Yoğun Bakım Ünitesinde Stres Ülseri: Tanı ve Profilaksi
Özet
Yoğun bakım ünitesinde yatan kritik hastalarda strese bağlı üst gastrointestinal sistem kanamalarını önlemek amacıyla uygulanan stres ülseri profilaksisi (SÜP), günümüzde yan etkileri ve kar-zarar oranları nedeniyle tartışılmaktadır. Stresle ilişkili mukoza hasarının patogenezinde artan gastrik asit sekresyonu, mukozal iskemi, sepsis, çoklu travma ve özellikle 48 saatten uzun süren mekanik ventilasyon gibi risk faktörleri rol oynar. Asemptomatik seyredebilen bu lezyonlar, bazen hayati önem taşıyan klinik kanamalara dönüşebilir. Profilakside kullanılan antiasitlerin sık kullanım zorunluluğu gibi dezavantajları bulunurken, histamin-2 reseptör antagonistlerinde (H2RA) hızlı taşifilaksi gelişebilir; proton pompa inhibitörleri (PPİ) ise tolerans gelişmemesi avantajıyla öne çıkar. Yapılan araştırmalar ve meta-analizler, PPİ ile H2RA tedavileri arasında gastrointestinal kanama, ventilatör ilişkili pnömoni (VİP) gelişimi veya mortalite açısından klinik olarak anlamlı bir fark olmadığını göstermektedir. Ayrıca bu ilaçların VİP ve Clostridium difficile enfeksiyon riskini artırabileceğine dair endişeler bulunmaktadır. Bu nedenle, gastrointestinal kanama riski düşük olan ve 48 saatten az ventile edilen kritik durumdaki hastalarda rutin profilaksi yerine vaka bazlı değerlendirme yapılması ve risk ortadan kalktığında tedavinin derhal sonlandırılması önerilmektedir.
Stress ulcer prophylaxis (SUP), widely administered to prevent stress-induced upper gastrointestinal bleeding in critically ill patients in the intensive care unit, is currently debated due to its side effects and risk-benefit ratios. In the pathogenesis of stress-related mucosal damage, factors such as increased gastric acid secretion, mucosal ischemia, sepsis, multiple trauma, and particularly mechanical ventilation lasting longer than 48 hours play a critical role. These lesions, which can progress asymptomatically, may sometimes turn into clinically significant bleedings. While antacids used in prophylaxis have disadvantages like frequent dosing, histamine-2 receptor antagonists (H2RAs) can rapidly develop tachyphylaxis; on the other hand, proton pump inhibitors (PPIs) stand out due to the absence of tolerance development. Research and meta-analyses show no clinically significant difference between PPI and H2RA treatments in terms of gastrointestinal bleeding, ventilator-associated pneumonia (VAP) development, or mortality. Furthermore, there are concerns that these suppressive drugs might increase the risk of VAP and Clostridium difficile infection. Therefore, rather than routine prophylaxis, case-by-case evaluation is recommended for critically ill patients with low bleeding risks and those ventilated for less than 48 hours, and the treatment must be discontinued immediately once the risk is resolved.
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