Prevention of stress ulceration: Current trends in critical care

Division of Trauma and Critical Care, University of Vermont, Burlington, Vermont, United States
Critical Care Medicine (Impact Factor: 6.15). 11/2004; 32(10):2008-13. DOI: 10.1097/01.CCM.0000142398.73762.20
Source: PubMed

ABSTRACT To identify the level of current intensivist's knowledge regarding risk assessment and intensive care unit (ICU) clinical practice pertaining to stress-related mucosal bleeding, including pharmacologic approaches for stress ulcer prevention.
A nationwide survey of critical care physicians.
Two thousand random physician members of the Society of Critical Care Medicine.
The response rate was 519 (26%) of 2000, with data analysis from 501 (25.1%) usable surveys. Respondents were affiliated with internal medicine (44.3%), surgery (42.3%), and anesthesiology (12.6%). Gut ischemia was indicated as the perceived major cause of stress ulceration (59.7%). The estimated incidence of clinically important bleeding was 2% or less by 62% of respondents; however, 28.6% of physicians surveyed initiate stress ulcer prophylaxis in all ICU patients, regardless of bleeding risk. Respiratory failure was most frequently indicated as a reason for stress ulcer prophylaxis (68.6%), followed by shock/hypotension (49.4%), sepsis (39.4%), and head injury/major neurologic insult (35.2%). The first-line agents selected for stress ulcer prophylaxis include histamine-2 receptor antagonists (63.9%), followed by proton pump inhibitors (23.1%), and sucralfate (12.2%). Concern for nosocomial pneumonia was regarded as more prevalent with antisecretory therapies in those who chose sucralfate (61%) as initial therapy compared with overall respondents (26.9%) (p < .001).
The majority of intensivists surveyed recognize stress-related mucosal bleeding as a relatively infrequent event; however, implementation of a stress ulcer prophylaxis risk stratification scheme for ICU patients is necessary. Histamine-2 receptor antagonists are consistently perceived as appropriate initial agents, although proton pump inhibitors have become first-line therapy in an increasing percentage of critical care patients, despite limited data regarding their use in this population.

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    • "[3] In the same time period, the use of PPI for stress ulcer prophylaxis increased from 13% to 45%. Stress ulcer prophylaxis has been used unnecessarily in ICU patients without significant risk of bleeding [4] and some physicians even prescribe therapy in all ICU patients regardless of risk [5]. "
    02/2014; 2(1). DOI:10.1016/j.ejccm.2014.01.001
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    • "In the cirrhotic patient, there is a higher risk of bleeding from gastroduodenal stress ulcers; favoring factors are severe sepsis, prolonged mechanical ventilation, liver failure and abdominal surgery [32]. Several studies have demonstrated an increased risk of nosocomial pneumopathy related to the use of antisecretory agents (compared with sucralfate) by alkalinization and colonization of the gastric contents [33]. "
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    ABSTRACT: Gastric ulcers have been known to develop in critically ill patients secondary to physiological stress since the 19th century. It is only relatively recently that stress ulcer prophylaxis has become an established routine practice in the intensive care unit. Numerous terms have been used to describe stress ulcers, but stress-related mucosal disease (SRMD) is commonly used. Significant morbidity and mortality in critically ill patients is caused by SRMD and related bleedings, but the incidence depends on the definition of bleeding. Pathophysiology of SRMD is multifactorial and involves a complex set of interactions that causes a breakdown of mucosal proactive defenses, leading to ulceration. Critically ill patients are at an increased risk for developing SRMD and subsequent bleeding secondary to several risk factors. To minimize stress-related mucosal bleeding, several regimens have been used. This article presents an update on the incidence, pathophysiology, risk factors, and prophylaxis of SRMD.
    AACN Advanced Critical Care 18(2):119-26; quiz 127-8. DOI:10.1097/01.AACN.0000269254.39967.8e
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