From the Guidelines
Gastrointestinal (GI) prophylaxis is indicated for patients with sepsis or septic shock who have risk factors for gastrointestinal (GI) bleeding, as well as those receiving NSAIDs with higher risk for GI complications. The primary indications for GI prophylaxis include:
- Mechanical ventilation for more than 48 hours
- Coagulopathy
- History of GI bleeding within the past year
- Severe burns (>35% body surface area)
- Traumatic brain injury
- Spinal cord injury
- Multiple trauma
- Organ transplantation
- Prolonged ICU stays
- Patients receiving high-dose corticosteroids (>250mg hydrocortisone or equivalent daily), NSAIDs, or anticoagulants, especially when used in combination, should also receive prophylaxis 1. For prophylaxis, proton pump inhibitors (PPIs) like pantoprazole 40mg IV/PO daily or omeprazole 20mg PO daily are first-line options, as they are effective in raising gastric pH above 4, which inhibits pepsin activity and reduces acid-mediated mucosal damage 1. Histamine-2 receptor antagonists (H2RAs) such as famotidine 20mg IV/PO twice daily are alternatives, but may not be as effective as PPIs in preventing GI bleeding 1. It is also recommended to assess for and treat H pylori if present, and to institute gastroprotection with misoprostol (600 mg/day) or PPIs in high-risk patients receiving NSAIDs 1. Treatment should continue only for the duration of the risk factor and discontinued upon resolution to minimize risks of long-term acid suppression, including C. difficile infection, pneumonia, and nutrient malabsorption. Enteral nutrition, when possible, provides additional mucosal protection and may reduce the need for pharmacological prophylaxis in some patients.
From the Research
Indications for G.I. Prophylaxis
The indications for gastrointestinal (G.I.) prophylaxis, also known as stress ulcer prophylaxis, are based on the risk of clinically important gastrointestinal bleeding in critically ill patients. The following are the indications for G.I. prophylaxis:
- Critically ill patients at high risk (>4%) of clinically important gastrointestinal bleeding, such as those with coagulopathy, chronic liver disease, or receiving mechanical ventilation but not enteral nutrition or two or more of mechanical ventilation with enteral nutrition, acute kidney injury, sepsis, and shock 2
- Patients with a history of gastrointestinal bleeding or ulcer disease
- Patients receiving certain medications, such as steroids or antiplatelet agents, that increase the risk of gastrointestinal bleeding
Risk Factors for G.I. Bleeding
The following are risk factors for gastrointestinal bleeding in critically ill patients:
- Coagulopathy
- Chronic liver disease
- Mechanical ventilation
- Acute kidney injury
- Sepsis
- Shock
- Use of certain medications, such as steroids or antiplatelet agents
Choice of Prophylaxis
The choice of prophylaxis depends on the individual patient's risk factors and medical history. The following are options for G.I. prophylaxis:
- Proton pump inhibitors (PPIs)
- Histamine-2 receptor antagonists (H2RAs)
- Sucralfate (not recommended due to lack of efficacy) 2
Efficacy of Prophylaxis
Studies have shown that PPIs and H2RAs are effective in reducing the risk of clinically important gastrointestinal bleeding in critically ill patients 2, 3, 4, 5. However, the choice of prophylaxis should be based on individual patient factors, such as the risk of bleeding and the presence of other medical conditions.