SRMB Flashcards
SRMD definition
“stress related mucosal disease”
acute development of superficial lesions most commonly involving mucosal layers of the stomach in the critically ill
SMRB definition
“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
how is SRMD different from PUD
SRDM is acute and primarily affects the stomach
PUD is chronic and primarily affects the duodenum
pathophysiology of SRMB/SRMB
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
“major” risk factors for SRMD/SRMB***
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
incidence of SRMD/SRMB
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%
increased morbidity/mortality with SRMB
clinically important bleeding = mortality around 50%, increase ICU stay and healthcare costs
effectively evaluate risk factors = effectively prevent SRMB
indication for SRMD prophylaxis (ICU)
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)
indication for SRMD prophylaxis (non-ICU)
ASHP guidelines do NOT recommend prophylaxis for patients residing in non-ICU settings
goals of SRMD prophylaxis
prevent clinically important bleeding (increased mortality)
prevent progression of mucosal damage
prevent potential complication resulting from SRMD
SRMD prophylaxis options
antacids, sucralfate, H2RAs, PPIs, enteral feeding
most effective if initiated early
antacids as SRMD prophylaxis
historically used, not anymore due to burdensome dosing and SE concerns
enteral feeding as SRMD prophylaxis
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
sucralfate as SRMD prophylaxis
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**
H2RAs as SRMD prophylaxis
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
H2RA agents/doses for SRMB prophylaxis
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
calculate CrCl
(140-age)(weight in kg)/(72)(SCr)
multiply by 0.85 if female
PPIs used for SRMB prophylaxis
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
PPI agents/doses
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
d/c SRMD prophylaxis
in most trials, prophylaxis was stopped Without clinically important bleeding upon extubation, Upon patient’s discharge from the ICU
