University of Maryland Medical Center PAGE: 1 PROCEDURE NO:

Division: Surgical Critical Care

EFFECTIVE DATE: REVISION NO:
July 1, 2003
SUBJECT: APPROVED BY:
Guidelines for stress ulcer prophylaxis in Adult Surgical Critical Care March 2003
surgical/medical intensive care units Therapeutics Committee May 2003

1.0 Purpose
1.1 To establish an evidence-based, cost-effective guideline for prophylaxis against stress-
related ulcers in Adult intensive care unit (ICU) patients. Active treatment of documented
stress ulcers is not included.

2.0 Scope
2.1 These guidelines are recommended for use in all Adult surgical/medical critical care units
at the University of Maryland Medical Center.

3.0 Procedure
3.1 Assess patients at risk for stress ulcers (SU) on arrival to the ICU by identifying any of the
major risk factors.
3.2 Risk factors for development of SU 1,2,3,6,7:
3.2.1 Anticipated requirement for mechanical ventilation > 48 hours
3.2.2 Coagulopathy
3.2.3 History of GI hemorrhage or ulcer
3.2.4 Spinal cord injury
3.2.5 Glasgow coma scale < 10
3.2.6 Thermal injury covering > 35% of BSA
3.2.7 Organ Transplant
3.2.8 Hepatic Failure
3.2.9 Multiple Trauma (Injury severity score > / = 16)
3.2.10 Short bowel syndrome
3.2.11 At least 2 of the following:
• Sepsis
• ICU stay > 1 week
• Occult bleeding > / = 6 days or more
• Use of high dose steroids (hydrocortisone >250mg per day
or equivalent)
3.3 If the patient has no risk factors, continue periodic assessments for SU.

3.4 If the patient has risk factors, assess ability to adequately absorb PO medicines.
3.4.1 Criteria for assessing patient’s ability to adequately absorb PO medicines.
3.4.1.1 Inclusion Criteria
• The patient is receiving an oral medicine (PO, PEG, NG) that relies
upon gastrointestinal absorption for efficacy.
• The patient is receiving tube feeds of at least 50% of their goal rate.
 3.4.1.2 Exclusion Criteria
• Patients who are hemodynamically unstable.
• Patients designated NPO for any reason.
• Patients receiving scheduled antiemetics.
• Patients with mucositis and/or receiving chemotherapy that causes
mucositis.
• Patients who are being treated for active GI bleed.

3.5 Recommendations for oral SU prophylaxis.

Agent Dose Adjustment for Renal insufficiency

Ranitidine granules 150mg PO/NG bid CrCl < 50ml/min: 150mg QD
(Zantac) CrCl < 10ml/min: 75 mg QD
HD: 150mg QD (on days of dialysis,
give dose after HD)
CVVHD: 150mg bid

Sucralfate (Carafate 1 gram PO/NG qid NONE

)

NOTE: If carafate is chosen, monitor for drug interactions (ex: dilantin, digoxin,
gatifloxacin, ciprofloxacin, levothyroxine)

3.6 Recommendations for IV SU prophylaxis.

3.6.1 Famotidine (Pepcid) 20mg IV q12hrs
3.6.2 Adjust for renal insufficiency: CrCl < 50 ml/min: 20mg IV q24hrs
CrCl < 10 ml/min: 20mg IV q24hrs
HD: 20mg IV q24hrs (on days of dialysis,
give dose after HD)
CVVHD: 20mg IV q12hrs

NOTE: Patients may be switched to PO ranitidine granules if tolerating other PO

medicines.

3.7 Use of proton pump inhibitors.1,5

3.7.1 Currently, proton pump inhibitors (PPI’s) have not been shown to be superior over
H2-antagonists for SU prophylaxis. No randomized controlled trials have addressed
this issue to date. Therefore, PPI’s are recommended only in those patients:
• Stabilized on these medicines prior to ICU admission (i.e. Recent GI bleed,
chronic GERD).
• Documented intolerance to H2-antagonists.
• Documented SU or active PUD despite H2-antagonist therapy.

3.7.2 Recommended dose for use of pantoprazole for SU is 40mg IV/PO QD.
 3.8 Use of more than one agent for SU prophylaxis.
3.8.1 The use of H2-antagonists plus PPI’s has not been shown to improve protection
against SU prophylaxis and therefore is not recommended.
3.8.2 The use of sucralfate in combination with any gastric acid inhibitor (i.e. H2-
antagonists or PPI’s) will decrease the effectiveness of carafate (mucosal
adherence) and is therefore, not recommended.

4.0 Discontinuation of SU prophylaxis1

4.1 Discontinuation of SU prophylaxis is recommended if any of the following conditions are
met:
• Tolerance of full enteral feedings or oral diet
• Resolution of risk factors
• Upon discharge from the ICU
4.2 Patients on therapy for chronic conditions should remain on their regiments.

References:
1. American Society of Health-System Pharmacists. ASHP therapeutic guidelines on stress ulcer
prophylaxis. Am J Health-Sys Pharm. 1999; 56: 347-79
2. Cook D, Heyland D, Griffith L, et.al. Risk factors for clinically important upper gastrointestinal
bleeding in patients requiring mechanical ventilation. Crit Care Med 1999; 27: 2812-7.
3. Cook DJ, Fuller H, Guyatt GH, et.al. Risk factors for gastrointestinal bleeding in critically ill
patients. NEJM 1994; 330: 377-81.
4. Lu Wy, Rhoney DH, Boling WB, et.al. A review of stress ulcer prophylaxis in the neurosurgical
intensive care unit. Neurosurgery. 1997 Aug; 41(2): 416-25; discussion 425-6.
5. Morgan D. Intravenous proton pump inhibitors in the critical care setting. Crit Care Med 2002;
30(6 suppl): S369-72.
6. Steinberg KP. Stress-related mucosal disease in the critically ill patient: risk factors strategies to
prevent stress-related bleeding in the intensive care unit. Crit Care Med. 2002 Jun; 30 (6 suppl):
S362-4.
7. Westergaard H. Short bowel syndrome. Semin Gastrointest Dis; 2002 Oct; 4: 210-20.

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