Stress Prophylaxis in Intensive Care Unit Patients and the Role of Enteral Nutrition

Abstract

Use of acid‐suppressive therapy (AST) to prevent stress gastropathy in the intensive care unit has grown rapidly over the past 20 years. The primary indications for such use of AST include need for mechanical ventilation, overt gastrointestinal bleeding, severe burn, and head trauma. Despite this limited list of indications, proton pump inhibitors (PPIs) often are overprescribed for purposes of stress prophylaxis. Decreased mucosal blood flow with subsequent tissue ischemia is thought to be the mechanism responsible for stress‐induced gastropathy. Subsequent activation of inflammatory and vasoconstrictive mediators determines the severity of the gastropathy. Numerous basic science studies suggest that enteral nutrition (EN) can improve mucosal blood flow and reverse the generation of these inflammatory mediators. Clinical studies evaluating the effectiveness of EN vs acid‐suppressive medications, however, have shown variable results (and there are no randomized controlled trials to date). In hypersecretory states (such as head trauma and burns), AST should be given, even in patients who are tolerating EN. In the absence of a hypersecretory state, pharmacologic AST may be avoided or discontinued in patients who are tolerating EN. Stress prophylaxis medications also should be discontinued in patients who do not have a clear indication for their use. Overt bleeding in a patient receiving EN for stress prophylaxis should prompt the initiation of a PPI. Randomized controlled studies investigating the efficacy of EN for stress ulcer prophylaxis are needed. Protocols should be developed to alert healthcare teams to consider discontinuation of AST, especially when tolerance of EN is achieved.

ASPEN Safe Practices for Enteral Nutrition Therapy

“…They recommended that organizations use a diarrhea risk management algorithm. Hurt et al 73 suggested that incorporation of EN as a base strategy for stress ulcer prophylaxis to reduce the need for acid‐suppressive therapy may reduce C difficile pseudomembranous colitis. Others have recommended allowing stopping EN for periods of time (eg, 6‐hour break) to allow gastric pH to return to its more normal acidic pH to help reduce gastric microbial growth 44 …”

Stress ulcer prophylaxis in the intensive care unit: an international survey of 97 units in 11 countries

“…Former surveys support that enteral nutrition is taken into consideration when evaluating the risk of stress‐related bleeding and upon commencing SUP . Current evidence is based on case reports, a limited number of serial studies in humans and several animal studies, and this explains why there is no firm evidence regarding the role of enteral nutrition in the prevention of stress ulcers . Consequently, more research into this issue is needed.…”

Enteral Nutrition and Acid-Suppressive Therapy in the PICU: Impact on the Risk of Ventilator-Associated Pneumonia*

“…Mechanical ventilation is one of the few indications for stress ulcer prophylaxis and acid-suppressive therapy is expected to reduce the incidence of gastrointestinal bleeding (18). The effect of mechanical ventilation on splanchnic blood flow coupled with the presence of gastric acid has been thought to increase the frequency of ulcerating lesions in the stomach (19, 20). Several adult studies have demonstrated that mechanically ventilated adults receiving pantoprazole have a higher incidence of VAP than patients receiving ranitidine (21-23).…”