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Stress Ulcer Prophylaxis – Guidelines and future direction
Bushra Abdul hadi Epidemiology Pathophysiology Current Guidelines Evidence Agent Selection Administration Complications Applications For our purposes Gastrointestinal ulcerations of the upper alimentary tract Stomach Duodenum Ileum Jejunum Macroscopic bleeding ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis, AJHP 1999;56(4) 347-379 Up through the 1970 stress ulcers were much more common (30% of ICU patients) Today, less than 5% of ICU patients have stress ulcers with macroscopic bleeding ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis, AJHP 1999;56(4) 347-379 Del Valle, J. Chapter 287 - Peptic Ulcer Disease and Related Disorders , Harrisons Principles of Internal Medicine - 17th Ed. (2008). Etiology is complex Decreased Gastric pH Ischemia Decreased mucous production Usually occur within 24-48 hours of trauma/stress Gastric pH is a factor and a surrogate marker, not the root cause of stress ulcers Del Valle, J. Chapter 287 - Peptic Ulcer Disease and Related Disorders , Harrisons Principles of Internal Medicine - 17th Ed. (2008). Cook and collegues conducted a large (n=2252) multicenter prospective trial evaluating the risk factors of significant bleeding Mortality for patients with a significant bleed 48.5% with significant bleeding 9.1% without significant bleeding Cook DJ, et al. Risk factors for gastrointestinal bleeding in critically ill patients. NEJM 1994;330(6):377-81 Two independent factors for a clinically significant bleed: Respiratory failure (OR=15.6) Coagulopathy (OR=4.3) Incidence of significant bleeds With one or both risk factors 3.7% Without either risk factor 0.1% Number need to treat for significant bleeding Without risk factors = 900 With risk factors = 30 Cook DJ, et al. Risk factors for gastrointestinal bleeding in critically ill patients. NEJM 1994;330(6):377-81 ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis Coagulopathy platelet count of 50,000mm3 INR1.5 PTT of 2 times the control Mechanical Ventilation Longe
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