morbidity & mortality conference department of internal medicine catherine a. chu, m.d monina...
TRANSCRIPT
MORBIDITY & MORTALITY CONFERENCEDepartment of Internal Medicine
Catherine A. Chu, M.DCatherine A. Chu, M.DMonina Clauna, M.D.Monina Clauna, M.D.
OBJECTIVES
To discuss the case of a strong elderly patient who had continuous active gastrointestinal bleeding.
To discuss the role and timing of endoscopy or surgical intervention in such cases.
To discuss the appropriate fluid replacement to maintain hemodynamics in hemorrhagic shock
•E.R. •71 YEAR OLD•MALE•FILIPINO•CATHOLIC•MEYCAUAYAN, BULACAN
PATIENT
Chief Complaint
Hematemesis and
Hematochezia/ Melena
History of Present Illness
1 month PTA motorcycle accident muscular lower
extremity trauma
- Diclofenac 25mg 1 tab TID, Omeprazole 40mg 1 tab OD
1 week PTA shifted to Meloxicam 15mg BID-TID
History of Present Illness
3 days PTA hematemesis followed by hematochezia (~100ml each)
(+) dizziness no abdominal pain or no retching local hospital Hgb:5mg/dl
4 units of PRBC transfusion Endoscopy was not done Pending CP clearance Symptoms persisted
Admission
What is the duration of NSAID use that will cause bleeding?
16.3 % during the first 30 days of use20.9 % over the next 31-180 daysFor long-term users (180 days or more of
continuous NSAID use), the ulcer hospitalization rate remained elevated at 26.3
Griffin, F.R., Smalley, W.E., Ray, W.A., and Daugherty, J.R. Nonsteroidal anti-inflammatory drugs and the incidence of hospitalizations for peptic ulcer disease in elderly persons.
Am J Epidemiol 2005 Mar 15;141(6):539-45.
Review of Symptoms
No fever, headache, weight lossNo chest pain, palpitation, orthopnea,PNDNo cough, colds, dyspneaNo dysuria, hematuria, low back painNo easy bruisabilty
Past Medical History
(+) HTN – for 10 years; takes Nifedipine as needed for BP elevation up to 160/100 mmHg.
ASA taken intermittently(+) Gouty Arthritis - on Diclofenac prn(+) PUD secondary to chronic NSAID (15-20 years
ago) – reason for a previous hospital admission; previously on PPI for sometime; asymptomatic since then
(-) DM (-)Bronchial Asthma (-) liver cirrhosis (-) blood dyscrasia (-) history of surgeries
Family Medical History
(+) HTN and Coronary Artery Disease – parents
(-) bleeding dyscrasia nor oncologic diseases(-) Bronchial Asthma, DM, PTB
Personal Social History
previous smoker - stopped about 40 years ago- 3 sticks of cigarette per day non alcoholic beverage drinker
Physical Examination
Weak-looking, conscious, coherent, not in cardio respiratory distress
Vital Signs:BP :110/60mmHg, HR: 88 bpm, RR:20cpm, T
36ºC. Weight: 90 kgDry and pale skin, pale palpebral conjunctivae,
anicteric sclerae, neck vein not distendedEqual chest expansion, no retractions, clear
breath sounds
Physical Examination
Adynamic precordium, normal rate and regular rhythm, no murmur
flabby abdomen,soft, nontender, no muscle guarding, no palpable mass, no organomegaly, normoactive bowel sounds,
slightly cyanotic nail beds on lower extremities with faint pulses, (+) grade 2 bipedal edema
black tarry stool per rectum
SALIENT FEATURES
• 71 year old, Male• motorcycle accident (Diclofenac and Meloxicam)hematemesis ,hematochezia /melenaNazareno Hospital Hgb = 5mg/dlS/P 4 units of PRBC transfusion(+) Gouty Arthritis - on Diclofenac prn(+) PUD secondary to chronic NSAID(15-20 years
ago)Stable VSDry,pale, (+) cyanotic nail bed,faint pulses, grade II
bipedal edemaBlack tarry stool per rectum
Admitting Impression
•Upper Gastrointestinal Bleeding probably secondary to Peptic Ulcer Disease due to Chronic NSAID use
•S/P 4u PRBC transfusion
COURSE IN THE WARDS
0200Hawake, conversant
BP 110/60, HR 88 bpm, RR 20cpm, T36C
Skin: pale
Lungs: clear BS
Heart: NRRR
Abdomen: flabby, soft and nontender
Extremity: pale nail beds , (+),GrII peripheral edema
Rectum; black tarry stool
Patient Status
On Arrival…..
Ongoing 5th unit PRBC with700ml PNSS at KVO -right arm peripheral lineO2 at 2-3lpm Foley catheter -about 200ml yellow amber urine
0200HPatient StatusINTERVENTIONS:
NPOContinuation of BT and OxygenationPNSS 1L KVO to 80cc/hr.stat dose of Esomeprazole IV then Esomeprazole drip at 8mg/hrMetoclopramide 10mg every 8 hrs PRNDiagnostics: STAT5 and Blood typing 12-L ECG CXR
awake, conversant
BP 110/60, HR 88 bpm, RR 20cpm, T36C
Skin: pale
Lungs: clear BS
Heart: NRRR
Abdomen: flabby, soft & nontender
Extremity: slightly pale nail beds , (+) grII peripheral edema
Rectum: black tarry stool
Are we dealing with a hemorrhagic shock despite good dynamic parameters ?
Hemorrhagic shock- a condition of reduced
perfusion of vital organs leading to inadequate delivery of oxygen and nutrients necessary for normal tissue and cellular function secondary to blood loss
Krausz, M.,initial Resuscitation of Hemorrhagic shock,World journal of Emergency Surgery 2006
Hemodynamic Parameters:
•BP•PR/HR•RR•Urine output•Mentation
ATLS guidelines 2004, American College of Surgeons
Massive Hemorrhage
- Loss of total estimated blood volume(EBV) within a 24 hour period or loss of half of the total EBV in a 3 hour period
- EBV: 7% of body weight 0r 70ml/kg body weight
ex: 70kg man = 4.9L
Krausz, M.,initial Resuscitation of Hemorrhagic Shock, Journal of Emergency Surgery 2006 1:14
Are we dealing with a hemorrhagic shock despite good dynamic parameters ?
Primary goals:1. To find the source of bleeder and
prevent rebleeding (Issues: When and How?)
2. To maintain adequate hemodynamic parameters by fluid resuscitation
(Issues: Rate/Type of fluid, Roles of vasopressor)
YESHemorrhagic Shock Class I
0245H
awake, conversant
BP 110/60, HR 88 bpm, RR 20cpm, T36C
+ hematemesis (est. 10-20ml)
+ melena
Patient StatusINTERVENTIONS:
Another peripheral line was inserted at the left arm,3 units PRBC ordered for transfusion Referred to Gastroenterology service and agreed with present management.
0300H
Awake, conscious
110/60 to 80/50 80s to 120s
BP 90/50
HR 120s
BP 90/60,HR 110s
Patient StatusINTERVENTIONS:
.
200ml PNSS
200ml PNSS
Regulated to 120cc/hr Dopamine 5mcg
On going BT 1st0330
STAT5 & Blood type(extracted ()320H)STAT5 & Blood type(extracted ()320H)
Stat 5 0345HHgb 5.4 g/dlHct 16%Na 138 mmol/LK 4.4 mmol/LGlu 145 mg/dl
Blood type Type O+
RESULTS
ECG 03:17HECG 03:17H CXR 0342HCXR 0342H
RESULTS
0400H
80/60, 110s
O2 sat 69%
(+) melena 2x
BP 70/50- dizzy
(+) Chest Pain
Patient Status INTERVENTIONS:
.
0410H600ml PNSS then 120ml/hr
NC shifted to MVM 50%
0450HRegulated to 120cc/hr
0420HAnother 2u PRBC ordered
Tranexamic acid
Diagnostics: PT,PTT, Triage Panel
PT/PTTPT/PTT Triage PanelTriage Panel
0535HCKMB <1.0Myoglob. 44.2Trop I <0.05BNP 5.4d Dimer 362
RESULTS
PTT 0525HPx 23Control 27.6
PT 0525HActivity 83.1INR 1.17
5-800H
BP 70/50
HR 130s
BP 90/60
HR 130s
Initial CVP:O
Patient Status INTERVENTIONS:
0500HHaesteril 500 free flowPNSS then 120ml/hr
0750Central line inserted right arm
0645Brought to regular room
Diagnostics: CXR post intubation
RATE Since the time of World War II, the accepted
therapeutic dogma has been to restore blood volume rapidly and achieve normal physiologic parameters
Generations of physicians have been trained to reverse shock within the ‘golden hour’ in order to preserve organ function and prevent death
Early correction of the volume deficit is essential t0 prevent irreversible shock
How do we go about fluid restoration?
Gutierrez et.al. Clinical Review: Hemorrhagic Shock, Critical Care 2004
How do we go about fluid restoration?
It is not possible to precisely predict the total fluid deficit in a given patient particularly if fluid loss is continous
initial resuscitation should be at least 1 to 2 liters of isotonic saline which is given as rapidly as possible
Fluid repletion should continue at the initial rapid rate as long as the systemic blood pressure remains low (guide: BP, UO, Mental Status, Periph.Perfusion)
- An arterial line: placed in all patients who fail to respond promply to initial fluid resuscitation
- CVP help direct therapy
Rose et.al. Treatment of Severe Hypovolemia in Adults,www.uptodate.com Feb 2009
8-10H
BP palp 60
HR 130s
dyspneic
Patient Status INTERVENTIONS:
0800HHaesteril 500ml free flow
Endotracheal intubation /NGT insertion
Diagnostic: ABGABG 0910HpO2 55.9pH 7.04pCO 2 30.3HCO3 7.4O2 sat. 73.1B.E. 22.9
0930H: NaHCO3 2 amps given
8-10HBP palp 60
dyspneic
BP palp 80
HR 130
Patient Status INTERVENTIONS:
0800HHaesteril 500ml free flow
Endotracheal intubation /NGT insertion
0845H500cc PNSS/Dopamine
10mcg/kg/min
Diagnostic: ABG
0930H: ReferralsCardiology,/Pulmonology/Nephrology.
1000HBP 100/60 from palp 80
HR120s
RR17
CVP O
-on dopamine of 10mcg/kg/min
Patient Status
Fluid hydration of 200ml PNSS 2d echocardiography
Cardiology Assessment:Hypovolemic shock secondary to GI bleed; Tachycardia secondary to Anemia
What fluid should we use?
What fluid should we use?
Choice depends in part upon the type of fluid that has been lost
- blood components are initially indicated in patients who are bleeding but hematocrit should not be raised above 35%*Further increase of hct is not necessary for oxygen transport.*May increase blood viscosity leading to stasis in the already compromised capillary circulation
* crystalloids/colloids are used to replace the extracellular fluid
Rose et.al. Treatment of Severe Hypovolemia in Adults,www.uptodate.com Feb 2009
1010HBP 100/60
HR120s
RR 28
CVP0
-on dopamine of 10mcg/kg/min
Patient StatusInterventions:
Results of ABG & Blood Chem reviewed by Nephrology service.
Blood Chemistry
0345H 0720HGlucose 145.04 H 236.79BUN H 69Creatinine H 1.9K 4.4 4.3Na 147Ca L 6.9Total protein L 3Albumin L 1.5Globulin 1.5A/G ratio 1Alk.Phos. 28AST 10Total Bili. 0.17Uric acid 7ALT 21Triglyceride 92.65Cholesterol 72.99HDL 13.15ALDL 41.01
1010HBP 100/60
HR120s
RR 25-30s
CVP0
-on dopamine of 10mcg/kg/min
Patient StatusInterventions:
Nephrology Assessment:Acute renal failure secondary to acute blood loss
Left Femoral line insertedAnother 2 amps of NaHCO3
50meqs IV and another 1 amp every 2 hours for 4 doses
fast drip of 500ml Voluven Another 2 units available PRBC
were ordered for transfusion and hematology referral suggested
Stat CBC was ordered
1040HBP 100/60
HR120s
O2 sat 98-100% from 60s
Patient StatusInterventions:
Pulmonology Assessment:
Hypoxemic Acute Respiratory Failure
•Mechanical Ventilator set at:TV 630FiO2 100RR 20AC mode
12-13H
BP 120/8 0
HR 124
BP 140/80
Patient Status INTERVENTIONS:
At 1205HDopamine dec to 8mcg/kg/min
Norepinehrine 50ng/kg/hr
Gastroenterology Service:Octreotide 100mcg SC every 8 hours Piperacillin at 2.25gm every 6HDiagnostic: CBC (then q6H)Referral to HematologyReferral to Surgery
Cleared for endoscopy
When do we use vasopressors?
Vasopressors( eg.norepinephrine and dopamine) generally should NOT be administered since they do not correct the primary problem and tend to further reduce tissue perfusion
Rose et.al. Treatment of Severe Hypovolemia in Adults,www.uptodate.com Feb 2009
When do we use vasopressors?
Hypovolemia should be corrected prior to the institution of vasopressor therapy
Vasopressors are indicated for a decrease of >30 mmHg from baseline systolic blood pressure, or a mean arterial pressure <60 mmHg when either condition results in end-organ dysfunction due to hypoperfusion.
Nalaka et al, Use of vasopressors and inotropes. www.uptodate.com Mar 2009
12-13HBP 140/8 0
HR 120s
O2sat 98-100%
Patient StatusInterventions:
• Result of CBC reviewed by Hematology service
CBC 0345H 1135HHgb 5.4 3.7Hct 16 11.3WBC 18.83Segm 75Lympho 16Platelet 80,000
12-13HBP 140/8 0
HR 124
O2sat 98-100%
Patient StatusInterventions:
Hematology Assessment:Anemia of acute bleeding; dilutional thrombocytopenia and coagulopathy
• 7th unit PRBC ordered for transfusion•Transfusion will be subsequently followed up with 2 units of FWB.•2 units PRBC, 4 units FFP and 1 unit platelet apheresis secured for standby.
CBC
CBC 0345H 1135H 1415HHgb 5.4 3.7 3.4Hct 16 11.3 10.4WBC 18.83 12.83Segm 75 73Lympho 16 20Platelet 80,000 45,000
14-16HConscious
Communicates by sign language
BP 140/8 0
HR 120s
95-98%
(+) continouos bleeding per rectum
Patient StatusInterventions:
1600H Patient was seen by the surgery resident yet the consultant was out of the country
1400H Three 500ml Voluven; Two 500ml Haesteril Calcium Gluconate 2g SIVP Human Albumin 25% 100 FD Two free flowing PNSS lines
1630H
Patient restless
Bp 140/80
HR 130s
BP NA
HR NA
Flatline by cardiac monitor
Patient Status INTERVENTIONS:
1630H
Self extubation
•Reintubation attempted immediately but patient arrested after about 3 minutes extubation•CPR •Meds:Total of 5 doses of Epinephrine, 2 doses of Calcium Gluconate and 2 doses of NAHCO3
•expired after 25minutes CPR.
Cardiopulmonary Arrest secondary to Multiple Organ
Failure secondary to Hypovolemic Shock from
NSAID Induced UGIB
DIAGNOSIS
Urgent Endoscopy Vs. Surgery in Massive GI
Bleeding
A Study of Jensen et al. on Severe hematochezia with an unknown
cause
Objectives: to prospectively evaluate(a) the evaluate the diagnosis and treatment of 80 consecutive patients with severe, ongoing hematochezia from unknown source(b) the effectiveness and safety of urgent endoscopy after oral purge.
Jensen, D.M., and Machicado, G.A. Diagnosis and treatment of severe hematochezia. The role of urgent colonoscopy after purge.
Gastroenterology 2004 Dec;95(6):1569-74.
A Study of Jensen et al. on Severe hematochezia with an unknown
cause
Fifty-two men and 28 women (mean age, 64.5 yr) received a mean of 6.5 U of blood and had negative endoscopy, rigid sigmoidoscopy, and nasogastric tube aspiration before our evaluation.
Emergency panendoscopy was performed before purge.
Jensen, D.M., and Machicado, G.A. Diagnosis and treatment of severe hematochezia. The role of urgent colonoscopy after purge.
Gastroenterology 2004 Dec;95(6):1569-74.
A Study of Jensen et al. on Severe hematochezia with an unknown
causeUrgent endoscopy was performed in the
intensive care unit after patients received oral purge and their gut was cleared of blood, clots, and stool.
Final diagnosis: 74% colonic lesions (30% angiomata, 17% diverticulosis, 11% polyps or cancer, 9% focal ulcers, 7% other), 11% UGI lesions and 9% presumed small bowel lesions.
Jensen, D.M., and Machicado, G.A. Diagnosis and treatment of severe hematochezia. The role of urgent colonoscopy after purge. Gastroenterology 2004 Dec;95(6):1569-74.
A Study of Jensen et al. on Severe hematochezia with an unknown
cause
No lesion site was identified in 6%.64% of patients had intervention for control of
bleeding: 39% had therapeutic endoscopy, 24% surgery, and 1% therapeutic angiography.
For 22 pxs who also had emergency visceral angiography, the diagnostic yield was 14% & the complication rate was 9%.
Jensen, D.M., and Machicado, G.A. Diagnosis and treatment of severe hematochezia.
The role of urgent colonoscopy after purge. Gastroenterology 2004 Dec;95(6):1569-74.
A Study of Jensen et al. on Severe hematochezia with an unknown
cause
Conclusions: (a) Before urgent colonoscopy and purge, emergency
panendoscopy was indicated to exclude an upper gastrointestinal bleeding source.
(b) Urgent colonoscopy after purge was effective, safe, and often diagnostic.
Jensen, D.M., and Machicado, G.A. Diagnosis and treatment of severe hematochezia. The role of urgent colonoscopy after purge.
Gastroenterology 2004 Dec;95(6):1569-74.
A Study of Jensen et al. on Severe hematochezia with an unknown
cause
Conclusion:(c) Compared with urgent endoscopy, urgent visceral angiography was often nondiagnostic
(d) Hemostasis via colonoscopy has a definitive role in the treatment of some focal colonic lesions such as bleeding angiomata
Jensen, D.M., and Machicado, G.A. Diagnosis and treatment of severe hematochezia. The role of urgent colonoscopy after purge.
Gastroenterology 2004 Dec;95(6):1569-74
Non-Variceal Upper Gastrointestinal Hemorrhage: Guidelines
Endoscopy is done urgently in patients who have sustained major bleeding but it was emphasized that it should only be done when resuscitation has been achieved.
Ideally blood pressure and CVP should be stable but in patients who are actively bleeding this is not always possible.
Palmer, K.R. Non-Variceal Upper Gastrointestinal Hemorrhage: Guidelines. Gut. 2002: 51 (Suppl IV): iv1-iv6.
Endoscopic therapy for Acute Non-Varicial Hemorrhage: a Meta-Analysis
Endoscopic therapy reduces rebleeding, need for surgical intervention&mortality. (Grade A)
A range of endoscopic treatments are available for treating patients who have major stigmata of recent hemorrhage like injection of adrnaline, application of heater probe/ multipolar coagulation or mechanical clips.
Cook, D.J., Gayatt, Gayatt, G.H., Salena, B.J., et al. Endoscopic therapy for Acute Non-Varicial Hemorrhage: a Meta-Analysis. Gastroenterology 1992; 102: 139-
148
Endoscopic retreatment compared with surgery in patients w/ recurrent bleeding after
initial endoscopic control of bleeding ulcers
Patients whose rebleeding is treated by further endoscopic therapy have at least as good a prognosis as those randomised to urgent/emergent surgery without repeat endoscopic therapy. (Grade A)
Lau, J.Y.W., Lam T., et al. Endoscopic retreatment compared with surgery in patients w/ recurrent bleeding after initial endoscopic control of bleeding
ulcers. New England Journal of Medicine. 1999. 340; 751-6
Take Home Message
Hemorrhagic shock can be rapidly fatal. Uncertainties remain regarding the best
method for resuscitation, what type of fluid, how much,when, and how fast
Resuscitation may well depend on estimated severity of hemorrhage
Endoscopy must be done urgently in patients who have sustained massive bleeding but in patients who are actively bleeding this is not always the case; thus, taking the risk of performing endoscopy must be considered.
ATLS guidelines 2004, American College of Surgeons
Aggressive resuscitation of hemorrhagic shock however raises the concern on the scenario that
“ raising the blood pressure in a bleeding patient would eliminate the clot and increase bleeding’
How do we go about fluid restoration?
Cannon WB, Fraser J, Cowell EM: The preventive treatment of wound shock. JAMA 1918, 70:618-621.34.
How do we go about fluid restoration?
A total of 598 matched control patients with SBP of 60mmHg were included in the study group
immediate resuscitation group received an average of 900 ml fluid- 62% were discharged
Delayed resuscitation group 100 ml fluid in the delayed - 70% were discharged, as compared with of the immediate
- trended to have fewer complications.
Bickell WH, et al.: Immediate versus Delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl JMed 1994, 331:1105-1109.
How do we go about fluid restoration?
systematic review of the animal studies also showed an increased risk for death from aggressive resuscitation in animals with less severe hemorrhage
- suggesting that excessive fluid resuscitation can be instituted when there is the presence of severe hemorrhage
Mapstone J, Roberts I, Evans P: Fluid resuscitation strategies: a systematic review of animal trials. J Trauma 2003, 55:571-589.
Colloid vs Crystalloid
- Some advocated to colloid containing solution due to 2 possible advantages:
1. More rapid plasma vol expansion since colloid remains in the vascular space2. Lesser risk of pulmonary edema since dilutional hypoalbuminemia will not occur
Rose et.al. Treatment of Severe Hypovolemia in Adults,www.uptodate.com Feb 2009
Colloid vs. Crystalloid
Although colloid prevent pulmonary edema, it is not effective in preserving pulmonary function.
Several studies showed that saline solutions are equally effective in expanding plasma volume
Although 1.5-3x as much saline must be given because of its extravascular distribution. - not deleterious since fluid loss also leads to an interstitial fluid deficit
Acute saline-induced hypoalbuminemia can lead to peripheral edema (cosmetic but not life threatening)
Rose et.al. Treatment of Severe Hypovolemia in Adults,www.uptodate.com Feb 2009
Colloid vs Crystalloid
Saline solutions are generally preferred in patients with severe volume depletion
- safe and effective, less expensive
Rose et.al. Treatment of Severe Hypovolemia in Adults,www.uptodate.com Feb 2009
What is the role of buffer therapy?
Patients with marked hypoperfusion may develop lactic acidosis leading to reduction in extracellular pH below 7.10.
Marked acidemia may contribute to continued tissue hypoperfusion by decreasing cardiac contractility via a reduction in myocardial cell pH
- administration of NaHCo3 may be of benefitHowever, variety of problems may be
encountered in Na HCO3 infusion- Fluid overload, postrecovery metabolic
alkalosis, hypernatremia
What is the role of buffer therapy?
Utility of bicarbonate administration to patients with severe metabolic acidosis remains controversial
In general, bicarbonate should be given at an arterial blood pH of </=7.0.
The amount given should be what is calculated to bring the pH up to 7.2.
- Bicarbonate can also prevent improvement in cardiac function by inducing a fall in the ionized calcium due to increased protein binding
- Cautious administration of Calcium may be necessary
Sabatini et al, Bicarbonate Therapy in Severe Metabolic Acidosis ,J Am Soc Nephrol 20: 692-695, 2009
What is the role of buffer therapy?
The urge to give bicarbonate to a patient with severe acidemia is apt to be all but irresistible. Intervention should be restrained, however, unless the clinical
situation clearly suggests benefit
Sabatini et al, Bicarbonate Therapy in Severe Metabolic Acidosis J Am Soc Nephrol 20: 692-695, 2009
When and how much to transfuse?
The use of blood and blood products is necessary when the estimated blood loss from hemorrhage exceeds 30% of the blood volume (class III hemorrhage)
a hypotensive patient who fails to respond to 2 lcrystalloid in the face of probable hemorrhage should be treated with blood and blood products.
Guillermo etal, Clinical Review: Hemorrhagic Shock, Critical Care 2004
When and how much to transfuse?
American College of Physicians, the American Society of Anesthesiology, and the Canadian Medical Association Guidelines for blood transfusion
- recommend a hemoglobin level between 6 and 8 g/dl as a threshold for transfusion in patients without known risk factors
- They also agree in their disapproval of prophylactic blood transfusion, because patients with hemoglobin levels greater than 10 g/dl are unlikely to benefit from blood transfusion.
Guillermo etal, Clinical Review: Hemorrhagic Shock, Critical Care 2004
When and how much to transfuse?
A study conducted by Wu and coworkers indicated that a substantial number of people who present to the hospital with acute myocardial infarction and a hematocrit of 24% or lower may benefit from blood transfusion.
Wu etal, Blood transfusion in the Elderly Patients with Acute Myocardial Infarction,N eng J Med 2001,345: 1230-1236
When and how much to transfuse?
In a restrospective analysis of data from 78,974 patients aged 65 years or older and who were hospitalized with acute myocardial infarction
those with lower hematocrit values (<24%) on admission had higher 30-day mortality rates.
Blood transfusion was associated with a reduction in 30-day mortality among patients whose hematocrit on admission was in the 5–24% range.
Blood transfusion did not improve survival among those whose hematocrit values fell in the higher ranges.
Wu etal, Blood transfusion in the Elderly Patients with Acute Myocardial Infarction,N eng J Med 2001,345: 1230-1236
Emergency Angiography
50 pxs with massive gastrointestinal bleeding were initially managed with emergency angiography.
The average age was 67.2; mean hematocrit, 23.7; and average transfusion, 7.6 units.
36 pxs (72%) had bleeding site located.
Browder , W., Cerise, E.J. and Litwin, M.S. Impact of emergency angiography in massive lower gastrointestinal bleeding. Ann Surg 2006 Nov;204(5):530-6.
Impact of emergency angiography in massive gastrointestinal bleeding
20 of 22 (91%) pxs receiving selective intra-arterial vasopressin stopped bleeding
50% rebled on cessation of vasopressin.35 of 50 (70%) patients underwent surgery,
with 57% operated on electively after vasopressin therapy.
17 pxs had surgery, with no rebleeding.
Browder , W., Cerise, E.J. and Litwin, M.S. Impact of emergency angiography in massive lower gastrointestinal bleeding. Ann Surg 2006 Nov;204(5):530-6.
Impact of emergency angiography in massive gastrointestinal bleeding
9 of the 17 patients had diverticular disease in the remaining colon.
Operative morbidity in these 35 patients was significantly improved when compared to previously reported patients undergoing emergency surgery without angiography (8.6% vs. 37%) (p less than 0.02).
Browder , W., Cerise, E.J. and Litwin, M.S. Impact of emergency angiography in massive lower gastrointestinal bleeding. Ann Surg 2006 Nov;204(5):530-6.
Impact of emergency angiography in massive gastrointestinal bleedingConclusion:Emergency angiography successfully locates the
bleeding site, allowing surgery. Vasopressin infusion transiently halts bleeding,
permitting elective surgery in many instances.
Browder , W., Cerise, E.J. and Litwin, M.S. Impact of emergency angiography in massive lower gastrointestinal bleeding. Ann Surg 2006 Nov;204(5):530-6.