Who requires gastrointestinal (GI) prophylaxis?

Who Requires Gastrointestinal Prophylaxis?

Critically ill patients at high risk (>4%) of clinically important gastrointestinal bleeding should receive GI prophylaxis, while those at lower risk (≤4%) generally do not require prophylaxis. 1

High-Risk Patients Requiring Prophylaxis

The following patients meet criteria for GI prophylaxis:

Definite High-Risk Criteria

• Mechanical ventilation for >48 hours (strongest predictor) 2, 3
• Coagulopathy (OR = 4.3 for GI bleeding; one of the strongest clinical predictors) 2, 3
• Acute liver failure requiring ICU admission 2
• Severe liver disease (e.g., MELD ≥35) 3

Additional High-Risk Criteria (≥2 factors increase risk significantly)

• Sepsis or septic shock 3, 1
• Acute kidney injury 3
• Shock states (particularly hypovolemic shock causing gastric hypoperfusion) 3
• Multiple organ failure 3
• History of GI bleeding or peptic ulcer disease 3
• Mechanical ventilation WITHOUT enteral nutrition 1

Moderate-Risk Criteria

• Chronic liver disease 1
• Burns >35% body surface area 4
• Traumatic brain injury or spinal cord injury 5
• Major surgery (vascular, abdominal) 3

Patients Who Do NOT Require Prophylaxis

• Critically ill patients without the above risk factors (bleeding risk ≤4%) 1
• General medical ward patients without critical illness 1
• Patients receiving adequate enteral nutrition (provides natural mucosal protection) 3

Preferred Prophylactic Agents

First-Line Recommendation

Proton pump inhibitors (PPIs) are preferred over H2-receptor antagonists (H2RAs) for stress ulcer prophylaxis in high-risk patients. 3, 1

• Intravenous pantoprazole 40 mg daily is the preferred agent for critically ill patients unable to take oral medications, particularly those with severe liver disease 3
• PPIs provide superior acid suppression and probably reduce bleeding risk more than H2RAs (moderate certainty evidence) 1
• Both PPIs and H2RAs are acceptable options when prophylaxis is indicated, though PPIs are generally preferred 3, 1

Second-Line Options

• H2-receptor antagonists (e.g., ranitidine) are effective but may be associated with drug interactions and encephalopathy in neurocritical patients 2, 5
• Sucralfate should NOT be used (strong recommendation against) due to inferior efficacy 1

Timing and Duration

• Initiate prophylaxis immediately upon ICU admission for high-risk patients 3
• Continue prophylaxis as long as risk factors persist and critical illness continues 3
• Discontinue when sepsis resolves and patient tolerates enteral nutrition 3
• Reevaluate daily for continued need based on risk factor resolution 3

Important Caveats

Potential Harms to Consider

• PPIs and H2RAs might increase pneumonia risk (low certainty evidence), though this remains controversial 1, 5
• No mortality benefit has been demonstrated with prophylaxis (moderate certainty) 1
• Clostridioides difficile infection risk may be increased with acid suppression 6

Special Populations

• Acute liver failure patients should receive PPIs or H2RAs (or sucralfate as second-line) given their high bleeding risk from coagulopathy 2
• Neurocritical care patients should preferentially receive PPIs over H2RAs to avoid encephalopathy and anticonvulsant drug interactions 5
• Cancer patients with neutropenia do not require routine prophylaxis for infectious diarrhea, only for stress ulcers if other high-risk criteria are met 2

Monitoring Requirements

• Monitor for signs of GI bleeding (melena, hematemesis, hemoglobin drop) from admission 3
• Surveillance should continue throughout ICU stay in high-risk patients 3