From the Guidelines
The standard for proton pump inhibitor (PPI) use in the intensive care unit (ICU) is typically 40mg of pantoprazole or esomeprazole intravenously once daily for stress ulcer prophylaxis in high-risk patients, as recommended by the Society of Critical Care Medicine and American Society of Health-System Pharmacists guideline 1.
High-Risk Patients
High-risk patients include those with coagulopathy, shock, or chronic liver disease, as well as those with other risk factors such as mechanical ventilation for >48 hours, history of gastrointestinal bleeding, traumatic brain injury, burns >35% body surface area, or multiple organ failure.
Treatment Duration
Treatment should be reassessed daily and discontinued when risk factors resolve or when the patient leaves the ICU, as prolonged PPI use is associated with increased risks of Clostridioides difficile infection, pneumonia, and hypomagnesemia 1.
Mechanism of Action
PPIs work by irreversibly inhibiting the hydrogen-potassium ATPase pump in gastric parietal cells, reducing acid production and raising gastric pH above 4, which helps prevent stress-related mucosal damage in critically ill patients.
Dosage
Low-dose SUP should be administered in critically ill adults with risk factors for clinically important stress-related UGIB, with "low-dose" PPI therapy defined as a daily dose of less than or equal to 40mg esomeprazole, omeprazole, or pantoprazole 1.
Route of Administration
Either enteral or IV routes can be used for administering SUP in critically ill adults with risk factors for clinically important stress-related UGIB 1.
From the Research
Standard for PPI in ICU
The standard for proton pump inhibitor (PPI) use in Intensive Care Units (ICUs) is a topic of ongoing research and debate. Several studies have investigated the appropriate use of PPIs in ICU settings, including:
- A study published in 2014 2 found that intravenous pantoprazole and intravenous omeprazole are equivalent for stress ulcer prophylaxis in critically ill patients.
- A 2010 study 3 found that inappropriate use of IV PPI was significantly higher in non-ICU patients than in ICU patients, with the most common cause being stress ulcer prophylaxis.
- A 2023 systematic review and meta-analysis 4 found that PPI use was associated with an increased mortality risk in critically ill patients, although the results were not consistent across all studies.
- A 2016 study 5 found that new initiation of PPI therapy led to an increase in hospital mortality in about 90% of simulated patients, and continuation of outpatient PPI therapy on admission led to a net increase in hospital mortality in 79% of simulated patients.
- A 2025 retrospective analysis 6 found that prophylactic PPI use was associated with an increased risk of new-onset acute kidney injury in ICU patients.
Key Findings
Some key findings related to PPI use in ICUs include:
- PPIs are commonly used for stress ulcer prophylaxis in critically ill patients, but their use may be associated with increased mortality risk and other adverse outcomes.
- The choice of PPI and the duration of therapy should be carefully considered, taking into account the individual patient's risk factors and clinical status.
- Inappropriate use of PPIs is common, particularly in non-ICU settings, and can lead to unnecessary costs and potential harm to patients.
- Further research is needed to determine the optimal use of PPIs in ICUs and to minimize the risks associated with their use.
PPI Use in ICU Patients
PPI use in ICU patients should be guided by evidence-based guidelines and protocols, taking into account the individual patient's needs and risk factors. Some considerations include:
- The use of PPIs for stress ulcer prophylaxis should be limited to patients at high risk of bleeding or other complications.
- The choice of PPI and the duration of therapy should be carefully considered, taking into account the individual patient's clinical status and risk factors.
- Patients should be monitored closely for potential adverse outcomes, including increased mortality risk, acute kidney injury, and other complications.