SRMB

Question 1

SRMD definition

Answer 1

“stress related mucosal disease”

acute development of superficial lesions most commonly involving mucosal layers of the stomach in the critically ill

Question 2

SMRB definition

Answer 2

“stress related mucosal bleeding”
may or may not be clinically important
clinically important bleeding is responsible for complications, risky interventions and increased mortality
- necessity of RBC transfusions

Question 3

how is SRMD different from PUD

Answer 3

SRDM is acute and primarily affects the stomach

PUD is chronic and primarily affects the duodenum

Question 4

pathophysiology of SRMB/SRMB

Answer 4

Acid is an important (and necessary) cofactor for developing SRMD, However, acid hypersecretion is NOT found in all
SRMD cases, Higher pH values (over 4.5) do NOT ensure prevention of SRMD lesions
The role of H. pylori is somewhat unclear in SRMD

Question 5

“major” risk factors for SRMD/SRMB***

Answer 5

respiratory failure - mechanical ventilation for at least 48 hours
coagulopathy - platelet count under 50K/mm^3, INR over 1.5, or PTT over 2x control value
if pt has either of these, put on stress ulcer prophylaxis

Question 6

incidence of SRMD/SRMB

Answer 6

difficult to precisely determine
some studies suggest 75-100% of critically ill patients develop SRMD within 24-72 hours of ICU admission, however, clinically important SRMB is estimated at 1-4%

Question 7

increased morbidity/mortality with SRMB

Answer 7

clinically important bleeding = mortality around 50%, increase ICU stay and healthcare costs
effectively evaluate risk factors = effectively prevent SRMB

Question 8

indication for SRMD prophylaxis (ICU)

Answer 8

with coagulopathy
requiring mechanical ventilation 48+ hours
history of GI ulceration or bleeding within 1 year before admission and 2+ of the following:
-sepsis
-ICU stay over 1 week
-occult bleeding lasting 6+ days
-use of high dose CS (over 250 mg/day hydrocortisone or equivalent)

Question 9

indication for SRMD prophylaxis (non-ICU)

Answer 9

ASHP guidelines do NOT recommend prophylaxis for patients residing in non-ICU settings

Question 10

goals of SRMD prophylaxis

Answer 10

prevent clinically important bleeding (increased mortality)
prevent progression of mucosal damage
prevent potential complication resulting from SRMD

Question 11

SRMD prophylaxis options

Answer 11

antacids, sucralfate, H2RAs, PPIs, enteral feeding

most effective if initiated early

Question 12

antacids as SRMD prophylaxis

Answer 12

historically used, not anymore due to burdensome dosing and SE concerns

Question 13

enteral feeding as SRMD prophylaxis

Answer 13

can have beneficial effects on the critically ill patient’s overall care
insufficient data to recommend this as sole prophylaxis measure, esp in those w major risk factors

Question 14

sucralfate as SRMD prophylaxis

Answer 14

mucosal protectant -requires gastric administration**
does not increase gastric pH
variety of adverse reactions and issues - drug interations (not as concerning if meds are IV), constipation**

Question 15

H2RAs as SRMD prophylaxis

Answer 15

first choice
cimetidine, famotidine, ranitidine
many studies support H2RA use - PO used but limited data, IV can be given intermittently or continuously (better pH control)
adverse reactions and issues - tachyphylaxis
may show decrease of clinically important bleeding compared to sucralfate

Question 16

H2RA agents/doses for SRMB prophylaxis

Answer 16

cimetidine:
-PO: 300 mg QID
-CrCl under 30: 300 mg PO BID
famotidine:
-PO: 20mg BID
-IV (intermittent): 20mg BID
-IV (continuous): 1.7mg/hr
-CrCl under 30: 20mg PO/IV daily or 0.85mg/hr infusion
ranitidine:
-PO: 150mg BID
-IV (intermittent): 50mg Q6-8H
-IV (continuous): 6.25mg/hr
-CrCl under 50: 150mg PO BID/daily, 50mg IV Q12-24H, 2-4mg/hr infusion

Question 17

calculate CrCl

Answer 17

(140-age)(weight in kg)/(72)(SCr)

multiply by 0.85 if female

Question 18

PPIs used for SRMB prophylaxis

Answer 18

Omeprazole, lansoprazole, pantoprazole, esomeprazole, and rabeprazole
No tachyphylaxis issues like H2RA’s
Adverse reactions and issues - Possible risk of nosocomial pneumonia** suggested by data from non-ICU hospitalized patients, Possible risk of Cdiff**
Variety of regimens available, but potentially with more problems than H2RA’s - Formulation/administration issues (Most PO products are enteric-coated products, which are difficult to administer via feeding tubes), Limited efficacy data

Question 19

PPI agents/doses

Answer 19

esomprazole: limited data
lansoprazole: 30 mg QD
omeprazole: 40 mg x1, then 20-40 mg QD
zegrid: 40 mg x1, then 40 mg after 6-8 hours, then 40 mg QD
pantoprazole: 40 mg QD, IV limited data
rabeprazole: limited date

Question 20

d/c SRMD prophylaxis

Answer 20

in most trials, prophylaxis was stopped Without clinically important bleeding upon extubation, Upon patient’s discharge from the ICU