Gastroenterology, Liver, and Nutrition Therapies



Gastroenterology, Liver, and Nutrition Therapies














TABLE 7.1. Gastrointestinal Hemorrhage—Available Therapies































































Clinical Setting Suggested Therapy Dosage Comments
Acute Treatment
Acute upper GI hemorrhage Omeprazole 40 mg PO/NG q8–12h × 5 d Omeprazole is a sustained-release capsule that may be opened, but the contents must not be crushed before administration; the powder for oral suspension should be used in this setting
  Pantoprazole 40–80 mg IV bolus followed by 8 mg/h for 2–3 d  
  H2 antagonists or Vasopressin H2 antagonists: (see Table 7.4)  
    Vasopressin: 0.2–0.3 U/min IV, maximum 0.9 U/min Monitor ECG; use nitroglycerin prophylactically in patients at risk for cardiac ischemia
Acute variceal hemorrhage Octreotide 50–100 μg bolus, followed by continuous infusion at 50–100 μg/h for 24–48 h More effective in controlling bleeding than vasopressin with less side effects (e.g., headache, chest pain, abdominal pain)
  Vasopressin 0.2–0.3 U/min IV, maximum 0.9 U/min See acute upper GI hemorrhage
Acute lower GI hemorrhage Vasopressin 0.2–0.3 U/min IV, maximum 0.9 U/min See acute upper GI hemorrhage
Prophylaxis
Prophylaxis against stress gastritis H2 antagonists, Sucralfate, proton pump inhibitors, or antacids H2 antagonists: see Table 7.4
Sucralfate: 1–2 g PO/NG q4–6h
Lansoprazole 30 mg IV qd
Pantoprazole 40 mg IV qd
Esomeprazole 20 mg IV qd
Omeprazole 20 mg PO/NG qd		 H2 antagonists and antacids: titrate pH >4; may predispose to nosocomial pneumonia
Sucralfate: no effect on pH
Limited data supporting the use of proton pump inhibitors for stress ulcer prophylaxis
Omeprazole is a sustained-release capsule that may be opened but the contents must not be crushed before administration; the powder for oral suspension should be used in this setting
Prevention of recurrent upper GI hemorrhage H2 antagonists or antacids H2 antagonists: see Table 7.4
Antacids: 30 ml PO/NG q2h (or continuously at 0.5 ml/min)		 See stress gastritis
Prevention of recurrent variceal hemorrhage β-blockers Propranolol 10 mg PO qid Titrate to 25% reduction in resting heart rate
Consider sclerotherapy or surgery
ECG, electrocardiogram; GI, gastrointestinal; IV, intravenous; NG, nasogastric; PO, by mouth









TABLE 7.2. Hepatic Encephalopathy—Therapies
















Clinical Setting Dosage Comments
Acute hepatic encephalopathya Lactulose: 30–45 ml PO/NG q1h until laxative effect occurs, then 30–45 ml tid
Neomycin: 1.5–6 g/d PO/NG divided q6–8h		 Lactulose retention enema: 300 ml lactulose in 700 ml water or saline PR for 30–60 min q4–6h
Chronic hepatic encephalopathy Titrate dose to 2–3 soft stools/day  
PO, by mouth; PR, per rectum; NG, nasogastric
aElectrolyte correction, avoidance of sedatives and narcotics, and attention to volume status, nutrition, intracranial pressure, and infection are also indicated.









TABLE 7.3. Antacids

























































































Composition/Preparation Content per 15 ml      
Al+2 Mg+2 SMC Acid Neutralizing Content (mEq per ml) Sodium Content (mg per 15 ml) Dosage
Aluminum Hydroxide Plus Magnesium Hydroxidea,b
Maalox TC 1,800 900 0 5.44 2.40 5–10 ml qid
Maalox 675 600 0 2.66 4.20 10–20 ml qid
Aluminum Hydroxide Plus Magnesium Hydroxidea,b Plus Simethicone
Mylanta 600   60 2.54 2.04 10–20 ml 4–6 × d
Mylanta Double Strength 1,200 1,200 120 5.08 3.42 10–20 ml tid
Extra StrengthMaalox Plus 1,500 1,350 120 5.8   10–20 ml qid
Aluminum Hydroxidec,d
AlternaGel 1,800 0 0 3.2 7.50 15–30 ml 3–6 × d
Amphojel 960 0 0 2 6.90 10 ml 4–6 × d
Magaldrate (Aluminum and Magnesium Oxides)
Riopan
Pluse		 0 0 0 3 0.30 15–30 ml qid
SMC, simethicone
aMagnesium containing antacids may cause diarrhea.
bHypermagnesemia may occur in patients with renal failure who receive magnesium containing antacids.
cAluminum containing antacids may cause constipation.
dAluminum containing antacids may cause hypophosphatemia.
eContains the equivalent of 29% to 40% magnesium oxide and 18% to 26% aluminum oxide.










TABLE 7.4. Nonantacid Therapies for Gastritis















































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Jun 16, 2016 | Posted by in CRITICAL CARE | Comments Off on Gastroenterology, Liver, and Nutrition Therapies

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Therapy Usual Dosage Comments
H2 Antagonists
Cimetidine Intermittent: 300 mg IV q6–8h
Infusion: 37.5 mg/h
PO/NG: 300 mg q6h		 Adverse effects: altered mental status, thrombocytopenia, elevated liver enzymes, many drug interactions
Famotidine Intermittent: 20 mg IV q12h
Infusion: not applicable
PO/NG: 20 mg q12h		 Adverse effects: altered mental status, thrombocytopenia, elevated liver enzymes
Ranitidine Intermittent: 50 mg IV q6–8h
Infusion: 6.25 mg/h
PO/NG: 150 mg q12h		 Adverse effects: altered mental status, thrombocytopenia, elevated liver enzymes
Proton Pump Inhibitors
Esomeprazole PO/NG: 20–40 mg qd Enteric-coated granules in capsule form may be opened, but contents must not be crushed before administration
NG administration: Empty capsule contents into 60 ml syringe and mix with 50 ml water; vigorously shake syringe for 15 s; flush NG tube with additional water after administering granules; do not administer if pellets have dissolved or disintegrated
Do not administer with meals
Adverse effects: headache, nausea, vomiting, diarrhea, abdominal pain, potential drug interactions
Lansoprazole PO/NG: 15–30 mg qd Enteric coated granules in capsule form may be opened, but contents must not be crushed before administration
The contents of the capsule can be emptied into 60 ml of tomato, apple, or orange juice and swallowed immediately
The contents of the oral suspension packet should be mixed with 30 ml of water
The oral disintegrating tablet should be placed on the tongue and allowed to disintegrate with or without water; the tablet should dissolve within a minute and should not be swallowed intact or chewed. Alternatively a 15-mg tablet may be placed into an oral syringe with 4 ml of water or a 30 mg tablet with 10 ml of water; gently shake to allow quick dispersal; after tablet dispersal administer contents; refill syringe with 2 ml water, shake gently, and administer remaining contents
Do not administer with meals
Omeprazole PO/NG: 20 mg qd Sustained-release capsule may be opened, but contents must not be crushed before administration; the powder for oral suspension should be used in this setting
Do not administer with meals
Pantoprazole PO: 40 mg qd Swallow tablets whole, with or without food
Do not split, chew, or crush tablets
Rabeprazole PO: 20 mg qd Swallow tablets whole, with or without food
Do not split, chew, or crush tablets
Other Agents
Sucralfate (a sulfated disaccharide) PO/NG: 1 g qid