Critical Care: Preventing Stress Ulcers

Question 1

The incidence of stress-related mucosal bleeding in critically ill adult is estimated to me about __%

Answer 1

6%

Question 2

List four signs and symptoms of stress ulcers

Answer 2

1. Hematemesis
2. Gross blood in gastric tube aspirates
3. Coffee ground emesis/aspiration from gastric tube
4. Melena

Question 3

Define a clinically significant stress ulcer

Answer 3

Those that cause hemodynamic compromise or necessitate blood transfusion

Question 4

List three ways that cause someone to be selected for Stress Ulcer Prophylaxis (SUP)

Answer 4

1. Any one of the major risk factors
2. Two or more of minor risk factors
3. History of GI ulceration or bleeding within 1 year before ICU admission

Question 5

List two major risk factors that are indications for SUP

Answer 5

1. Respiratory failure necessitating mechanical ventilation (for more than 48 hours)
2. Coagulopathy

Question 6

List three lab parameter derangements that would designate coagulopathy

Answer 6

1. Platelet count less than 50,000 cells/mm3
2. INR greater than 1.5
3. Activated partial thromboplastin time greater than twofold the control value

Question 7

List four categories of minor risk factors for stress ulcer prophylaxis

Answer 7

1. Trauma
2. Organ damage
3. Surgery
4. Medication

Question 8

List 3 “traumatic” minor risk factors for SUP

Answer 8

1. Head or spinal cord injury
2. Severe burn (more than 35% of BSA)
3. Multiple trauma

Question 9

List four “organ damage” minor risk factors for SUP

Answer 9

1. Hypoperfusion
2. Acute organ dysfunction
3. Liver failure with associated coagulopathy
4. Acute kidney injury

Question 10

List two “surgery” minor risk factors for SUP

Answer 10

1. Transplantation

2. Major surgery

Question 11

List 1 “Medication” minor risk factor for SUP

Answer 11

High doses of corticosteroids (more than 250 mg/day of hydrocortisone or equivalent)

Question 12

What is the balance of risk/benefit for SUP?

Answer 12

1. The benefits of preventing stress ulcers by increasing the stomach pH must be weighed against
2. An increased risk of infection, including C. Diff, hospital-acquired pneumonia, and community-acquired pneumonia (for patients discharged with a PPI).

Question 13

Efficacy of IV _____ in preventing stress-related upper GI bleeding has been shown in several clinical trials

Answer 13

IV H2 blockers

Question 14

Despite limited evidence, IV or PO _____ are often used for SUP

Answer 14

PPI

Question 15

How to choose route of administration for SUP?

Answer 15

Enteral administration is preferred for patient who can tolerate

Question 16

List three H2 receptor blockers that can be dosed by IV bolus

Answer 16

1. IV Ranitidine 50 mg every 8 hours
2. IV famotidine 20 mg every 12 hours
3. IV Cimetidine 300 mg every 6 hours

Question 17

List 1 H2 receptor blocker than can be dosed by continuous IV infusion

Answer 17

IV Cimetidine 37.5-50 mg/hour

Question 18

List four H2 receptor blockers that can be dosed PO

Answer 18

1. Ranitidine 150 mg PO every 12 hours
2. Famotidine 20 mg PO every 12 hour
3. Nizatidine 150 mg PO every 12 hour
4. Cimetidine 300 mg PO every 6 hour

Question 19

Describe the bioavailability of H2 blockers

Answer 19

Excellent bioavailability

Question 20

Describe the cost of H2 receptor blockers

Answer 20

Cheapter than PPI

Question 21

Describe the risk of infection of H2 blockers

Answer 21

Low risk of nosocomial pneumonia

Question 22

Describe dose adjustment for H2 blockers

Answer 22

Renal dysfunction adjustment

Question 23

H2 blockers have a potential for reduced ______ over time

Answer 23

Efficacy (tachyphylaxis)

Question 24

Cimetidine is not routinely used because of ____ and ____

Answer 24

Drug interactions and adverse effects

Question 25

What is a unique adverse effect of cimetidine?

Answer 25

Thrombocytopenia

Question 26

What is a class-wide effect of H2 blockers?

Answer 26

Mental status changes

Question 27

List four dosing options for PO PPIs

Answer 27

1. Omeprazole 20 mg PO daily
2. Esomeprazole 20-40 mg PO daily
3. Lansoprazole 30 mg PO daily
4. Pantoprazole 40 mg PO daily

Question 28

What 3 PPIs are available as a powder for oral suspension?

Answer 28

1. Omeprazole powder for oral suspension
2. Lansoprazole delayed-release orally disintegrating tablets and oral suspension
3. Pantoprazole granules for oral or tube administration

Question 29

List 3 IV dosing options for PPI

Answer 29

1. IV Esomeprazole 20-40 mg daily
2. IV Lansoprazole 30 mg daily
3. IV Pantoprazole 40 mg daily

Question 30

Describe dose adjustments for PPI

Answer 30

No adjustment needed for renal or liver dysfunction

Question 31

Describe risk of infection with PPIs

Answer 31

1. Risk of ventilator-associated pneumonia increased

2. Risk of C. Diff infection (nosocomial or community-acquired)

Question 32

List 5 common side effects of PPI

Answer 32

1. headache
2. dairrhea
3. constipation
4. abdominal pain
5. nausea

Question 33

When should SUP be discontinued?

Answer 33

When risk factors are no longer present

Question 34

What class of acid-reducers are not used for SUP?

Answer 34

Antacids and sucralfate