Restraint urged before prescribing SUP to ICU patients

Jun 02, 2017

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Indiscriminate use of acid-suppressive therapy and stress ulcer prophylaxis (SUP) may unnecessarily raise risk of serious infections, according to article in Critical Care Nurse

– June 1, 2017 – Routine use of acid-suppressive therapy for all hospitalized patients, even all critically ill patients, is inappropriate and should be limited to patients who meet specific criteria, according to an article in Critical Care Nurse (CCN).

Patients who are critically ill are at increased risk of gastrointestinal (GI) ulceration and bleeding, which has led to standing orders to give stress ulcer prophylaxis (SUP) in an effort to preempt the condition. The therapy has become commonly prescribed for patients in intensive care units (ICUs), and the practice has migrated beyond the ICU to noncritically ill patients as well.

However, giving acid-suppressive therapy indiscriminately to hospitalized patients to reduce GI bleeding may also place these patients at a higher risk of pneumonia, Clostridium difficile infection and other infections.

"Prophylactic Acid-Suppressive Therapy in Hospitalized Adults: Indication, Benefits, and Infectious Complications," published in the journal’s June 2017 issue, examines the role of SUP in select patients and contrasts that with important infectious consequences of its indiscriminate use.

Co-authors Andrew Faust, Kelly Echevarria, Rebecca Attridge, Lyndsay Shepard and Marcos Restrepo represent several Texas hospitals, health systems and health science centers.

"Suppressing gastric acid is necessary in select critically ill patients to reduce GI bleeding, but doing so also affects its effectiveness as an antiseptic barrier," said Faust, a critical care clinical pharmacist at Texas Health Presbyterian Hospital Dallas. “Preventing GI bleeding through acid-suppressive therapy, especially proton pump inhibitors, may increase a patient’s risk for serious and potentially life-threatening infectious complications."

The authors conducted a thorough review of published research related to the risk of infections with the use of acid-suppressive therapy to support their recommendations for restraint.

They conclude that the minimal benefit of acid-suppressive therapy in critically ill patients who are at low risk of GI bleeding and patients not in ICUs is most likely far outweighed by the risk of infection.

The article provides risk-scoring flowcharts for patients who are critically ill, as well as patients who are not, to guide clinicians through indications for initiating acid-suppressive therapy and discontinuing medications.

In the authors’ institutions, critical care providers screen patients daily for risk factors related to GI bleeding and discuss SUP during multidisciplinary care rounds. The risk-scoring tool is integrated into an electronic medical record’s decision-support technology, which may assist in appropriate prescribing. They also opted to remove SUP from standard order sets and restrict its use in non-ICU settings, which may help curb widespread overuse.

One of the most common indications for SUP is mechanical ventilation for longer than 48 hours, and other major risk factors include traumatic brain injury, spinal cord injury and respiratory failure. Sepsis syndrome, history of alcohol abuse, surgery lasting longer than four hours, renal failure and other conditions are considered minor risk factors, since evidence of an independent association with GI bleeding is not as strong.

Once risk factors are no longer present or when the patient transfers out of the ICU, SUP should be reevaluated and discontinued in most patients.

As the American Association of Critical-Care Nurses bimonthly clinical practice journal for high-acuity, progressive and critical care nurses, CCN is a trusted source of information related to the bedside care of critically and acutely ill patients.

Access the article abstract and full-text PDF by visiting the CCN website at

About the National Teaching Institute & Critical Care Exposition: Established in 1974, AACN’s National Teaching Institute & Critical Care Exposition (NTI) represents the world’s largest educational conference and trade show for nurses who care for acutely and critically ill patients and their families. Bedside nurses, nurse educators, nurse managers, clinical nurse specialists and nurse practitioners attend NTI.

About the American Association of Critical-Care Nurses: Founded in 1969 and based in Aliso Viejo, California, the American Association of Critical-Care Nurses (AACN) is the largest specialty nursing organization in the world. AACN represents the interests of more than half a million acute and critical care nurses and has more than 200 chapters throughout the United States. The organization’s vision is to create a healthcare system driven by the needs of patients and their families in which acute and critical care nurses make their optimal contribution.

American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656-4109; 949-362-2000;;;