Supportive and Preventive Medicine
2017;45:486-552).
The 2020 clinical practice guideline for gastrointestinal bleeding prophylaxis for critically ill patients
recommended SUP with a gastrointestinal bleeding risk of at least 4% based on several well-studied
risk factors. The guidelines made a weak recommendation for PPIs over H2RAs, with both PPIs and
H2RAs as strongly preferred to sucralfate. (BMJ 2020;368:l6722).
guideline for the prevention of stress-related GI bleeding in critically ill adults suggests that
coagulopathy, shock, or chronic liver disease should be considered risk factors for clinically important
upper GI bleeds. These patients should receive SUP compared with no SUP using either PPIs or H2RAs
Patients with other risk factors (ie, critically ill but absence of coagulopathy, shock, or chronic liver
disease) may be considered at low risk of clinically important stress-related GI bleeding.
Contrary to past guidelines, mechanical ventilation alone is found not likely to be a risk factor and
does not necessitate SUP.
Patient Case
Questions 2–4 pertain to the following case.
A 45-year-old woman is admitted to the ICU for severe respiratory failure from community-acquired pneumo-
nia. She is endotracheally intubated and placed on mechanical ventilation. An NGT is placed to begin enteral
nutrition. Three days later, she is receiving norepinephrine and vasopressin infusions and appropriate antimicro-
bial agents. Her WBC is 20 x 103 cells/mm3, Plt 45,000/mm3, BUN 70 mg/dL, SCr 4.5 mg/dL (baseline 0.9 mg/
dL), K 4.5 mEq/L, INR 1.4, AST 30 IU/mL, and ALT 46 IU/mL.
Which would be most appropriate for preventing stress-related bleeding?
One week later, the patient’s respiratory status has greatly improved. She has been off sedation and vaso-
pressors for the past 4 days, working with physical therapy, and is now extubated. Her only medications
include ceftriaxone, heparin subcutaneously, and SUP. Her current laboratory values are as follows: WBC 6
x 103 cells/mm3, Plt 256,000/mm3, BUN 10 mg/dL, SCr 1.1 mg/dL, K 4.0 mEq/L, INR 0.8, AST 15 IU/mL,
and ALT 10 IU/mL. Which would be the most appropriate recommendation regarding this patient’s SUP
regimen?