1. December 20, 2013 Salman Khalid PGY-3 Eric Loman PGY-2 CRITICAL CARE M&M

2. PITFALLS Was the urgency of unstable GI bleed promptly recognized in this case? Was proper risk stratification and measures like NGT lavage used to help build a case for urgent EGD? Was the patient adequately resuscitated and was the massive transfusion protocol timely instated? Were non-endoscopic interventions timely anticipated and requested?

3. Upper GI Bleed Over 300,000 hospitalizations in US annually 80-90% of cases occur due to non-variceal causes Most common non-variceal causes include: Gastro-duodenal peptic ulcer (20-50%), gastro duodenal erosions (8-15%), erosive oesophagitis 95-15%0, Mallory-Weiss tear (8-15%) and AVMs (5%). Adequate IV access and hemodynamic resuscitation with blood and plasma expansion and correction of coagulopathy are fundamental steps of management. Risk stratification of UGIB patients with scoring systems help identify patients at high risk for mortality and rebreeding. Early EGD improves outcomes

4. Bleeding Peptic Ulcer － Natural History － Approximately 80-85% bleeding stops spontaneously Remaining 15-20% recurrent or continuous bleeding Re-bleeding increase mortality by 10 times

5. Risk startification Patients should be stratified into low and high risk by using prognostic scales, on the basis of clinical, laboratory, and endoscopic criteria. Early identification of high-risk patients allows appropriate intervention, which minimizes morbidity and mortality Clinical predictors of poor outcome include: age greater than 65 years; hemodynamic shock; c- morbid illnesses; low initial hemoglobin levels; melena; transfusion requirement; fresh red blood on rectal examination, in the emesis, or in the nasogastric aspirate; sepsis; and elevated urea, creatinine, or serum aminotransferase levels

6. Pre-endoscopic risk startification Blatchford Score A scoring tool that evaluates gender based Hgb levels, BUN, Admission BP, Syncope, melena and cardiac and liver failure as risk factors. A score of 0 has 96% sensitivity and 32% specificity for adverse clinical outcomes in cases of UGIB bleeding. Another study showed that a cut-off value of 2 will have sensitivity of 100% and specificity of 13% for identifying high risk patients that need endoscopic intervention. Often advocated as a tool to identify high risk patients that would benefit from closer monitoring and early EGD.

8. Rockall Scoring system

9. This scoring system is used to identify patients at higher risk of mortality and re-bleeding It takes into account both clinical and endoscopic features. A score of <2 accurately predicts low risk patients for mortality and re-bleeding It has better discriminative ability for mortality than re- bleeding. In 3 studies comparing clinical prediction rule scores in the same study population, the Blatchford score performed better than the Clinical Rockall score for predicting patients at high risk for clinical intervention

10. Role of pre-endoscopic PPIs Meta analysis with 6 randomized trials between 1992-2007 showed that pre-endoscopic administration of PPIs does not reduce mortality, re-bleeding or progression to surgery. However, this treatment resulted in significantly reduced rates of high-risk stigmata identified on EGD (Odds ratio 0.67 95% CI 0.54-0.84) and need for endoscopic therapy (OR 0.68 CI 0.50-0.93). Therefore, the routine administration of upstream PPIs is recommended.

11. Pro-kinetic agents Routine use of pro-kinetic agents is not recommended and is guided by clinical judgment of the probability of large amount of blood or clots in stomach. Recent Meta-analysis showed that pro-kinetic agents decrease the need for repeat EGD to determine the site or cause of bleeding but do not affect other outcomes such as mortality, re-bleeding, need for surgery or length of hospitalization.

12. Role of early EGD National guidelines recommend EGD within first 24 hours and sooner in cases of hemodynamic instability as adequate control of bleeding can be established in majority of cases. Despite early endoscopic intervention, inadequate control or re-bleeding occurs in 8-25% cases. Re-bleeding especially in elderly with co-mornids can have a very high mortality of upto 60%.

13. Endoscopic predictors stigmata of recent bleeding Percent Johnston JH. Endoscopic risk factors for bleeding peptic ulcer. Gastrointest Endosc 1990;36:S16.

14. Endoscopic Risk Stratification Endoscopic FindingRebleedMortality Active bleeding55%11% Visible vessels43%11% Adherent dot22%7% Flat spots10%3% CLEAN UCLER BASE5%2% Laine et al. NEJM 1994; 331:717

15. Role of NGT lavage NGT lavage helps screen patients with high-risk lesions on endoscopy. Around 45% patients with bloody aspirate have high-risk lesions on EGD compared to only 15% patients with clear or bilious aspirate. This helps identify patients in whom early EGD should be planned. Despite this information, a recent meta-analysis showed that the sensitivity of NGT in identifying active UGI bleed ranges from 42- 84% and specificity from 52% to 91%. Further studies have show that bloody aspirate predicts high risk lesions and leads to EGD sooner but in turn does not improve mortality or other clinical outcomes.

16. Therefore, the role of NGT remains controversial. While it may give important diconvinced GI to perform diagnostic information to hasten EGD, it does not improve outcomes in the end. Therefore, should NGT have been placed in our patient? If placed it would have drained the blood sitting in the stomach (later seen on EGD) and may have convinced GI to avoid the delay in EGD for this patient.

17. NG tube aspirate Active bleeding by endoscopy Requires Surgery Death Clear 16 % 10 % 6 % Coffee ground 30 % 13 % 10 % Red blood 48 % 23 % 18 % American Society For Gastrointestinal Endoscopy

18. Role of angioembolization Angio-embolization should be considered for patients who have failed endoscopic attempts. Few studies have shown comparable success rates of angio- embolization and surgery as well and therefore it should be strongly considered for patients who are too unstable for surgery. One retrospective study showed 80% success rate with angio-embolization in gastric or duodenal ulcer bleeding patients who had failed endoscopic interventions. Complications are rare but include secondary duodenal stenosis, bowel ischemia and gastric, hepatic or splenic infraction.

19. Massive Transfusion Protocol (MTP) Scope: Any attending Trauma Physician or designee acting upon their behalf. Also other services providing emergency or critical care services. Purpose: to provide a standard approach to blood product resuscitation of trauma patients with life threatening bleeding. Population: Transfusion should be considered massive if replacement of at least one blood volume (70-80 ml/kg) will be needed in a 12-24 hour period for a patient with life-threatening bleeding. Any attending physician or designee acting upon their behalf can call the main blood bank at 545-2845 to notify that the MTP has been activated

20. Massive Transfusion Protoclol Criteria for Activation of the MTP: 1. Immediate life-threatening bleeding, any cause (trauma, DIC, etc.) And 2A. Physician judgment that the patient will require a massive transfusion Or 2B. 3 of 4 of following indicators of risk of shock or coagulopathy associated with active bleeding: Tachycardic (>95th %tile for age) or hypotensive (<5th% tile for age) Base deficit ≥ 6 or lactate ≥ 4 mmol/l INR ≥ 1.5 Hemoglobin ≤ 9 g/dl

21. MTP blood packs by patient weight and protocol >40Kg 6 Units of RBC, 6 units Plasma, 5 pack of random donor PLTS

22. Responsibilities A. The Blood Bank tech receiving the request to initiate MTP will immediately notify the Transfusion Service Medical Director or his/her designee. B. Manual Transportation The department managing the patient is responsible for transporting blood product from the Blood Bank to the point of care. C. Once MTP is initiated immediately prepare 1st blood pack. 1. Type O RBCs will be utilized until type specific, cross-matched RBC are available. 2. Type AB thawed plasma will be utilized until type specific plasma is available. 3. Random donor platelets will not be type specific. D. As soon as a blood pack is dispensed the next blood pack will be processed immediately. E. Automatic processing of next blood pack will stop when attending of record or designee calls and stops the MTP.

23. THANKS