Current guidelines on stress ulcer prophylaxis.
Acute uppergastrointestinal bleeding in intensive care unit (ICU) patients may occur due to peptic ulcer disease, adverse drug effects, gastric tube lesions, acute renal failure, liver failure or stress-induced gastric mucosal lesions. Gastric acid hypersecretion can be observed in patients with head trauma or neurosurgical procedures. Gastric mucosal ischaemia due to hypotension and shock is the most important risk factor for stress ulcer bleeding. Preventive strategies aim to reduce gastric acidity (histamine H2 receptor antagonists, antacids), strengthen mucosal defensive mechanisms (sucralfate, antacids, pirenzepine) and normalise gastric mucosal microcirculation (sucralfate, pirenzepine). However, the most important prophylactic measure is an optimised resuscitation and ICU regime aiming to improve oxygenation and microcirculation. All drugs approved for stress ulcer prophylaxis in Europe (H2 antagonists, antacids, pirenzepine, sucralfate) have been shown to be effective in prospective controlled randomised trials. However, due to insufficient clinical data, prostaglandins and omeprazole cannot be recommended for this use. Stress ulcer prophylaxis is indicated only in patients at risk, and not in every ICU patient. The selection of drugs today depends not only on efficacy but also on possible adverse effects and on costs. In this regard, the most cost-effective drug is sucralfate. The clinical relevance of nosocomial pneumonia due to gastric bacterial overgrowth has decreased during the past decade due to several changes in the management of critically ill patients.
Tryba
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M
Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Bergmannsheil, Bochum, Germany. tryba@gus.de
Cook
D
D
D000863:Antacids / Q000009:adverse effects / Q000627:therapeutic use; D000897:Anti-Ulcer Agents / Q000009:adverse effects / Q000627:therapeutic use*; D002319:Cardiovascular System / Q000187:drug effects; D002490:Central Nervous System / Q000187:drug effects; D018849:Controlled Clinical Trials as Topic; D003362:Cost-Benefit Analysis; D004347:Drug Interactions; D005765:Gastrointestinal Agents / Q000009:adverse effects / Q000627:therapeutic use*; D017408:Guidelines as Topic; D006635:Histamine H2 Antagonists / Q000009:adverse effects / Q000627:therapeutic use; D006801:Humans; D010437:Peptic Ulcer / Q000188:drug therapy* / Q000191:economics / Q000401:mortality; D011453:Prostaglandins / Q000009:adverse effects / Q000627:therapeutic use; D054328:Proton Pump Inhibitors; D012137:Respiratory System / Q000187:drug effects; D018570:Risk Assessment; D013312:Stress, Physiological / Q000150:complications*; D013392:Sucralfate / Q000009:adverse effects / Q000627:therapeutic use
D000863:Antacids; D000897:Anti-Ulcer Agents; D005765:Gastrointestinal Agents; D006635:Histamine H2 Antagonists; D011453:Prostaglandins; D054328:Proton Pump Inhibitors; D013392:Sucralfate