Prevention of stress ulceration: current trends in critical care.

Pharmacotherapy Department, Fletcher Allen Health Care, Burlington, VT, USA.
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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    ABSTRACT: Bleeding from stress-related mucosal disease in critically ill patients remains an important clinical management issue. Although only a small proportion (1-6%) of patients admitted to an intensive care unit (ICU) will bleed, a substantial proportion exhibit clinical risk factors (mechanical ventilation for >48 h and a coagulopathy) that predict an increased risk of bleeding. Furthermore, upper gastrointestinal mucosal lesions can be found in 75-100% of patients in ICUs. Although uncommon, stress-ulcer bleeding is a severe complication with an estimated mortality of 40-50%, mostly from decompensating an underlying condition or multiorgan failure. Although the vast majority of patients in ICUs receive stress-ulcer prophylaxis, largely with PPIs, some controversy surrounds their efficacy and safety. Indeed, no single trial has shown that stress-ulcer prophylaxis reduces mortality. Some reports suggest that the use of PPIs increases the risk of nosocomial infections. However, several meta-analyses and cost-effectiveness studies suggest PPIs to be more clinically effective and cost-effective than histamine-2 receptor antagonists, without considerable increases in nosocomial pneumonia. To help clinicians use the most appropriate strategy for treatment of patients in the ICU, this Review presents the latest information on all aspects of stress-related mucosal disease.
    Nature Reviews Gastroenterology &#38 Hepatology 01/2015; · 10.43 Impact Factor
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    ABSTRACT: What is known and objectivePractices vary between institutions and amongst prescribers regarding when to initiate stress ulcer prophylaxis (SUP), which agent to choose (including doses and frequencies) and rationale, and decisions about escalation or discontinuation of therapy. The purpose of this survey is to evaluate the perceptions of prescribers about risk assessment of stress-related mucosal bleeding (SRMB) and practice patterns of SUP.MethodsA cross-sectional survey of 800 US critical care prescribers using the membership of the Society of Critical Care Medicine. The levels of agreement with specific statements were rated on a nine-point Likert scale.ResultsOf 712 eligible recipients, 245 (34·4%) completed the questionnaire. Respondents were primarily attending physicians (81·2%) working in adult medical or surgical (59·2%) intensive care units. Mucosal ischaemia was identified as the pathophysiological cause of SRMB by 110 (44·9%) respondents. Respondents agreed that risk factors for SRMB were acute hepatic failure, anticoagulant use, burns >35%, coagulopathy, absence of enteral feeding, recent gastroduodenal ulcer, corticosteroid use, Helicobacter pylori infection, neurologic injury, trauma, NSAID use, mechanical ventilation, shock and sepsis. Histamine subtype 2 receptor antagonists (58·4%) and proton pump inhibitors (39·6%) were the most frequently chosen agents. No consensus was reached about whether either class is associated with clostridium difficile infection or nosocomial pneumonia. Reasons to discontinue therapy included clinically improved patient status (73·1%), extubation (68·2%), reversal of ‘nil-by-mouth’ (68·6%) and transfer to a non-ICU setting (67·8%).What is new and conclusionsConsiderable variability exists in the perceptions surrounding risk factors for SRMB and prescribing patterns for SUP therapy likely because limited or conflicting data are available addressing these issues. Opportunities exist to educate prescribers and conduct research about the pathologic cause and risk factors for SRMB, the preferred class of agents, and the appropriate discontinuation of therapy.
    Journal of Clinical Pharmacy and Therapeutics 09/2014; · 2.10 Impact Factor
  • Critical Care Medicine 01/2005; 33(2):472. · 6.15 Impact Factor


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