SUP in ICU

 Q: At what level of International Normalized Ratio (INR), it would be prudent to add stress ulcer prophylaxis (SUP) in ICU patients? (select one)

A) > 1.5

B) > 2.0

Answer: A

There is a long list of risk factors which cause stress induced gastrointestinal (GI) bleed in ICU patients. Coagulopathy is high on the list. SUP is advisable if platelet count is less than 50,000/m3, INR above 1.5, or a partial thromboplastin time (PTT) > 2 times the control. 

Other major risk factors (but not limited to) are: 

• Mechanical ventilation for more than 48 hours
• Septic shock 
• Renal failure (including CRRT)
• Liver failure
• History of peptic ulcer with H.Pylori -or history upper GI bleed
• ECMO
• Trauma
• Burns (mostly over 35% of TBSA)  
• Organ transplant
• Anti-platelet drugs or drugs prone to cause GI bleed like NSAIDs
• Steroids 

#ICU-Mx

#GI

References:

1. Cook DJ, Fuller HD, Guyatt GH, et al. Risk factors for gastrointestinal bleeding in critically ill patients. Canadian Critical Care Trials Group. N Engl J Med 1994; 330:377.

2. Ye Z & et.al - Gastrointestinal bleeding prophylaxis for critically ill patients: a clinical practice guideline. BMJ. 2020 Jan 6;368:l6722. doi: 10.1136/bmj.l6722. PMID: 31907223.

3. Quenot JP, Thiery N, Barbar S. When should stress ulcer prophylaxis be used in the ICU? Curr Opin Crit Care. 2009 Apr;15(2):139-43. doi: 10.1097/MCC.0b013e32832978e0. PMID: 19578324. 

4. PEPTIC Investigators for the Australian and New Zealand Intensive Care Society Clinical Trials Group, Alberta Health Services Critical Care Strategic Clinical Network, and the Irish Critical Care Trials Group, Young PJ & et. al - Effect of Stress Ulcer Prophylaxis With Proton Pump Inhibitors vs Histamine-2 Receptor Blockers on In-Hospital Mortality Among ICU Patients Receiving Invasive Mechanical Ventilation: The PEPTIC Randomized Clinical Trial. JAMA. 2020 Feb 18;323(7):616-626. doi: 10.1001/jama.2019.22190. PMID: 31950977; PMCID: PMC7029750.