We No Longer Need to Stress Ulcer Prophylaxis in the Critically Ill

Preventing stress gastropathy has been a mainstay in the management of critically ill patients for decades. A landmark trial in 1994 identified the most significant risk factors for stress gastropathy as mechanical ventilation for greater than 48 h and primary coagulopathy. Since this study's publication more than two decades ago, the incidence of clinically significant gastrointestinal bleeding secondary to stress gastropathy has significantly declined. In addition, the most widely used agents for prophylaxis have been associated with an increasing number of adverse effects, including myocardial infarction, Clostridium difficile infection, osteoporosis, and ventilator associated pneumonia. As the incidence of significant bleeding decreases and the knowledge about prophylaxis-related adverse events increases, it is necessary to revisit current clinical practice. Major practice changes, including early aggressive fluid resuscitation and development of dynamic markers for volume status, have reduced the likelihood for prolonged hypoperfusion states. Additionally, the recognition of the important of enteral nutrition early in the ICU stay encourages mesenteric perfusion and reduces risk for development of ischemic damage. Contemporary studies have failed to replicate significant rates of gastrointestinal bleeding, likely in part due to these advances in care. Recent studies, including a pilot randomized trial, are questioning the necessity of pharmacologic prophylaxis in the modern era, with undetectable rates of gastrointestinal bleeding in enrolled patients. Patients with risk factors for stress gastropathy who demonstrate no evidence of splanchnic hypoperfusion may not benefit from receiving stress ulcer prophylaxis and tolerance of enteral nutrition may be used as a surrogate marker for adequate perfusion. Overall there is a lack of high quality data supporting stress ulcer prophylaxis in the modern era.