GI prophylaxis guidelines

Gastrointestinal , gi prophylaxis guidelines in the intensive care unit (ICU) is important in the prevention of stress gastritis. The incidence of clinically significant bleeding in critically ill patients is 2% to 15%. However, it is important to understand the actual indications for prophylaxis.

Most experienced clinicians feel it should be limited to patients at high risk for stress-related mucosal diseases, which include the following conditions: mechanical ventilation longer than 48 hours; coagulopathy; endoscopic or radiographic diagnosis of peptic ulcer or gastritis; history of an upper GI bleed less than 6 weeks prior to admission; significant burns (greater than 15% of total body surface area); traumatic brain injury; and large doses of glucocorticoids (e.g., >50mg hydrocortisone/day).

The commonly used gi prophylaxis guidelines is described below. Prophylactic medications to prevent stress gastritis include antacids, sucralfate, histamine-2 receptor antagonists (H2-blockers), and proton pump inhibitors (PPIs).

Cook et al., in a multicenter randomized double-blind controlled trial, demonstrated that H2-blockers (ranitidine) compared with sucralfate decreased clinically significant bleeding with no difference in ventilator-associated pneumonia.

To date there are no studies about gi prophylaxis guidelines that have prospectively evaluated the ability of intravenous PPIs to reduce clinically significant bleeding in high-risk critically ill patients; however, PPIs have been shown to raise and maintain an elevated gastric pH.

When deciding between H2-blockers and PPIs, side effects and cost should be considered. If the patient requires intravenous medications, H2-blockers are the most cost-effective.

However, if the patient is able to tolerate oral medications, PPIs are a good choice given their ability to maintain gastric pH for a sustained period of time. The overall need for prophylaxis should be assessed when patients are able to meet their nutritional requirements by mouth.

Side effects of both drugs should be kept in mind.

According to the gi prophylaxis guidelines H2-blockers have been associated with tachyphylaxis (i.e., tolerance and thus decrease in gastric pH), interstitial nephritis, confusion, inhibition of the cytochrome oxidase enzyme system (cimetidine only), and dose adjustment in patients with creatinine clearance of less than 50 mL/min. PPIs are generally safe but rare side effects include diarrhea, nausea, and pruritus.

 

 

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