Stress Ulcer Prophylaxis in Critically III Patients

Give your patient a fast hug (at least) once a day*

“…There is probably no need for the routine use of antiulcer agents in all ICU patients, including after trauma or major surgery (49 -51). There are several possible treatment options, including antacids, sucralfate, H 2 -antagonists, and the more recently proposed proton pump inhibitors; however, despite several randomized, controlled studies and meta-analyses comparing these agents (51)(52)(53)(54)(55)(56), the optimal medication is still not clear. In a multicenter study by Cook et al (55), involving 1,200 critically ill patients undergoing mechanical ventilation, patients treated with ranitidine had significantly lower rates of clinically significant gastrointestinal bleeding than patients treated with sucralfate (relative risk, 0.44; 95% confidence interval, 0.21-0.92; p ϭ .02), although there was no difference in the mortality rates between the two groups.…”

Prevention of nosocomial bacterial pneumonia

“…The evidence on the effects of H 2 -antagonists on the development of nosocomial pneumonia is conflicting with some studies reporting a definite increased incidence49 and others reporting no increased risk50 51 of nosocomial pneumonia. In a meta-analysis of the literature Cook et al 52 concluded that there was a trend towards an increased risk of pneumonia in patients treated with H 2 -receptor antagonists. In view of this potential increased risk of pneumonia related to the effects of H 2 -blockers on gastric pH, sucralfate has sometimes been preferred and, indeed, several meta-analyses of the literature have concluded that there is a reduced incidence of pneumonia in patients treated with sucralfate compared with H 2 -blockers or antacids 52-54.…”

Stress ulceration: prevalence, pathology and association with adverse outcomes

“…Sucralfate acts by adhering to epithelial cells forming a physical cytoprotective barrier at the ulcer site, thereby protecting the gastric mucosa from the effects of acid and pepsin. Sucralfate is more effective than placebo in reducing overt bleeding, but has been shown to be inferior to H2RBs to reduce clinically significant bleeding [13]. Furthermore, sucralfate can impair the absorption of enteral feeds and co-administered oral medication [14], and there is a potential risk of bezoar formation (particularly in the setting of impaired gastric motility) when administering sucralfate to patients who are concurrently receiving enteral liquid nutrient [15].…”