Intern Report

July 14, 2004

Janet Buccola, M.D.

Basic Approach To Managing The Patient With

AGI Bleed

1. Assess Stability of Patient

• Vitals signs

• Stigmata of active bleeding

• Evidence of end organ hypoperfusion?

• The hematocrit??

• ICU admission criteria

2. Resuscitation

Why Does It Matter?

IV Access

• For peripherals, large bore x 2

• For central venous access, consider a single lumen catheter (i.e. Cordis)

• Consider CVP monitors if a patient has renal failure or CHF (even if compensated at presentation)

All Fluids Are Not Created Equal

• Colloids

• Crystalloids

Transfusing Blood

• Estimate your patient’s needs/ hematocrit goal• 1 u PRBC raises hct by approx 3 points• For active bleeders, consider keeping 2 extra units

on hold in blood bank. At minimal, make sure you have an active clot (i.e. the “type and screen” option in POE) in the blood bank

• Keep in mind your pt’s overall fluid status• Consider transfusing 1u FFP for every 4 units

PRBC transfused

Transfusing Platelets

• The threshold for platelet transfusion in an active bleeding pt is 50,000

• Consider dilutional effects of other resuscitative fluids

• Consider platelet transfusions for actively bleeding patients on medications which cause platelet dysfunction(clopidogrel, dipyridamole)

Bleeding In Patients On Anticoagulants

• FFP works immediately, short overall duration

• Vitamin K, takes longer, works longer

• Consider your INR goal/ why your patient is anticoagulated

Antacid Therapy

• Both H2 Blockers and PPIs have been shown to reduce mortality in patients admitted to hospitals with UGIB

• Consider starting on all patients if source of bleeding is unknown

• Definitively start in all patients with a known upper GI bleeding source

3. Localize Source of Bleeding

• Consider lavage on all pts w/ GIB– 10% of patients w/ LGIB have an upper source

– Thrombocytopenia is a relative contraindication

– Suspected variceal bleed is not a contraindication!

• Know the limitations of lavage• Endoscopy• Nuclear medicine (tagged RBC study)• Angiography

MK’s colonoscopy

MK’s colonoscopy