A variety of prophylactic treatment strategies are effective in preventing upper gastrointestinal bleeding in critically ill pa-tients although there is no proof that prophylaxis decreases mortality. Antacids administered every 2 hours neutralize gas-tric acid but are inconvenient to use because of increased nurs-ing time and diarrhea. Sucralfate at a dose of 1 g every 6 hours is also effective but requires placement of a nasogastric tube. H2 receptor antagonists given as either a continuous infusion or by bolus injection every 12 hours in the case of more potent a-gents such as famotidine or ranitidine are safe, convenient, and should be titrated to an intragastric pH of greater than 4 to minimize the activity of pepsin. Studies now show that admin-istration of Ha receptor antagonists does not increase the risk of of pneumonia in these patients.

Studies suggest that routine prophylaxis is no longer indi-cated in all critically ill patients. Coagulopathy and respiratory failure requiring mechanical ventilation for 48 hours are clear risk factors for clinically significant bleeding in the intensive care unit. Other patients who need prophylaxis include those with central nervous system trauma, burns, organ transplanta-tion a history of peptic ulcer disease with or without bleeding, multiorgan failure, trauma, and major surgery.

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