Applying peptic ulcer disease prophylaxis is an appropriate intervention in all patients who are sedentary, however the higher incidence of stress ulceration in critical illness justifies greater vigilance. In addition, decreasing the pH of gastric contents may protect against a greater pulmonary inflammatory response to aspiration of gastrointestinal contents.
Aspiration causes either pneumonitis or pneumonia and can be prevented. The effects of aspirating acidic contents may be worse than those with a higher pH. Although some studies have shown increased risks of VAP with certain agents, such a sucralfate, others have not shown this association. In addition, the extent to which reflux of gastric contents and secretions occurs even in healthy individuals suggests that these critically-ill patients are susceptible to aspiration events. Critically-ill intubated patients lack the ability to defend their airway.
The Surviving Sepsis Campaign Guidelines were produced after a thorough review of the literature including peptic ulcer disease prophylaxis. They conclude, “H2 receptor inhibitors are more efficacious than sucralfate and are the preferred agents. Proton pump inhibitors have not been assessed in a direct comparison with H2 receptor antagonists and, therefore, their relative efficacy is unknown. They do demonstrate equivalency in ability to increase gastric pH.” [1]
While it is unclear if there is any association with decreasing rates of ventilator acquired pneumonia, our experience is that when applied as a package of interventions for ventilator care, the rate of pneumonia decreases precipitously. The intervention remains excellent practice in the general care of ventilated patients.
References:
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Dellinger RP, Carlet JM, Masur H, et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med. Mar 2004;32(3):858-873.
