• Robert MacLaren, Joanna C Dionne, Anders Granholm, Waleed Alhazzani, Paul M Szumita, Keith Olsen, Jeffrey F Barletta, MøllerMorten HylanderMHDepartment of Intensive Care, Righospitalet, University of Copenhagen, Copenhagen, Denmark., Constantine J Karvellas, Paul Wischmeyer, Ashley DePriest, Victor Carlos, Debora Argetsinger, John J Carothers, Rosemary Lee, Lena Napolitano, Dan Perri, and Douglas F Naylor.
• Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO.
• Crit. Care Med. 2024 Aug 1; 52 (8): e421e430e421-e430.

RationaleCritically ill adults can develop stress-related mucosal damage from gastrointestinal hypoperfusion and reperfusion injury, predisposing them to clinically important stress-related upper gastrointestinal bleeding (UGIB).ObjectivesThe objective of this guideline was to develop evidence-based recommendations for the prevention of UGIB in adults in the ICU.DesignA multiprofessional panel of 18 international experts from dietetics, critical care medicine, nursing, and pharmacy, and two methodologists developed evidence-based recommendations in alignment with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Conflict-of-interest policies were strictly followed during all phases of guideline development including task force selection and voting.MethodsThe panel members identified and formulated 13 Population, Intervention, Comparison, and Outcome questions. We conducted a systematic review for each question to identify the best available evidence, statistically analyzed the evidence, and then assessed the certainty of the evidence using the GRADE approach. We used the evidence-to-decision framework to formulate the recommendations. Good practice statements were included to provide additional guidance.ResultsThe panel generated nine conditional recommendations and made four good practice statements. Factors that likely increase the risk for clinically important stress-related UGIB in critically ill adults include coagulopathy, shock, and chronic liver disease. There is no firm evidence for mechanical ventilation alone being a risk factor. Enteral nutrition probably reduces UGIB risk. All critically ill adults with factors that likely increase the risk for stress-related UGIB should receive either proton pump inhibitors or histamine-2 receptor antagonists, at low dosage regimens, to prevent UGIB. Prophylaxis should be discontinued when critical illness is no longer evident or the risk factor(s) is no longer present despite ongoing critical illness. Discontinuation of stress ulcer prophylaxis before transfer out of the ICU is necessary to prevent inappropriate prescribing.ConclusionsThe guideline panel achieved consensus regarding the recommendations for the prevention of stress-related UGIB. These recommendations are intended for consideration along with the patient's existing clinical status.Copyright © 2024 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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