In this episode, I’ll discuss the new SCCM and ASHP joint guidelines on stress ulcer prophylaxis in critically ill patients.
All the way back in episode 134 (nearly 8 years ago), I discussed the anticipated update to the 1999 stress ulcer prophylaxis guidelines that were first scheduled to come out on the ASHP website in October 2014 but were continuously delayed. Conflicting evidence and the irrelevance of older study designs due to changes in ICU practice was what most likely caused the delay, but the SCCM and ASHP have now come together to review recent data and perform their own network meta-analysis to publish the first guidelines on stress ulcer prophylaxis from a major medical society in 25 years.
The guidelines offer nine conditional recommendations and four good practice statements.
Stress ulcers and the resulting upper GI bleeding (UGIB) are thought to result from GI mucosa damage due to hypotension and hypoperfusion and then subsequent reperfusion associated with critical illness and patient resuscitation.
Risk factors for clinically important stress-related UGIB have been streamlined to only 3:
- Coagulopathy
- Shock
- Chronic Liver Disease
Noticeably absent from this list is mechanical ventilation.
Critically ill patients with these risk factors are recommended to receive stress ulcer prophylaxis and in a good practice statement the authors state this should be accomplished with either a low dose PPI or H2RA by either the enteral or IV route.
Another recommendation, albeit based on weaker evidence, is to give stress ulcer prophylaxis to neurocritical patients such as those with traumatic brain injury or intracerebral hemorrhage due to the increased risk of stress ulcers in this subgroup of patients.
The provision of enteral nutrition is recognized by the guideline authors to reduce the risk of stress ulcer, but patients receiving enteral nutrition that have risk factors for stress ulcers are still recommended to receive pharmacological prophylaxis.
Additional good practice statements suggest that pharmacologic SUP be discontinued before the patient leaves the ICU when risk factors are no longer present, and that patients who present to the ICU on a PPI or H2RA but without risk factors have the need for such medications compared against whether an actual indication exists.
While the evidence for the optimal way to prevent stress ulcers will continue to evolve, and the recommendations in this guideline are all conditional due to the state of the currently available evidence, this guideline provides an important foundation for clinicians to base their stress ulcer prophylaxis strategy on for their critically ill patients.
Members of my Hospital Pharmacy Academy have access to practical training on the new stress ulcer guidelines including a detailed explanation of the evidence that underpins each recommendation. You can get immediate access to this and hundreds of other trainings and resources to help in your practice at pharmacyjoe.com/academy.
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