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Stress Ulcer Prophylaxis Protocol

Division of Acute Care Surgery
Updated August 2024

1. Background

Critically ill patients are at increased risk for gastrointestinal (GI) bleeding, primarily due to gastric or duodenal ulceration.
- Overt bleeding risk: ~4.4%
- Clinically significant bleeding: ~1.5%
- Risk increases with Injury Severity Score (ISS) >15 in trauma patients

Definitive Indications for Prophylaxis:

  1. Traumatic Brain Injury (TBI)
  2. Major Burn Injury
  3. Mechanical Ventilation >48 hours
  4. Coagulopathy
  5. INR > 1.5
  6. Platelets < 50,000

Other Risk Factors:

  • Alcohol use disorder
  • Acute hepatic failure
  • Sepsis
  • Acute renal failure
  • Trauma
  • Chronic NSAID use
  • High-dose steroids

Both H2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs) are acceptable agents for prophylaxis.
- No conclusive evidence favoring one class over the other
- Enteral Nutrition (EN) provides mucosal protection and should be initiated early when feasible

2. Indications for Prophylaxis

A. High Risk — Prophylaxis indicated for all patients

  • Mechanical ventilation >48 hours
  • Coagulopathy
  • Traumatic brain injury
  • Spinal cord injury
  • Significant burn injury (>20% TBSA)
  • History of prior GI hemorrhage

B. Moderate Risk — Consider prophylaxis if ≥2 present

  • Chronic NSAID or aspirin use
  • High-dose NSAID therapy
  • Ibuprofen >1200 mg/day
  • Naproxen >1000 mg/day
  • Any scheduled ketorolac regimen
  • Sepsis
  • Vasopressor or inotrope requirement
  • Corticosteroids ≥ 250 mg/day hydrocortisone equivalent
  • New gastroduodenal or gastrojejunal anastomosis

C. Low Risk or Tolerating PO Intake — No prophylaxis needed

  • Discontinue prophylaxis if previously initiated

3. Prophylaxis Algorithm

A. Trauma Critical Illness

Condition Duration of Prophylaxis
TBI, SCI, Burn Continue for entire ICU stay
Intubation >48h or Coagulopathy Discontinue when EN goal met (unless additional moderate risk factors persist)

4. Medication Management

First-Line Agent:

  • Famotidine 20 mg PO/PT/IV q12h
  • If CrCl < 50 mL/min → dose q24h

Suspected or Confirmed Upper GI Bleed:

  • If enteral access available:
  • Omeprazole 40 mg PO/PT q12h (oral suspension for DHT)
  • If no enteral access:
  • Pantoprazole 40 mg IV q12h

5. Special Situations

Continuation/Initiation for High-Risk NSAID Use:

  • High-dose NSAIDs plus one or more of the following:
  • Anticoagulation
  • Aspirin
  • Corticosteroids
  • Peptic ulcer disease
  • History of H. pylori infection
  • GI anastomosis

  • Spinal cord injury

  • Consider switching to celecoxib 100–200 mg BID if patient can tolerate oral capsules

Home PPI Use:

  • Resume home PPI if patient was taking one prior to admission

6. References

  1. Cook DJ et al. Risk factors for gastrointestinal bleeding in critically ill patients. N Engl J Med. 1994; 330(6):377–381.
  2. Cook DJ et al. Sucralfate vs. ranitidine for GI bleeding in ventilated patients. N Engl J Med. 1998; 338(12):791–797.
  3. Hurt RT et al. Stress prophylaxis and enteral nutrition. JPEN. 2012; 36(6):721–731.
  4. Guillamondegui OD et al. EAST Guidelines for Stress Ulcer Prophylaxis. 2008. EAST.org
  5. Marik PE et al. Stress ulcer prophylaxis review. Crit Care Med. 2010; 38:2222–2228.
  6. Lin PC et al. PPI vs. H2RA meta-analysis. Crit Care Med. 2010; 38:1197–1205.
  7. Alhazzani W et al. PPI vs. H2RA in critically ill. Crit Care Med. 2013; 41:693–705.
  8. Liu Y et al. Prophylaxis in non-ICU patients: network meta-analysis. Clin Ther. 2020; 42(3):488–498.
  9. Marker M et al. Pantoprazole in ICU GI bleeding. N Engl J Med. 2018; 379(2):199–208.
  10. Gwee KA et al. Co-prescribing PPIs with NSAIDs. J Pain Res. 2018; 11:361–374.

7. Authors

  • Bradley Dennis, MD
  • Jill Streams, MD
  • Leanne Atchison, PharmD
  • Jennifer Beavers, PharmD