P79 What’s SUP – Stress Ulcer Prophylaxis in intensive care units, are we overprescribing?

<h3>Introduction</h3> Stress-related mucosal disease (SRMD) refers to stress-related response of the gastric mucosa ranging from single lesions to multiple ulcers that occur secondary to haemodynamic changes and inflammatory signals in critical illness.¹ This is increased in patients with risk factors including respiratory failure, coagulopathy, hypotension, sepsis, hepatic failure, renal failure, surgery, burns, and major trauma.² Thus, most patients admitted in the ICU are prescribed stress ulcer prophylaxis(SUP).³ However, there have been increasing concerns related to the adverse effects of SUP such as nosocomial pneumonia and Clostridium difficile infection.⁴ This, together with multicentre studies on cost-benefit analyses, have prompted strict guidelines for initiation and discontinuation of SUP⁵ Despite these guidelines, patients who do not meet the criteria are often initiated on SUP and are continued on it beyond the timeframe recommended. With this background I undertook a quality improvement project (QIP) to assess prescription of SUP. <h3>Methods</h3> As per guidelines, SUP in the ICU should be initiated in patients who are on invasive mechanical ventilation, within 48 hours of intubation if they are not on nasogastric feeds; or if on nasogastric feeds but have coagulopathy, on anticoagulation/steroids, have acute kidney injury (AKI)/sepsis/multiple organ dysfunction syndrome (MODS) or had a previous gastrointestinal bleed. SUP should be discontinued when these risk factors no longer exist unless an additional indication for use.⁵ The QIP was registered and over a period of 3 weeks, data was audited from 30 patients who were admitted in our 10-bedded ICU. Following this, posters detailing SUP prescription guidelines were put up. An email will also be shortly released. PDSA cycle 2 aims to review compliance post these measures. <h3>Results</h3> Out of 30 patients, 19(63.3%) met the criteria for SUP initiation and SUP was initiated. SUP was also initiated for 2 patients who did not meet the criteria. In terms of discontinuation, SUP was continued for 12 patients (40%) for whom SUP should have been discontinued when they no longer possessed the risk factors, 2 patients required SUP to be continued and 3 patients died in ICU. <h3>Conclusion</h3> Initiation of SUP seems to be prompt among most clinicians. However, despite known adverse effects and well-established guidelines, SUP is often continued beyond recommended timeframe. Serial education measures are needed to ensure better compliance to guidelines. Results from the next PDSA cycle will provide useful information. Further cycles to address the barriers to compliance have been planned. <h3>References</h3> Stollman N, Metz DC. Pathophysiology and prophylaxis of stress ulcer in intensive care unit patients. <i>J Crit Care</i>. 2005;<b>20</b>(1):35–45. Cook DJ, Fuller HD, Guyatt GH, Marshall JC, Leasa D, Hall R,<i> et al</i>. Risk factors for gastrointestinal bleeding in critically ill patients. Canadian critical care trials group. <i>N Engl J Med</i>. 1994;<b>330</b>(6):377–8. Saeed M, Bass S, Chaisson NF. Which ICU patients need stress ulcer prophylaxis? <i>Cleve Clin J Med</i>. 2022;<b>89</b>(7):363–7. MacLaren R, Reynolds PM, Allen RR. Histamine-2 receptor antagonists vs proton pump inhibitors on gastrointestinal tract hemorrhage and infectious complications in the intensive care unit. <i>JAMA Intern Med</i>. 2014;<b>174</b>(4):564–74. Ye Z, Reintam Blaser A, Lytvyn L, Wang Y, Guyatt GH, Mikita JS,<i> et al</i>. Gastrointestinal bleeding prophylaxis for critically ill patients: a clinical practice guideline. <i>BMJ</i>. 2020;<b>368</b>:l6722.