A step-wise protocol for stress ulcer prophylaxis in the neurosurgical intensive care unit

BACKGROUND: Neurosurgical patients are at risk for stress induced gastric erosion. Clinical criteria for monitoring stress ulcer prophylaxis (SUP) efficacy and predicting clinical bleeding are limited. SUP in the 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 300 mg IV every 6 hours, or continuous infusion up to 2400 mg/day) in 136 evaluable cases. Combination therapy was implemented if continued gastric pH < 4 and guaiac positive aspirates occurred (N = 45). RESULTS: Significant correlations were observed between low gastric pH values and both GCS < 8 (P ≤ 0.01) and length of ventilatory support (P ≤ 0.005). Single agent therapy was more effective in patients with GCS ≤ 8 (P ≤ 0.001). Endoscopy was performed in 25 patients. No patient with GCS < 8 had pathologic lesions. The presence of asymptomatic gastrointestinal lesions was higher in patients requiring longer ventilatory support (P ≤ 0.001) and intensive care unit stay (P ≤ 0.0001). Patients requiring pentobarbital and vasopressors had statistically higher rates of clinical bleeding (P < 0.05). Patients with GCS < 8 had increased rates of pneumonia (P ≤ 0.005) with a higher pneumonia rate when treated with combination therapy (P ≤ 0.05). Overall, the incidence of clinical bleeding was 3.7%. CONCLUSIONS: This protocol was effective for prospective monitoring of SUP efficacy and limited multiple drug therapy to patients at risk for clinical bleeding.