REBEL Core Cast 39.0 – Upper GI Bleed

Take Home Points

• Focus on resuscitating well by focusing on the basics
• Recognize Massive GIB (MGIB) with a thorough exam of the patient and vital signs (Shock index >0.7 is ABNORMAL and signals impending shock)
• Obtain large bore PIV access and prioritize transfusion over crystalloids for MGIB
• Get consultants on board early
• Give adjunctive medications that impact mortality (ie A 3^rd generation cephalosporin in patients with variceal bleeding or a history of cirrhosis)

REBEL Core Cast 39.0 – Upper GI Bleed

Definition and Recognition of Massive GI Bleeding (MGIB)

• Not one consensus definition exists
• Any bleeding from the GI tract (upper or lower) that results in
  • Hemodynamic instability (hypotension, dysrhythmias)
  • Poor perfusion (AMS, syncope, pallor, delayed capillary refill, decreased pulses)
  • Overt and rapid bleeding
  • Transfusion of ≥2 units pRBC in initial resuscitation
• Spend time at the bedside looking for these things
  • AMS
  • Skin temperature, color
    • Pallor
    • Mottling
    • Capillary refill
  • Vital signs
    • Hypotension
    • Hypoxia
    • Shock Index (HR/SBP)
      • > 0.7 is ABNORMAL
      • > 1.0 may signal a need for massive transfusion
• Characteristics that may predict the need for immediate intervention
  • UGIB
    • Tachycardia (LR 4.9)
    • Syncope (LR 3.0)
    • Hx of malignancy or cirrhosis (LR 3.7)
    • NG lavage returning BRB (LR 3.1)
  • LGIB
    • Similar for LGIB
    • Tachycardia
    • Syncope
    • HD instability
    • Active rectal bleeding
    • Non-tender abdominal exam
    • ASA use
    • Hx/o renal failure, liver failure, malignancy
• A NORMAL HR is predictive for a NON-massive GIB
  • Check if patient is on a BB or CCB that may mask tachycardia
• Localizing the bleed
  • Hematemesis
    • UGIB
  • Melena
    • Usually UGIB or
    • Proximal LGIB
  • Hematochezia
    • Usually LGIB or
    • Brisk UGIB (very sick patients!)

Basic Resuscitation First!

• Reliable peripheral IV access
  • Short and fat lines!
  • IO if peripheral fails

• Blood > crystalloid
• Reverse anticoagulants
• Secure the airway if needed
• Get your consultants on board early (endoscopy/GI, surgery)

Adjunctive Medications

• Proton pump inhibitors (PPI)
  • Cochrane Review
    • No effect on mortality, rebleeding, need for surgery
    • Decrease high risk stigmata in patients with peptic ulcer disease (PUD)
  • Bottom line: Doesn’t affect mortality so don’t prioritize during the initial resuscitation.  May give bolus after.
• Octreotide
  • Somatostatin analog, vasoconstricts the splanchnic circulation
  • No effect on mortality in undifferentiated GIB
  • However, can decrease
    • Initial bleeding
    • Total transfusion
    • Need for surgery
  • Bottom line: Doesn’t affect mortality so don’t prioritize during the initial resuscitation.  May give bolus + infusion after.
• TXA
  • Reduces the breakdown of fibrin clots, fibrinogen, and other plasma proteins
  • Recently published HALT-IT Trial provided good quality evidence
    • No difference in 5 day mortality due to bleeding
    • There WAS an increase in VTE (adverse events)
  • Bottom line: Not recommended to give routinely
  • If TEG/ROTEM demonstrates excessive fibrinolysis then TXA would be indicated
• Antibiotics – Cephalosporins!
  • Decreases mortality in patients with variceal bleeding or undifferentiated bleeding in patients with cirrhosis
    • These patients are immunocompromised at baseline and GI bleeding puts them at risk for subsequent sepsis
    • 3^rd generation cephalosporin
      • Ceftriaxone 1 gram
      • Cefotaxime 2 grams

Take Home Points:

• Focus on resuscitating well by focusing on the basics
• Recognize MGIB with a thorough exam of the patient and vital signs (Shock index >0.7 is ABNORMAL and signals impending shock)
• Obtain large bore PIV access and prioritize transfusion over crystalloids for MGIB
• Get consultants on board early
• Give adjunctive medications that impact mortality (ie A 3^rd generation cephalosporin in patients with variceal bleeding or a history of cirrhosis)

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)