A STEP-WISE PROTOCOL FOR STRESS-ULCER PROPHYLAXIS IN THE NEUROSURGICAL INTENSIVE-CARE UNIT

BACKGROUND Neurosurgical patients are at risk for stress induced gastr ic erosion. Clinical criteria for monitoring stress ulcer prophylaxis (SUP) efficacy and predicting clinical bleeding are limited. SUP in th e neurosurgical intensive care unit (NSICU) was evaluated utilizing a multidisciplinary quality assurance program with defined criteria for therapy. METHODS All patients admitted to the NSICU were managed using this protocol. Therapy was initiated with a single drug (cimetidine 3 00 mg IV every 6 hours, or continuous infusion up to 2400 mg/day) in 1 36 evaluable cases. Combination therapy was implemented if continued g astric pH < 4 and guaiac positive aspirates occurred (N = 45). RESULTS Significant correlations were observed between low gastric pH values and both GCS < 8 (P less than or equal to 0.01) and length of ventilat ory support (P less than or equal to 0.005). Single agent therapy was more effective in patients with GCS greater than or equal to 8 (P less than or equal to 0.001). Endoscopy was performed in 25 patients. No p atient with GCS < 8 had pathologic lesions. The presence of asymptomat ic gastrointestinal lesions was higher in patients requiring longer ve ntilatory support (P less than or equal to 0.001) and intensive care u nit stay (P less than or equal to 0.0001). Patients requiring pentobar bital and vasopressors had statistically higher rates of clinical blee ding (P < 0.05). Patients with GCS < 8 had increased rates of pneumoni a (P less than or equal to 0.005) with a higher pneumonia rate when tr eated with combination therapy (P less than or equal to 0.05). Overall , the incidence of clinical bleeding was 3.7%. CONCLUSIONS This protoc ol was effective for prospective monitoring of SUP efficacy and limite d multiple drug therapy to patients at risk for clinical bleeding. (C) 1996 by Elsevier Science Inc.