Supportive and Preventive Medicine

Patient Case

A 68-year-old man (weight 85 kg) is admitted to the ICU for the management of severe hypoxemic respira-

tory failure associated with community-acquired pneumonia. He is endotracheally intubated and placed on

mechanical ventilation. His medical history consists of Child-Pugh class B cirrhosis secondary to alcohol

abuse, heart failure, and myocardial infarction. His laboratory values show white blood cell count (WBC)

15 x 103 cells/mm3, Plt 150,000/mm3, BUN 15 mg/dL, SCr 1.1 mg/dL, K 4.5 mEq/L, glucose 210 mg/dL,

international normalized ratio (INR) 1.0, aspartate aminotransferase (AST) 58 IU/mL, and alanine amino-

transferase (ALT) 49 IU/mL. His current medications include azithromycin 500 mg intravenously daily,

ceftriaxone 1 g intravenously daily, vancomycin 1250 mg intravenously every 12 hours, heparin 5000 units

subcutaneously every 8 hours, fentanyl drip at 50 mcg/hour titrated to a Critical-Care Pain Observation

Tool (CPOT) score less than 2, midazolam drip at 1 mg/hour titrated to a Richmond Agitation-Sedation

Scale (RASS) of 0 to -1, and a regular insulin drip at 1.5 units/hour titrated to maintain blood glucose at

140–180 mg/dL. Currently, on day 3 of his ICU stay, the patient’s head is 30 degrees above the bed, his

RASS is documented as -4, he is on minimal ventilator settings, and an NGT is placed. As the clinical

pharmacist rounding on this patient, you go through the FAST-HUG mnemonic. Which are the best recom-

mendations for the team?

tion the insulin drip to sliding scale.

Early studies demonstrated endoscopic evidence of superficial mucosal damage in 75%–100% of

patients within 1–2 days after ICU admission.

Few current evaluations are available

Asymptomatic ulceration is likely clinically insignificant (Acta Anaesthesiol Scand 2017;61:216-23;

Stress ulcers and peptic ulcers are differentiated in Table 2

Several superficial erosive lesions occurring early in the course of critical illness, potentially progressing

to deep ulcers

intervention, as the patient’s clinical status improves.