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Intern Report
July 14, 2004
Janet Buccola, M.D.
Basic Approach To Managing The Patient With
AGI 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
MK’s colonoscopy