Sanjay Deshpande, MA Dessoky and Peter Brock used algorithm to identify patients at risk with stress related mucosal disease, those with an indication for IV prophylaxis, and those with indications for Proton Pump Inhibitor (PPI) use.
Summary
Stress related mucosal disease could be seen in more than 75 per cent of patients in ICU, with less than 4 per cent developing significant GI bleeding. It is important to identify those at risk of GI bleeding and provide prophylaxis against this, while avoiding inappropriate blanket treatment of all ICU patients.
Using the American Society of Health-System Pharmacists guidelines, we evaluated an algorithm to identify patients at risk, those with an indication for IV prophylaxis, and those with indications for Proton Pump Inhibitor (PPI) use.
The proposed algorithm increased the compliance with the guidelines. After implementation of the algorithm based assessment 100 per cent of patients requiring prophylaxis received it, versus 96 per cent before the implementation, 66 per cent of patients not requiring prophylaxis didn’t receive it versus 33 per cent before. 88 per cent of patients requiring PPI prophylaxis received it versus 66 per cent before. 76 per cent of patients requiring IV prophylaxis received it, versus 66 per cent before.
To date few guidelines has been proposed for SUP of which ASHP guidelines still a valid and recommended one. The use of an algorithm based intervention for SUP improves the compliance with the guidelines in our unit.
Introduction:
Stress related mucosal disease could be seen on endoscopy in 75-100 per cent of patients within 24 hours of arrival to ICU [1]. However, only 0.1-4 per cent of ICU patients will develop clinically significant gastrointestinal (GI) bleeding [2]. Of those who do develop GI bleeding, mortality is significantly increased 48.5 per cent vs 9 per cent [3].
The American Society of Health-System Pharmacists “ASHP” published guidelines in 1999 for the use of Stress Ulcer Prophylaxis “SUP” in medical and surgical ICU patients. It identifies the risk factors associated with stress related mucosal disease. [4]
Therefore, it is important to identify those at risk of GI bleeding and provide prophylaxis against this – given the significant mortality related to a GI bleed. However, blanket treatment of all critically ill patients is not appropriate for a multitude of reasons.
Clearly cost is a factor. Intravenous proton pump inhibitor “PPI” preparations are expensive in comparison to H2 blockers. Also PPI is associated with increased risk of clostridium difficile infection. [15]
The algorithm, which we developed in our unit, prompts to consider prescribing stress ulcer prophylaxis for every patient on the unit. ICU doctor then reviews patients and makes a decision based on their judgement.
An audit of practice in comparison to current ASHP guidelines for prescription of stress ulcer prophylaxis in critical care patients was performed.
Methods:
Using the American Society of Health-System Pharmacists guidelines as a standard, we expected that all patients with risk factors (as defined by the ASHP guidelines) for clinically significant GI bleed should receive stress ulcer prophylaxis. Patients without risk factors for clinically significant GI bleed should not receive stress ulcer prophylaxis. Of the patients given stress ulcer prophylaxis, only those with indications for PPI should receive it, and of the patients given stress ulcer prophylaxis, only those with indications for IV use should receive IV medication.
35 critical care patients on our unit were audited between 1 August 2012 and 7 October 2012.
With no current prescribing algorithm for stress ulcer prophylaxis in place we proposed an a