What is the protocol for Gastrointestinal (GI) prophylaxis in the Intensive Care Unit (ICU)?

From the Guidelines

Stress ulcer prophylaxis is recommended for critically ill patients in the ICU who have risk factors for gastrointestinal bleeding, such as coagulopathy, shock, or chronic liver disease, as it reduces the occurrence of clinically important stress-related upper gastrointestinal bleeding (UGIB) 1. The preferred agents for stress ulcer prophylaxis are proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs), with PPIs being generally preferred due to their superior acid suppression and reduced bleeding risk 1. Some key points to consider when implementing stress ulcer prophylaxis include:

• Initiating prophylaxis promptly upon ICU admission for high-risk patients, including those with coagulopathy, shock, or chronic liver disease 1
• Continuing prophylaxis throughout the ICU stay while risk factors persist, but discontinuing upon transfer to the ward unless there are ongoing indications 1
• Using low-dose regimens of PPIs or H2RAs to minimize potential side effects, such as pneumonia and C. difficile infection 1
• Considering enteral nutrition as an additional measure to reduce UGIB risk, but not as a replacement for pharmacologic prophylaxis in high-risk patients 1 Overall, the benefit of preventing potentially life-threatening GI bleeding outweighs the risks associated with stress ulcer prophylaxis in high-risk ICU patients, and PPIs or H2RAs should be used as first-line agents for stress ulcer prophylaxis in critically ill adults with risk factors for clinically important stress-related UGIB 1.

From the FDA Drug Label

14 CLINICAL STUDIES The safety and efficacy of Pantoprazole Sodium for Injection have been established based on adequate and well-controlled adult studies of another intravenous pantoprazole sodium product in GERD associated with a history of EE and pathological hypersecretory conditions, including Zollinger-Ellison syndrome

• The provided text does not directly address ICU GI prophylaxis.
• The studies mentioned are related to GERD and erosive esophagitis, but do not provide information on the use of pantoprazole for GI prophylaxis in ICU settings.
• Therefore, based on the provided information, no conclusion can be drawn about the use of pantoprazole for ICU GI prophylaxis 2.

From the Research

ICU GI Prophylaxis

• The use of proton pump inhibitors (PPIs) for gastric acid suppression in critical illness is a common practice in intensive care units (ICUs) to prevent stress-related mucosal damage (SRMD) 3.
• PPIs have been shown to achieve a more rapid and sustained increase in gastric pH compared to histamine H2 receptor antagonists (H2RAs) and are not associated with the rapid tachyphylaxis seen with H2RAs 3.
• A study published in 2018 found that among adult patients in the ICU who were at risk for gastrointestinal bleeding, mortality at 90 days and the number of clinically important events were similar in those assigned to pantoprazole (a PPI) and those assigned to placebo 4.
• A systematic review protocol published in 2024 aims to evaluate the efficacy and safety of PPIs versus no prophylaxis for critically ill patients, including the potential risks of pneumonia, Clostridioides difficile infection, and increased risk of death in severely ill patients 5.
• A clinical practice guideline published in 2020 recommends the use of gastrointestinal bleeding prophylaxis in critically ill patients at high risk (>4%) of clinically important gastrointestinal bleeding, and suggests using a PPI rather than a H2RA 6.
• The implementation of standardized guidelines for PPI use has been shown to result in lower rates of inpatient PPI use and PPI prescription at discharge 7.

Benefits and Risks of PPIs

• PPIs have been shown to reduce the risk of clinically important bleeding in critically ill patients, particularly those at higher bleeding risk 6.
• However, PPIs may also increase the risk of pneumonia, although the certainty of this evidence is low 6.
• The effect of PPIs on mortality is probably neutral, with moderate certainty 6.

Guideline Recommendations

• The guideline panel makes a weak recommendation for using gastrointestinal bleeding prophylaxis in critically ill patients at high risk (>4%) of clinically important gastrointestinal bleeding 6.
• The panel suggests using a PPI rather than a H2RA, and recommends against using sucralfate 6.
• Clinicians should consider individual patient values, risk of bleeding, and other factors such as medication availability when deciding whether to use gastrointestinal bleeding prophylaxis 6.