Sample Protocol

Stress Ulcer Prophylaxis Protocol

Background: Stress ulceration can occur in critically ill patients due to mucosal ischemia, decreased gastric pH, impaired mucosal barrier, and reperfusion injury. Patients at highest risk include those with traumatic brain injury, spinal cord injury, severe burns, coagulopathy, and mechanically ventilated patients. Stress ulcer prophylaxis has been shown to reduce clinically significant bleeding in high risk populations.

Indications for Stress Ulcer Prophylaxis:

High Risk (Use prophylaxis):

• Traumatic brain injury with GCS <8
• Spinal cord injury
• Major burns >20% TBSA
• Mechanical ventilation >48 hours
• Coagulopathy with INR>1.5 or platelets <50K
• History of GI bleed

Moderate Risk (Consider prophylaxis with 2+ risk factors):

• Sepsis
• High dose steroids (>250mg hydrocortisone)
• Therapeutic anticoagulation
• Chronic NSAID use
• Renal insufficiency (CrCl <50)

Low Risk (Do not use prophylaxis):

• Hemodynamically stable
• Tolerating enteral nutrition
• No risk factors above

First Line Prophylaxis:

• Oral/Enteral: Pantoprazole 40mg PO/tube daily
• IV: Pantoprazole 40mg IV daily

Alternative First Line:

• Oral/Enteral: Famotidine 20mg PO/tube q12h (if CrCl <50 then 20mg q24h)
• IV: Famotidine 20mg IV q12h (if CrCl <50 then 20mg q24h)

Second Line Prophylaxis:

• Pantoprazole 40mg IV daily

Discontinuation of Prophylaxis:

• Resolution of major risk factor(s)
• Tolerating enteral nutrition
• Hemodynamically stable

Monitoring:

• Daily review for ongoing need for stress ulcer prophylaxis
• Monitor for GI bleeding