How to Write the Order for Omeprazole 80 mg IV Bolus Followed by 8 mg/hr Continuous Infusion for 72 Hours
Order omeprazole 80 mg IV bolus over 15 minutes NOW, followed immediately by omeprazole 8 mg/hr continuous IV infusion for exactly 72 hours. This is the evidence-based high-dose PPI regimen recommended by the American College of Gastroenterology and World Society of Emergency Surgery for patients with high-risk nonvariceal upper GI bleeding after successful endoscopic hemostasis 1, 2.
Specific Order Components
Initial Bolus
- Write: "Omeprazole 80 mg IV push over 15 minutes NOW" 2, 3
- Administer this bolus immediately after successful endoscopic hemostasis 1
Continuous Infusion Setup
- Write: "Omeprazole 8 mg/hr continuous IV infusion x 72 hours, start immediately after bolus" 1, 2
- Total infusion volume calculation: Mix 240 mg omeprazole in appropriate diluent to deliver 8 mg/hr over 72 hours (total 192 mg over infusion period) 2
- Specify exact stop time: Document the precise date and time the infusion should end (72 hours from start) 2, 3
Post-Infusion Orders
- Write: "After 72-hour infusion complete: Omeprazole 40 mg PO twice daily on days 4-14, then omeprazole 40 mg PO once daily starting day 15" 2
- Continue oral PPI therapy for a total of 6-8 weeks to allow complete mucosal healing 1
Evidence Supporting This Regimen
Mortality and Rebleeding Benefits
- High-dose continuous infusion (80 mg bolus + 8 mg/hr x 72 hours) significantly reduces rebleeding rates from 10.3% to 5.9% (p=0.03) compared to placebo 1, 4
- This regimen reduces mortality (OR 0.56,95% CI 0.34-0.94) and need for surgery compared to lower doses or no PPI therapy 2
- The benefit is most pronounced during the first 72 hours when most rebleeding episodes occur 5
Pharmacologic Rationale
- Continuous infusion maintains intragastric pH >6.0 for 97.9% of the time over 72 hours, which is necessary for platelet aggregation and clot stability 2, 6
- Bolus dosing every 12 hours is inferior, maintaining pH >6.0 only 63.5% of the time 6
- The antisecretory effect lasts up to 72 hours due to prolonged binding to parietal H+/K+ ATPase enzyme 7
Critical Caveats and Common Pitfalls
Timing Considerations
- Start PPI therapy as soon as possible, even before endoscopy 1, 3
- Pre-endoscopy PPI reduces stigmata of recent bleeding and need for endoscopic therapy 8
- However, never delay urgent endoscopy while relying solely on PPI therapy - PPIs are adjunctive, not replacement for endoscopic hemostasis 2, 3
Patient Selection
- This high-dose regimen is specifically indicated for patients with high-risk endoscopic stigmata (active bleeding, visible vessel, or adherent clot) 2, 3
- The mortality and rebleeding benefits are most pronounced in this high-risk population 2
Duration Errors to Avoid
- Do not stop the infusion early - the full 72-hour duration is critical as most rebleeding occurs in this window 1, 2, 5
- Do not discontinue oral PPI therapy before 6-8 weeks - inadequate duration prevents complete mucosal healing 1, 2
- Do not continue long-term PPI therapy beyond 6-8 weeks unless the patient has ongoing NSAID use 1
Dosing Errors to Avoid
- Do not use lower infusion rates (4 mg/hr or 2 mg/hr) - these fail to maintain adequate intragastric pH 9
- Do not substitute bolus dosing every 12 hours - this is inferior to continuous infusion for maintaining pH >6.0 6
- Do not use intermittent dosing - continuous infusion is required to achieve sustained acid suppression 2, 9
Additional Management Considerations
Concurrent Therapies
- Administer pre-endoscopy erythromycin to enhance gastric visualization 1, 3
- Test all patients for H. pylori and provide eradication therapy if positive 2, 3
- For patients requiring antiplatelet therapy, restart aspirin within 7 days with continued PPI therapy 3