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the ICU
Doctor Chad
Pulmonary & Critical Care Medicine
Objectives
Initial approach to the patient with GIB
Evaluation and treatment of UGIB
Review pharmacologic and transfusion thresholds in
GIB
Evaluation and treatment of LGIB
Stress Ulcer Prophylaxis in the ICU
Board Review
2
Blood
Takes
VS
PE
Dieulafoys lesions
Aortoesophageal fistula
Causes of ALGIB
Diverticulosis
Ischemic colitis
Arterial-venous
malformations
Vascular ectasias
Hemorrhoids
Rectal varices
Inflammatory Bowel
Disease
Infectious diarrhea
5
Ligament of Treitz
Causes of UGIB
Dieulafoy's Lesion 1%
Melena
Blood
on exam [25]
BUN/Cr
> 30 [7.5]
Elizabeth D Agabegi; Agabegi, Steven S. (2008). Step-Up to Medicine (Step-Up Series). Hagerstwon, MD: Lippincott Williams & Wilkins. ISBN 0-7817-7153-6.
When to Intubate?
AMS - unable to protect airway
Severe bleeding prior to endoscopy
Poiseuilles law
Poiseuilles law states that the rate of flow through a
tube is proportional to the fourth power of the radius of
the cannula and is inversely related to its length.
Objective: Liberal blood transfusions Hg 9 g/dL vs. restrictive hemoglobin below 7g/dL.
Method: Randomized 921 patients with acute GI bleeding to undergo either a restrictive
blood transfusion strategy (to hemoglobin >7 g/dL) or a liberal strategy (to Hb > 9 g/dL).
The primary outcome was death at 45 days from any cause.
RESULTS
The average number of units transfused was 1.5 vs. 3.7.
At 45 days, 23 people (5%) restrictive blood transfusion group had died vs. 41 people
(9%) in the liberal blood transfusion group.
Those in the restrictive group had a 45% relative reduction, and a 4% absolute risk
reduction for death (5% vs. 9%, p=0.02).
People with mild to moderate cirrhosis with variceal bleeding were at clearly increased
risk of death by blood transfusion, while the risks or benefits of transfusion for people
with bleeding gastric ulcers or other non-variceal bleeds was uncertain.
Transfusions
In low risk patients with self-limited bleeding and
absence of high-risk features, blood loss anemia
of hemoglobin 7 to 10 g/dL may be well tolerated
without need for pRBC transfusion
In patients with active GIB are not appropriate
candidates for conservative transfusion thresholds
and were excluded from studies assessing the
safety of such thresholds
Acid Suppression
Use PPI as H2 blockers do not reduce ulcer
rebleeding
Infusion of high-dose omeprazole before index
endoscopy accelerated the resolution of signs of
bleeding in ulcers but does not reduce mortality or
transfusion requirements
High dose Oral and IV PPI equally effective
Lancet. 1996;347(9009):1138
Variceal bleed
Child A or B liver disease: Hepatic venous pressure
gradient < 20 octreotride for at least 48 hours after
onset of bleeding, and endoscopic therapy within 12
hours
Antibiotics - prophylaxis against spontaneous
bacterial peritonitis
Childs C: Emergent EGD
Causes of ALGIB
Management of ALGIB
Colonoscopy after prep
If unclear UGIB vs LGIB, do EGD first
If cannot find lesion on colonoscopy, radionuclide scanning
with technetium- 99m-labeled red cell scintigraphy - need
bleeding rate 0.1 to 0.5 mL/min
Sepsis
ICU admission of >1 week
Occult GIB >6 days
Steroid therapy
References
Does this patient have a severe upper gastrointestinal bleed?
Srygley FD, Gerardo CJ, Tran T, Fisher DA. JAMA. 2012
Mar;307(10):1072-9.
Baradarian R, Ramdhaney S, Chapalamadugu R, Skoczylas L,
Wang K, Rivilis S, et al. Early intensive resuscitation of patients with
upper gastrointestinal bleeding decreases mortality. Am J
Gastroenterol. 2004 Apr. 99(4):619-22.
Adler DG, Leighton JA, Davila RE, Hirota WK, Jacobson BC,
Qureshi WA, et al. ASGE guideline: The role of endoscopy in acute
non-variceal upper-GI hemorrhage. Gastrointest Endosc. 2004 Oct.
60(4):497-504
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