Critical Care Medicine-Gastrointestinal, Nutrition and Genitourinary Disorders>>>>>Stomach
Question 2#

A 25-year-old man is the unrestrained driver in a head-on motor vehicle collision. He arrives with a Glasgow Coma Score of 5 and is intubated in the trauma bay. CT head demonstrates skull fractures with subdural and subarachnoid hemorrhage requiring craniotomy. Postoperatively he is admitted to the ICU intubated and sedated. On postoperative day 6 his nurse notices that his orogastric tube aspirate has become red-brown with coffee-ground appearance.

What is the BEST way to avoid this complication?

A. Avoid prophylactic heparin
B. Avoid gastric tube placement
C. Administer an H2 blocker or proton pump inhibitor
D. Administer Helicobacter pylori treatment
E. Avoid enteral nutrition

Correct Answer is C

Comment:

Correct Answer: C

This patient is critically ill with traumatic brain injury and has been intubated for over 48 hours. Greater than 40% of mechanically ventilated patients may develop evidence of GI bleeding. Traumatic brain or spinal cord injury has also been associated with stress ulcer development. Stress ulcers are generally attributed to an imbalance in mucosal protection and gastric acid production. There is not clear evidence for superiority of histamine H2-receptor antagonists versus proton pump inhibitors for stress ulcer prophylaxis and either may be used. The use of prophylactic heparin is not associated with an increased risk of upper GI bleeding. Critically ill intubated patients frequently require gastric decompression and/or enteral feeding access, and orogastric tube is a reasonable choice. Early enteral feeding is protective against stress ulcer development, and in addition provides nutritional support necessary in critically ill patients, and should not be withheld. Although H. pylori may contribute to stress ulcer development, there is nothing to suggest that this patient has a peptic ulcer related to H. pylori infection, and he should not be treated prophylactically. 

References:

  1. Cook DJ, Fuller HD, Guyatt GH, et al. Risk factors for gastrointestinal bleeding in critically ill patients. N Engl J Med. 1994;330:377-381.
  2. Chu Y, Jiang Y, Meng M, et al. Incidence and risk factors of gastrointestinal bleeding in mechanically ventilated patients. World J Emerg Med. 2010;1(1):32-36.
  3. Toews I, George AT, Peter JV, et al. Interventions for preventing upper gastrointestinal bleeding in people admitted to intensive care units. Cochrane Database Syst Rev. 2018;6:CD008687.
  4. Maury E, Tankovic J, Ebel A, Offenstadt G. An observational study of upper gastrointestinal bleeding in intensive care units: is Helicobacter pylori the culprit? Crit Care Med. 2005;33(7):1513-1518.