Contents

1. 1 GI stress ulcer prophylaxis
2. 2 VTE Prophlaxis
3. 3 CLABSI
4. 4 CAUTI
5. 5 References

GI stress ulcer prophylaxis

• Prospective studies have demonstrated similar rates of GI hemorrhage in adults and children in the intensive care unit (up to 10%) (Chaibou, Pediatrics 1998)
• Risk factors include respiratory failure, coagulopathy PRISM >10, circulatory shock, multitrauma, or recent prolonged surgery
• Others have demonstrated mechanical ventilation as a risk factor after multivariate analysis
• Sucralfate, H2 receptor antagonists, and PPIs have all shown efficacy in pediatric patients
• Sucralfate was shown to be less effective in adult patients (Cook et al, NEJM 1998)
• Generally, H2 receptor antagonists used as first line agent
• Potential adverse events incude: thrombocytopenia, drug interactions, and CNS impairment in the presence of renal injury
• PPI's used as a second line agent
• Potential adverse events include larger association with ventilator associated pneumonia and C difficile. Cost is also a factor
• A large randomized adult trial of 3298 patients showed no benefit of using pantoprazole vs. placebo in critically ill adults (primary outcome of death at 90 days- 31.1% in intervention group and 30.4% in placebo group p=0.76) (Krag et al, NEJM 2018)

• Bottom line: Patients on mechanical ventilation, with ARDS, ALI, septic shock, coagulopathy, high dose steroids, or critically ill with high PRISM score may benefit from being placed on stress ulcer prophylaxis, using H2 receptor antagonists (ie famotidine) as a first line with the addition of PPI's if gastric pH <4 or if there are contradindications to H2 blocker use. That being said, there is limited data to support this practice.  

VTE Prophlaxis

Guidelines from CHOP, Raffini et al, Pediatrics 2011. 

• Catheters (particularly CVL's and PICC lines) are the leading cause of VTE in hospitalized children
• At risk population for non-catheter related VTE are those 14y old or greater
• Major risk factors include impaired mobility, spinal cord injury, major trauma or recent operation to the lower extremities, acute infections, burns, pregnancy, obesity, oral contraceptives, inflammatory bowel disease, nephrotic syndrome, known congenital or acquired thrombophilia, or history of DVT/PE. 
• Generally in those 14-21 years of age, if they are immobile or have risk factors, pneumatic compression devices (SCD's) should be used. Strong consideration for prophylactic anticoagulation should be made for those with several risk factors
• However, in adult critically ill patients, Arabi et al found in an RCT of 2003 patients that adding SCD's to pharmacologic prophylaxis did not change the incidence of VTE's (RR 0.6-1.44, p=0.74) nor did it affect all-cause mortality. 

Figure 1: CHOP Algorithm for Pediatric VTE Prophylaxis

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CLABSI