Stress-related gastric mucosal
bleeding occurs in a substantial number of
critically ill patients, with clinically important gastrointestinal
bleeding prolonging
intensive care stay and increasing mortality. This paper reviews the role of
proton-pump inhibitors in the prevention of stress-related mucosal
bleeding.
Bleeding prophylaxis appears to be warranted in patients in intensive care units on
mechanical ventilation or those who have coagulopathy. Intravenous
histamine H2 receptor antagonists, particularly
cimetidine, have demonstrated efficacy for the prevention of
bleeding in
critically ill patients. Standard delayed-release
proton-pump inhibitors have not been extensively studied in this patient group, but there are some data to support their efficacy in increasing intragastric pH, and in the case of intravenous
pantoprazole in preventing gastrointestinal
bleeding. In a large, randomized controlled trial, immediate-release
omeprazole [(IR-OME)
Zegerid powder for oral
suspension; Santarus Inc., San Diego, CA, USA] administered via gastric tube, was as effective as intravenous
cimetidine in the prevention of clinically significant
bleeding, and more effective in increasing gastric pH. Effective antisecretory
therapy does not appear to increase the risk of
nosocomial pneumonia. In conclusion, immediate-release
omeprazole provides a safe and effective alternative to intravenous
cimetidine for the prevention of stress-related mucosal
bleeding in
critically ill patients.