ICU · gi-nutrition

Stress Ulcer Prophylaxis (SUP) — Comprehensive ICU Management

Also known as Stress ulcer prophylaxis · SUP · Stress-related mucosal disease · SRMD · Stress ulceration · PPI prophylaxis · SUP-ICU trial · REVISE trial

Stress ulcer prophylaxis (SUP) — prevention of stress-related mucosal disease (SRMD) in critically ill patients. Upper GI mucosal lesions are found in 75-100% of ICU patients on endoscopy, but clinically significant bleeding occurs in only 1-6%, carrying an estimated 40-50% mortality when it happens. 2024 SCCM/ASHP guideline: factors that likely increase bleeding risk are coagulopathy, shock, and chronic liver disease; there is no firm evidence for mechanical ventilation alone as a risk factor; enteral nutrition probably reduces risk; give a PPI or H2RA at low dosage to patients WITH a risk factor; discontinue when the risk factor resolves or before ICU transfer. Classic risk-factor teaching (mechanical ventilation >48h plus coagulopathy) comes from earlier cohort data and still anchors exams. Trials: SUP-ICU (pantoprazole 40 mg IV daily, 3298 patients) reduced clinically important bleeding 2.5% vs 4.2% without changing 90-day mortality (31.1% vs 30.4%); REVISE (4821 ventilated patients) confirmed bleeding reduction 1.0% vs 3.5% (HR 0.30) with no significant mortality difference. PPIs beat H2RAs for bleeding prophylaxis (meta-analysis OR 0.30); H2RAs develop tolerance (tachyphylaxis within 42h of prolonged IV dosing). Ranitidine recalled worldwide for nitrosamine (NDMA) impurities — do NOT use; famotidine (20 mg IV q12h or 1.7 mg/h infusion) or a PPI instead. With clopidogrel avoid omeprazole/esomeprazole; pantoprazole does not reduce clopidogrel's antiplatelet effect. Review the indication DAILY and stop when it resolves.

Checked against its sources on 2 Sept 2026