A 68-year-old man is brought to the emergency department with hypoxemic respiratory failure. He has had worsening shortness of breath associated with fevers and a cough productive of yellowish sputum for the past 2 days. The patient has a past medical history of stable angina, hypertension, severe chronic obstructive pulmonary disease, and peptic ulcer disease. His trachea is intubated and mechanical ventilation is initiated.
Which of the following is most likely to decrease the risk of stress ulcers associated with gastrointestinal bleeding in this patient?

Question

A 68-year-old man is brought to the emergency department with hypoxemic respiratory failure.  He has had worsening shortness of breath associated with fevers and a cough productive of yellowish sputum for the past 2 days.  The patient has a past medical history of stable angina, hypertension, severe chronic obstructive pulmonary disease, and peptic ulcer disease.  His trachea is intubated and mechanical ventilation is initiated.
Which of the following is most likely to decrease the risk of stress ulcers associated with gastrointestinal bleeding in this patient?

Quizplus · Accepted Answer

Stress ulcers can cause significant bleeding in approximately 1%-4% of critically ill patients, with mortality approaching 50%. They are often associated with hemodynamic instability, respiratory failure, and anemia warranting transfusion. Risk factors include coagulopathy, mechanical ventilation > 48 hours, prolonged ICU stay, traumatic spinal cord or brain injury, thermal injury, history of prior gastrointestinal bleeding, or high-dose corticosteroid use (Choice C). Patients having more than 1 risk factor require prophylaxis against stress ulcers. Recommended agents for prophylaxis include an oral proton pump inhibitor or intravenous H2 receptor blocker depending on the patient's ability to receive oral medications. However, these agents have been associated with a higher risk of nosocomial pneumonia and Clostridium difficile infection. Many observational studies have shown that early enteral feeding alone reduces the incidence of stress ulcers. Antisecretory therapy is more beneficial in high-risk patients and those not receiving enteral nutrition. It is unclear whether early enteral nutrition alone (compared to antisecretory therapy) is sufficient to prevent stress ulcers in high-risk patients. (Choices A, B & E) Vasopressors, antibiotics, and platelet transfusions may be used to treat critically ill patients with hemodynamic instability, possible infection, or bleeding. However, they have not been found to prevent stress-induced ulcers. Educational objective: Early enteral feeding is associated with a decreased incidence of stress ulcers in critically ill patients. Recommended agents for prophylaxis in high-risk individuals include an oral proton pump inhibitor or intravenous H2 receptor blocker depending on the patient's ability to receive oral medications. __________ References: Stress-induced ulcer bleeding in critically ill patients. (http://www.ncbi.nlm.nih.gov/pubmed/19446257) Stress ulcer prophylaxis in critically ill patients: review of the evidence. (http://www.ncbi.nlm.nih.gov/pubmed/22354363) Stress ulcer prophylaxis in the new millennium: a systematic review and meta-analysis (http://www.ncbi.nlm.nih.gov/pubmed/20711074)

A 68-Year-Old Man Is Brought to the Emergency Department with Hypoxemic