medical ICU. In conclusion, the prevalence of clinically significant bleeding has decreased from 1.
Patients with risk factors for stress gastropathy who demonstrate no evidence of splanchnic hypoperfusion may not benefit from receiving stress ulcer prophylaxis. Tolerance of enteral nutrition may be the surrogate marker for adequate perfusion as seen in the studies discussed above. Overall there is a lack of high quality data supporting SUP in the modern era. All Published work is licensed under a Creative Commons Attribution 4. May 31, s Citation: Visit for more related articles at Journal of Intensive and Critical Care.
Keywords Stress ulcer prophylaxis; Gastrointestinal bleeding ; Proton pump inhibitor; Nutrition Review Preventing stress gastropathy has been a mainstay in the management of critically ill patients for decades.
References Stollmann N, Metz D Pathophysiology and prophylaxis of stress ulcer in intensive care unit patients. J Crit Care Am J Health Syst Pharm Prevalence, pathology and association with adverse outcomes. Mohebbi L, Hesch K Stress ulcer prophylaxis in the intensive care unit. Proc Bayl Med Cent Surviving Sepsis Campaign Bundles. Crit Care Med Intensive Care Med A randomized controlled trial. McClave S, Martindale R, Vanek Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient.
J Parenter Enteral Nutr J Intensive Care Med Randomized double-blind exploratory study. J Crit Care Med Study protocol for a randomised controlled trial. A pilot randomized clinical trial and meta-analysis.
We No Longer Need to Stress Ulcer Prophylaxis in the Critically Ill | Insight Medical Publishing
Raff T, Germann G, Hartmann B The value of early enteral nutrition in the prophylaxis of stress ulceration in the severely burned patient. J Burn Care Res Select your language of interest to view the total content in your interested language.
Can’t read the image?