Prevention of stress ulceration: current trends in critical care.
OBJECTIVE
To identify the level of current intensivist's knowledge regarding risk assessment and intensive care unit (ICU) clinical practice pertaining to stress-related mucosal bleeding, including pharmacologic approaches for stress ulcer prevention.


METHODS
A nationwide survey of critical care physicians.


METHODS
Two thousand random physician members of the Society of Critical Care Medicine.


RESULTS
The response rate was 519 (26%) of 2000, with data analysis from 501 (25.1%) usable surveys. Respondents were affiliated with internal medicine (44.3%), surgery (42.3%), and anesthesiology (12.6%). Gut ischemia was indicated as the perceived major cause of stress ulceration (59.7%). The estimated incidence of clinically important bleeding was 2% or less by 62% of respondents; however, 28.6% of physicians surveyed initiate stress ulcer prophylaxis in all ICU patients, regardless of bleeding risk. Respiratory failure was most frequently indicated as a reason for stress ulcer prophylaxis (68.6%), followed by shock/hypotension (49.4%), sepsis (39.4%), and head injury/major neurologic insult (35.2%). The first-line agents selected for stress ulcer prophylaxis include histamine-2 receptor antagonists (63.9%), followed by proton pump inhibitors (23.1%), and sucralfate (12.2%). Concern for nosocomial pneumonia was regarded as more prevalent with antisecretory therapies in those who chose sucralfate (61%) as initial therapy compared with overall respondents (26.9%) (p < .001).


CONCLUSIONS
The majority of intensivists surveyed recognize stress-related mucosal bleeding as a relatively infrequent event; however, implementation of a stress ulcer prophylaxis risk stratification scheme for ICU patients is necessary. Histamine-2 receptor antagonists are consistently perceived as appropriate initial agents, although proton pump inhibitors have become first-line therapy in an increasing percentage of critical care patients, despite limited data regarding their use in this population.
Daley
Ryan J
RJ
Pharmacotherapy Department, Fletcher Allen Health Care, Burlington, VT, USA.
Rebuck
Jill A
JA
Welage
Lynda S
LS
Rogers
Frederick B
FB
D000897:Anti-Ulcer Agents / Q000627:therapeutic use*; D002983:Clinical Competence; D003422:Critical Care / Q000379:methods / Q000639:trends*; D016638:Critical Illness; D019538:Health Care Surveys; D006635:Histamine H2 Antagonists / Q000627:therapeutic use; D006801:Humans; D010437:Peptic Ulcer / Q000517:prevention & control*; D011364:Professional Practice; D054328:Proton Pump Inhibitors; D018570:Risk Assessment; D012307:Risk Factors; D013312:Stress, Physiological
D000897:Anti-Ulcer Agents; D006635:Histamine H2 Antagonists; D054328:Proton Pump Inhibitors