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Stress ulcer prophylaxis in the postoperative period
Michelle E Allen1, Brian J Kopp, Brian L Erstad
1Adult Critical Care, Shands at the University of Florida, Gainesville, USA.
Summary
Recent studies indicate that clinically important bleeding from stress ulcers is infrequent. Pharmacologic prophylaxis shows limited effectiveness, suggesting critical care advancements are key, alongside institution-specific guidelines for prophylaxis selection.
Area of Science:
- Critical Care Medicine
- Pharmacology
- Gastroenterology
Background:
- The American Society of Health-System Pharmacists (ASHP) published guidelines in 1999 for stress ulcer prophylaxis.
- Recent research addresses controversies and updates recommendations for stress ulcer prophylaxis in postoperative patients.
Purpose of the Study:
- To discuss the implications of recent studies on stress ulcer prophylaxis guidelines.
- To evaluate the effectiveness of pharmacologic agents and identify appropriate candidates for prophylaxis.
Main Methods:
- Review of recent prospective studies and meta-analyses on stress ulcer prophylaxis.
- Analysis of bleeding frequencies based on different definitions (overt vs. clinically important bleeding).
- Evaluation of pharmacologic agents, including proton-pump inhibitors (PPIs) and histamine H2-receptor antagonists.
Main Results:
- Clinically important bleeding rates are consistently low in recent investigations.
- Most studies and meta-analyses show minimal reduction in clinically important bleeding with pharmacologic prophylaxis.
- Proton-pump inhibitors (PPIs) appear effective in increasing gastric pH, comparable to H2-receptor antagonists, but further studies on bleeding endpoints are needed.
Conclusions:
- Institution-specific guidelines are recommended for identifying appropriate candidates for stress ulcer prophylaxis.
- The effectiveness of pharmacologic agents in reducing clinically important bleeding remains limited.
- Advances in critical care may play a more significant role in preventing stress-induced bleeding than pharmacologic interventions.