Which ICU patients need stress ulcer prophylaxis?

Mariam Saeed; Stephanie Bass; Neal F. Chaisson

doi:10.3949/ccjm.89a.21085

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TABLE 1

Categories, definition, and incidence of stress ulcers in critically ill patients

Category	Definition	Incidence
Stress ulceration with occult bleeding	Fecal samples with guaiac-positive test for blood	15%–50%
Stress ulceration with overt gastrointestinal bleeding	Hematemesis, bloody nasogastric tube aspirate, or melena	1.5%–8.5%
Stress ulceration with clinically important gastrointestinal bleeding	Overt gastrointestinal bleeding plus 1 or more of the following within 24 hours: Decrease in systolic, mean arterial blood pressure, or diastolic blood pressure of ≥ 20 mm Hg Orthostatic hypotension (systolic blood pressure > 10 mm Hg) or postural tachycardia (increase in pulse ≥ 20 beats/minute) Drop in hemoglobin ≥ 2 g/dL Received transfusion of ≥ 2 units of packed red blood cells Need for vasopressors or invasive interventions (eg, endoscopy)	1%–3%

↵Based on information in references 1 and 3–9.

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TABLE 2

Indications for stress ulcer prophylaxis in critically ill patients

Major risk factors (prophylaxis recommended)

Positive pressure ventilation > 48 hours, including extracorporeal life support
Coagulopathy (platelet count < 50 × 109/L, international normalized ratio > 1.5, activated partial thromboplastin time > 2 times normal)^{^a}
History of gastrointestinal ulceration or bleeding within past year
Acute traumatic brain or spinal cord injury
Major thermal injury (≥ 35% of total body surface area)

Minor risk factors (prophylaxis recommended if ≥ 2 minor criteria are present)

Sepsis
Intensive care unit stay > 1 week
Occult gastrointestinal bleeding for ≥ 6 days
Glucocorticoid therapy (> 250 mg of hydrocortisone or the equivalent)
Use of antiplatelet or nonsteroidal anti-inflammatory agents
Renal failure or renal replacement therapy
Hepatic failure
History of peptic ulcer disease
Extracorporeal life support
Organ transplantation

a Independent predictors of clinically important gastrointestinal bleeding in critically ill patients.
Based on information in references 3, 5, 6, 8, and 12.

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TABLE 3

Dosing recommendations for stress ulcer prophylaxis

Route	Proton pump inhibitor	Histamine-2 receptor blocker	Sucralfate
Parenteral	Pantoprazole 40 mg/day Esomeprazole 40 mg/day	Famotidine 20 mg every 12 hours
Enteral	Pantoprazole 40 mg/day Omeprazole 40 mg/day Lansoprazole 30 mg/day Esomeprazole 40 mg/day	Famotidine 20 mg every 12 hours Cimetidine 300 mg every 6 hours Ranitidine 150 mg every 12 hours	Sucralfate 1 g every 6 hours