Prevention of Stress-Related Gastrointestinal Bleeding in Critically Ill Adults

Publication Date: July 15, 2024
Last Updated: July 25, 2024

Summary of Recommendations

We suggest critically ill adults with coagulopathy, shock, or chronic liver disease be considered at risk for clinically important UGIB. (Conditional, Low to moderate)
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We suggest clinicians administer enteral nutrition to reduce clinically important stress-related UGIB in critically ill adults compared with no enteral nutrition. (Conditional, Moderate)
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We suggest critically ill adults with coagulopathy, shock, or chronic liver disease be considered at risk for overt UGIB. (Conditional, Low to moderate)
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We suggest clinicians provide SUP to prevent clinically important UGIB in critically ill adults with risk factors compared with no SUP. (Conditional, Moderate)
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We suggest using SUP in neurocritical care adults to reduce clinically important stress-related UGIB compared with no SUP. (Conditional, Very Low)
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We suggest using either PPIs or H2RAs as first-line agents for SUP in critically ill adults with risk factors for clinically important stress-related UGIB compared with no PPIs or H2RAs. (Conditional, Moderate)
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We suggest using either enteral or IV routes when administering SUP in critically ill adults with risk factors for clinically important stress-related UGIB compared with no enteral or IV routes. (Conditional, Low)
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Low dose SUP should be administered in critically ill adults with risk factors for clinically important stress-related UGIB compared with high-dose SUP. (BPS, )
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In critically ill adults with risk factors for developing clinically important stress-related UGIB, SUP should be discontinued when the risk factor(s) is no longer present. Discontinuation of SUP prior to transfer out of the ICU is necessary to prevent inappropriate prescribing. (BPS, )
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In critically ill adults who do not have risk factors for developing clinically important stress-related UGIB but are on a SUP agent before ICU admission, the indications for these medications should be reviewed and consideration made for discontinuing them. (BPS, )
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In critically ill adult patients with risk factors for developing clinically important stress-related UGIB and who are receiving a SUP agent before ICU, the consideration to change the medication to the most preferred agent for SUP must be weighed against the indication that required the SUP therapy before ICU admission. (BPS, )
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We suggest using SUP for critically ill adults who are enterally fed and possess one or more risk factor(s) for clinically important stress-related UGIB compared with no SUP. (Conditional, Very Low)
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We suggest not using SUP for critically ill adults who are enterally fed and at low risk for clinically important stress-related UGIB. (Conditional, Very Low)
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Recommendation Grading

Abbreviations

  • H2RA: Histamine2-receptor Blockers
  • PPI: Proton Pump Inhibitor
  • SUP:

    stress Ulcer Prophylaxis

  • UGIB: Upper GastroIntestinal Bleeding

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Prevention of Stress-Related Gastrointestinal Bleeding in Critically Ill Adults

Authoring Organizations

American Society of Health-System Pharmacists

Society of Critical Care Medicine

Publication Month/Year

July 15, 2024

Last Updated Month/Year

August 12, 2024

Document Type

Guideline

Country of Publication

US

Document Objectives

The objective of this guideline was to develop evidence-based recommendations for the prevention of UGIB in adults in the ICU. The guideline panel achieved consensus regarding the recommendations for the prevention of stress-related UGIB. These recommendations are intended for consideration along with the patient’s existing clinical status.

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Emergency care, Hospital

Intended Users

Nurse, nurse practitioner, health systems pharmacist, physician, physician assistant

Scope

Management, Prevention

Keywords

enteral nutrition, gastrointestinal bleeding, histamine 2 blockers, proton pump inhibitors, stress ulcer prophylaxis

Source Citation

MacLaren, Robert PharmD, MPH1; Dionne, Joanna C. MD, PhD, MSc2; Granholm, Anders MD3; Alhazzani, Waleed MD, MSc2,4; Szumita, Paul M. PharmD5; Olsen, Keith PharmD6; Barletta, Jeffrey F. PharmD7; Møller, Morten Hylander MD, PhD3; Karvellas, Constantine J. MD, MSc8; Wischmeyer, Paul MD9; DePriest, Ashley MS, RDN, LD10; Carlos, Victor11; Argetsinger, Debora DNP12; Carothers, John J. PharmD13; Lee, Rosemary DNP, APRN14; Napolitano, Lena MD15; Perri, Dan MD2,16; Naylor, Douglas F. MD17. Society of Critical Care Medicine and American Society of Health-System Pharmacists Guideline for the Prevention of Stress-Related Gastrointestinal Bleeding in Critically Ill Adults. Critical Care Medicine 52(8):p e421-e430, August 2024. | DOI: 10.1097/CCM.0000000000006330

Supplemental Methodology Resources

Data Supplement