COW#5
You are a resident in the ICU. You
admit a 57y/o male for a COPD exacerbation. When would prophylactic PPI not be
indicated with the following additional history?
Answer D: The patient is started on solumedrol 40mg
IV daily.
Data from large prospective
observational studies have found that ICU patients who have coagulopathy or
respiratory failure requiring mechanical ventilation have a substantially
higher risk of clinically important bleeding.
A prospective multicenter cohort study evaluated potential risk factors
for stress ulceration in patients admitted to ICUs (Cook et al, Risk Factors
for gastrointestinal bleeding in critically ill patients, NEJM 1994). Of 2252
patients, 33 (1.5%) had clinically important bleeding. Two strong independent
risk factors for bleeding were identified: respiratory failure requiring
ventilation x 48 hours (odds ratio [OR] 15.6) and coagulopathy (OR 4.3)
defined as Plt<50 inr="inr">1.5 or PTT>2x control. Of 847 patients who
had one or both of these risk factors, 31(3.7%) had clinically important
bleeding. Of 1405 patients without these risk factors, 2 (0.1%) had clinically
important bleeding. Of note, some potential risk factors for bleeding have not
been adequately studied and it is unclear if they are independent
predictors of bleeding. A majority of investigations excluded patients with a
history of ulcers or GI bleed as well as long term NSAID use. Additionally, it was found that as minor risk factors build up, there is a higher risk for GI bleed. In 1999, the
American Society of Health-System Pharmaciests (ASHP) released guidelines for
stress ulcer prophylaxis. The recommendations are as follows:
1) Prophylaxis is recommended in
patients with coagulopathy or patients requiring mechanical ventilation for
more than 48 hours. (Strength of evidence = C= Non randomized cohort studies)
2) Prophylaxis is also recommended
in patients with a history of GI ulceration or bleeding within one year before
admission(Strength of evidence = D = Expert Opinion)
3) Prophylaxis is also recommended
in patients with at least TWO of the following risk factors: sepsis, ICU stay
of more than one week, occult bleeding lasting six days or more, and use of
high-dose corticosteroids (>250 mg per day of hydrocortisone or the
equivalent). (Strength of evidence = D = Expert Opinion)
4) Many clinicians also recommend prophylaxis for patients with traumatic brain injury, traumatic spinal cord injury, or thermal injury (>35
percent of the body surface area), as these special populations are generally excluded from studies given their high risk of stress ulcers.
5) Lastly, it is recommended to continue a PPI for a patient already on a PPI as there is a risk for rebound gastric acid hypersecretion.
TAKE HOME POINT: The two biggest
risk factors for GI bleeding in the ICU is coagulopathy and intubation!
Click on the link below for a good summary
Also below are the 1999 guidelines. Its pretty long but read the portion on stress ulcer ppx. They have nice summaries in italics after each section:
ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis. ASHP Commission on Therapeutics and approved by the ASHP Board of
Directors on November 14, 1998 Am J Health Syst Pharm February 1, 1999 56:347-379
