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.