Intern Report July 14, 2004 Janet Buccola, M.D.

Basic Approach To Managing The Patient With A GI 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