A Risk Analysis of Stress Ulceration after Trauma

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Abstract
Prophylaxis for stress ulceration is considered standard care for most critically ill patients, but may be overutilized. We determined the incidence of stress ulceration in 33,637 major trauma patients treated in a regionalized trauma system from 1985 to 1991 using trauma registry data and chart review. Injury-related risk factors for stress ulceration and other associated infectious and organ failure complications were identified by regression analysis. Clinical stress ulceration developed in 57 patients (0.17%) despite prophylaxis. Eighteen patients (0.05%) developed severe ulceration with either gastroduodenal perforation (3 patients) or a >2 U blood transfusion requirement (16 patients). Independent risk factors with odds ratios (OR) were identified as follows: Injury Severity Score (ISS) greater than or equal to 16, OR = 12.6; spinal cord injury, OR = 2.0; and age > 55, OR = 2.4. Other serious complications, including pneumonia, sepsis, and organ failure (adult respiratory distress syndrome and renal and hepatic failure), were significantly associated with the development of stress ulceration. Clinically significant stress ulceration after trauma is uncommon, but occurs despite prophylaxis. Severe injury (ISS > 16) and spinal cord injury were identified as independent injury-related risk factors. All patients with severe ulceration had either one of these injury-related risk factors or a significant infectious complication or organ failure. Standard prophylaxis may be inadequate in high-risk patients, who should be targeted for increased surveillance and aggressive prophylaxis. On the other hand, routine prophylaxis in low-risk patients may be overutilized.