Chapter 34. Prevention of Clinically Significant Gastrointestinal Bleeding in Intensive Care Unit Patients

Background Stress-related gastric ulceration was first described in the early 1970s, and has since received extensive study. Appreciation of the physiologic changes that promote stress-related gastritis and general improvements in the care of critically ill patients have likely played a role in reducing the frequency of this complication. Nonetheless, the use of specific pharmacologic agents for the prevention of stress-related gastrointestinal (GI) bleeding is increasingly promoted as standard therapy in the ICU setting. Despite the common use of these agents, controversy about the evidence supporting this practice remains. Because specific pharmacologic prophylaxis for stress ulceration may increase the risk of other complications (eg, nosocomial pneumonia) and is associated with significant costs, recent efforts have focused on delineating an appropriate definition of clinically important GI bleeding and identifying patients who derive a clear benefit from pharmacologic prevention of this complication. Practice Description This chapter reviews evidence supporting the use of pharmacologic therapies for stress ulcer and GI bleeding prophylaxis in the ICU setting. We considered the use of histamine-2 receptor blocking agents (H2-receptor antagonists) and sucralfate, a mucosal protecting agent. Although the efficacy of aluminumand magnesium-based antacids has been demonstrated, their use is limited by dosing frequency and side effects. Proton-pump inhibitors (PPIs) and enteral nutrition have also shown benefit in small studies, but there are yet no large randomized evaluations.