Pharmacist-Driven Stress Ulcer Prophylaxis Minimization in the Intensive Care Unit

Historically, the two independent risk factors for stress-related GI bleeds were coagulopathy and mechanical ventilation for more than 48 hours; however, several additional risk factors have been identified, such as shock, multiple organ failure, traumatic brain injury, and major burns.

Acid suppressive medications such as proton pump inhibitors or histamine-2 receptor antagonists are prescribed to reduce the rate of bleeding from stress ulceration despite a lack of benefit from placebo-controlled trials. In addition to lack of proven benefit, the incidence of clinically significant stress-related GI bleeding has decreased over time, likely due to improvements in critical care and earlier enteral feeding.

Inclusion criteria

• Patients ≥18 years ICU location status

Exclusion criteria

• If patient has one of the following:

• Coagulopathy (defined as: platelets < 50,000/µL, international normalized ratio(INR) > 1.5, or partial thromboplastin time > 2 times the control value)
• Mechanical ventilation for > 48 hours and on < 50% goal tube feeds
• Shock state on vasopressors/inotropes and on < 50% goal tube feeds (or < 50% of diet)
• On total parenteral nutrition
• Use of acid suppressive therapy prior to admission
• Admission with GI bleeding
• History of peptic ulcer disease
• Surgery on the GI tract or cardiac surgery during the current hospital admission
• Pregnancy
• H. pylori infection treatment
• Hypersecretory disorder (ex: Zollinger-Ellison)
• Known erosive esophagitis/gastritis (not heartburn or gastroesophageal reflux disease)
• Traumatic brain injury with Glasgow Coma Scale score ≤ 10
• Major burn (˃30% body surface area)
• Major trauma requiring ICU admission
• Spinal cord injury requiring ICU admission

If patient has two or more of the following:

• Administration of ˃ 100 mg daily of prednisolone (or equivalent)
• Sepsis
• Acute renal failure
• Acute hepatic failure