#Upper GI bleed, active, likely 2/2 to __________
-Admit to telemetry
-DDx: UGI – Esophageal varices, Mallory-Weiss tear, Dieulafoy’s lesion, PUD, esophagitis, neoplasm, aortoenteric fistula (if hx of AAA repair).
-A rectal exam performed. Guaiac stool.
-D/C and avoid all meds that can cause or worsen GI bleed (Anticoagulants, antiplatelets, NSAIDs)
-Reviewed initial CBC, CMP, Coag Studies: evaluated H/H, Plts, PT, INR, AST, ALT, Albumin, BUN, and Cr.
-CBC q6hrs to follow H/H in this active bleeder
–Type and screen (or *type and crossmatch for hemodynamic instability, severe bleeding, or high-risk pt)
-Closely monitor ABCs, clinical status, vital signs, cardiac rhythm, UOP, NG output (if NGT in place)
-Orthostatic vital signs stat and then q4hrs. Tachycardia and orthostatic HoTN suggest moderate blood loss; HoTN suggests life-threatening blood loss (HoTN may be late finding in healthy younger adults)
-Establish two large bore IV lines (16 gauge or larger)
-Give IVF bolus before giving PRBC. Also maintenance fluids.
-NPO
-Supplement Oxygen to keep saturation >92%
-Consult GI stat. EGD and Colonoscopy decision to be made by GI
-PPI: Protonix drip – Pantoprazole 80mg in NS 100ml. Alt: Esomeprazole 40 mg IV bolus twice daily OR Pantoprazole 40 mg IV bolus twice daily
-IF pt devs hypotension, tx hypotension initially with rapid, bolus infusions of isotonic crystalloid
-IF needed, transfuse PRBC when:
–Hemodynamically unstable despite crystalloid resuscitation, OR
*–Hgb <9 in high-risk patients (eg, elderly, coronary artery disease), OR
*–Hgb <7 in low-risk patients
-IF coagulopathy devs, give FFP
-IF plt <50,000 or plt dysfunction (eg, chronic ASA tx), give plts
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GI bleed Pearls
- Transfusion thresholds.
- For lower GI bleed, get a GI consult for a colonoscopy if the patient is hemodynamically stable. If the patient is unstable, get an urgent tagged RBC scan. Also consider arteriography. You can’t do a colonoscopy in a patient who is unstable.
- For upper GI bleed, get elective endoscopy within 24 hrs if bleed has stopped and pt is hemodynamically stable. If the pt is unstable, call GI consult for urgent endoscopy for both diagnosis and treatment.
***IF pt has known or suspected esophagogastric variceal bleeding and/or cirrhosis, then give:
-Somatostatin or an analog: Octreotide 50 mcg bolus, followed by 50 mcg/hour infusion
-Prophylactic antibiotic: Ceftriaxone OR Amoxicillin-clavulanate OR Quinolone
FYI
To transfuse patient, complete the appropriate order set and complete the consent form. Explain the problem, alternatives, and risks/benefits to the patient.
If the patient has orthostatic hypotension, when transfusing, instead of one unit, give two units of PRBC.
Nasogastric lavage may be helpful if the source of bleeding is unclear (upper or lower GI tract) or to clean the stomach prior to endoscopy
Obtain surgery and interventional radiology consultation for any large-scale bleeding
Balloon tamponade may be performed as a temporizing measure for patients with uncontrollable hemorrhage likely due to varices using any of several devices (eg, Sengstaken-Blakemore tube, Minnesota tube); tracheal intubation is necessary if such a device is to be placed; ensure proper device placement prior to inflation to avoid esophageal rupture
Avoid over-transfusion with possible variceal bleeding
Read: http://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults