A 34-year-old previously healthy man was admitted to the intensive care unit after a motor vehicle collision 3 days ago in which he was the unrestrained driver. The patient sustained traumatic brain injury and blunt chest trauma, which are being managed nonoperatively. He has had episodes of hypotension, which improved after fluid resuscitation and packed red blood cell transfusion. He is mechanically ventilated and is receiving enteral feeding via the nasogastric tube. Today, the patient is noted to have black liquid stool that is heme-positive. He has had no fever or high gastric residuals. The abdomen is nondistended and soft with normal bowel sounds. Laboratory results are as follows: Which of the following would have been most effective at preventing this patient's current condition?

Question

A 34-year-old previously healthy man was admitted to the intensive care unit after a motor vehicle collision 3 days ago in which he was the unrestrained driver.  The patient sustained traumatic brain injury and blunt chest trauma, which are being managed nonoperatively.  He has had episodes of hypotension, which improved after fluid resuscitation and packed red blood cell transfusion.  He is mechanically ventilated and is receiving enteral feeding via the nasogastric tube.  Today, the patient is noted to have black liquid stool that is heme-positive.  He has had no fever or high gastric residuals.  The abdomen is nondistended and soft with normal bowel sounds.  Laboratory results are as follows:  Which of the following would have been most effective at preventing this patient's current condition?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c157_0a90_8f63_e9e133fd03e9_MD0005_00 This mechanically ventilated patient with recent head trauma has developed an upper gastrointestinal (GI) bleed, as evidenced by the melenic bowel movements and anemia. This is most likely from gastric or esophageal stress ulcers. Critically ill patients may have uremic toxins and reflux of bile salts into the stomach; both can disrupt the protective glycoprotein layer, which can lead to increased permeability of the gastric mucosa, predisposing to ulcer formation. Head trauma causes increased gastrin secretion, leading to parietal cell stimulation and acid secretion. Shock is associated with mucosal ischemia leading to ulcerations. Most of these ulcerations occur within the first 72 hours and tend to be located in the proximal stomach. Ulcerations occurring later in the hospital course tend to be located in the duodenum. Proton pump inhibitors (PPIs) as well as H₂ antagonists are used to increase the pH in the stomach by lowering gastric acid formation, which prevents the gastric injury associated with ulcer formation. PPI may have increased efficacy in acid suppression. Both PPIs and H₂ antagonists may be associated with increased risk of Clostridium difficile infection (CDI) and pneumonia. (Choice A) The addition of probiotics is sometimes used to prevent CDI; however, efficacy remains controversial. This treatment would not decrease risk of ulcer formation. CDI would cause leukocytosis and diarrhea, not melena. (Choice B) Avoidance of hypotensive episodes is beneficial in preventing end-organ damage, including gastric mucosal ischemia and ischemic colitis. However, ischemic colitis causes lower GI bleed with hematochezia, not melenic stools. In this intubated patient with multiple risk factors, stress ulcers would likely form despite normotension. (Choice C) Enteral feeding introduces higher pH tube feeds into the acidic environment of the stomach and may be protective from ulcer formation and bleeding. In critically ill patients, early initiation (eg, within 72 hours of ICU admission) is also associated with lower risk of infection. (Choice E) Fresh frozen plasma (FFP) is used to correct coagulopathies due to vitamin K antagonists or deficiencies and is generally not indicated unless INR >2.0. This patient's INR is 1.5 and is unlikely to improve with infusion of FFP. Educational objective: Prophylaxis for stress ulcers is recommended for intensive care unit (ICU) patients with coagulopathy, gastrointestinal (GI) bleeding in the last year, mechanical ventilation >48 hours, head trauma, spinal cord injury, or major burns; or for patients with 2 of the following: sepsis, ICU stay >1 week, occult GI bleeding >6 days, or glucocorticoid therapy. Proton pump inhibitors (PPI) or H₂ blockers may be used to decrease risk of stress ulcer formation, but PPIs may have increased efficacy. References: A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation. Canadian Critical Care Trials Group. (http://www.ncbi.nlm.nih.gov/pubmed/9504939) Proton pump inhibitors versus histamine 2 receptor antagonists for stress ulcer prophylaxis in critically ill patients: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/23318494)

A 34-Year-Old Previously Healthy Man Was Admitted to the Intensive