Question 1

College answer

Not available.

Discussion

This SAQ is very similar to Question 11 from the first paper of 2020, and the answer from 2020 is mostly reproduced below, with only a couple of changes to adjust to the fact that now the marking criteria and the expected structure are much better explained

Rationale:

• Gastrointestinal bleeding in the critically ill patient may be due to a variety of causes; these include bleeding from stress ulceration, oesophageal varices, and colonic polyps.
• ICU patients are also more susceptible to GI bleeding because they often have concomitant coagulopathy, are under the effect of antiplatelet agents, or have poor splanchnic perfusion due to the effects of shock 
• Given that in the ICU GI bleeding is combined with a series of other major organ dysfunction syndromes, it tends to have a catastrophic mortality rate
• Blood transfusion or gastroscopy are not without their risks

Disadvantages:

• Decreased gastric acidity, thus increased risk of non-sterile aspiration
• Increased risk of gastrointestinal bacterial overgrowth and translocation
• Increased risk of Clostridium difficile infections
• Economic disadvantage (cost)
• Side effects of the anti-ulcer agents (including drug interactions)

Evidence:

• A recent meta-analysis suggests that the quality and quantity of the evidence is still poor, but on the weight of the available evidence there is neither a mortality improvement nor any increase in the risk of nosocomial pneumonia.
• There appears to be no benefit for stress ulcer prophylaxis in patients who are tolerating enteral feeding, and in these patients stress ulcer prophylaxis is not needed.
• There is insufficient evidence to recommend the mandatory use of stress ulcer prophylaxis in any specific patient group 
• SUP-ICU (Krag et al, 2018): no mortality benefit; small reduction in the already low rate of clinically significant UGI bleeding events (even in the control group, the risk of bleeding was only 4.4%).
• PEPTIC (2020) suggested that H2 receptor antagonists were better than PPI, but the mortality benefit was only 0.8%.

My clinical practice:

• I use PPIs as routine stress ulcer prophylaxis for patients who are severely shocked, who are not tolerating enteral nutrition, or whose gastric mucosa is compromised in some other way (eg. high dose steroids) (though one might expect that pretty much anything not immediately insane would have been appropriate in this last section). 
• I rely more on early extubation and early enteral feeding to prevent gastric ulceration