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Ryan O’Gowan, MBA, PA-C FAPACVS FCCM St. Vincent Hospital, Worcester, MA.

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Presentation on theme: "Ryan O’Gowan, MBA, PA-C FAPACVS FCCM St. Vincent Hospital, Worcester, MA."— Presentation transcript:

1 Ryan O’Gowan, MBA, PA-C FAPACVS FCCM St. Vincent Hospital, Worcester, MA

2  I have no financial relationships with any drug or device manufacturers to disclose.

3  At the conclusion of this lecture the participant should be able to:  Describe the pathology and pathophysiology of the patient with upper and lower GI bleeding.  Outline the approach to diagnosing and treating GI bleeding, as well as clinical management.  Describe pitfalls or circumstances unique to the cardiac surgery population, as well as the literature pertaining to this population.

4  A 68 year old cardiac surgery patient who is POD #3 presents with intractable nausea and vomiting on the telemetry unit. The patient develops pronounced hematemesis.  Vital signs: HR 120, AF. SBP 88/60 laying flat; 78/58 sitting upright. Urine output 60cc in the last 4 hours. He is unable to stand secondary to dizziness. Respiratory rate 35, O2 Sat 89% 6LNC.

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6  Of note, the patient is an AVR with mechanical valve, has begun anticoagulation with coumadin, and has been on Amiodarone for AF.  Pre-op, the patient had an uncomplicated UTI treated with Levofloxacin.  What is your next step in managing this patient?

7 American College of Surgeons Committee on Trauma- ATLS Course Guidebook

8  Remember CAB:  Circulation: IV Access, Crystalloid vs. Colloid Resuscitation, Central line & pressors if appropriate.  Airway: Level of consciousness, airway assessment.  Breathing: Use of accessory muscles, respiratory rate.

9  Not all bleeding is created alike:  Above the Ligament of Treitz-  Hematemesis  Melena  Below the Ligament of Treitz-  Hematochezia

10  NGT/OGT: caution in patients with known varices. +/- ice water lavage with 250cc.  Consider Sengstaken-Blakemore tube in patients with Variceal bleeding.  Laboratory Studies; CBC, Coags, Lactate q6-8h. Consider Serial ABGs (as base deficit may signify degree of bleeding).  Fluid Resuscitation with blood/factor transfusions.

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12 Blood Loss Determination:  1.) Estimate Normal Blood Volume: 66ml/kg ( ♂ ) or 60ml/kg ( ♀ )  2.) Estimate % loss of Blood Volume:  Class 1: < 15%  Class 2: 15-30%  Class 3: 30-40%  Class 4: >40%  3.) Calculate the Volume Deficit (VD):  VD= Blood Volume (BV) x Percent Loss.  4.) Determine the Resuscitation Volume:  VD x 1.5 for Colloids or VD x 4 for Crystalloids. The ICU Book, 3 rd Edition. Marino, et. Al.

13  IV Proton Pump Inhibitors:  IV Omeprazole 20mg q12h.  Omeprazole infusion 8mg/hr.  Somatotatins:  Octreotide: Bolus of 25-50mcg followed by infusion of 25-50mcg/hr x 48 hours. (indicated for variceal bleeding or as an adjunct when endoscopy is not immediately available)

14  Empiric Antibiotic therapy:  Indicated for cirrhotic patients, as bacterial translocation may occur secondary to immunocompromise.  Tranexamic Acid:  Recent studies did not show benefit of Tranexamic Acid for GI bleeding over placebo.

15  Barret’s esophagus  Esophageal cancer  Esophagitis  Gastric Cancer  Gastric Ulcer  Gastrinoma  Mallory Weiss Tears  Variceal Disease

16  Initial labs showed a drop in the HCT to 19.9 with an INR of 3.9. Lactate was 3.1. ABG was 7.19/32/82/18 with a base deficit of -4.  The patient was intubated, was given 3 units RBCs and 2 units FFP. An arterial line was placed, and the patient was started on pressors. GI/General Surgery were consulted and the patient was started on IV pantoprazole and Octreotide.

17  Endoscopy: Approach is determined by if bleeding is upper vs. lower. UGI can be therapeutic and diagnostic-  Electrocautery  Banding of varices  Injection of bleeding vessels with Epinephrine  CTA has an evolving role in diagnosing GI Bleeding, and may have increased utility in detecting small bowel bleeding sites. (World J Gastroenterol August 21; 16(31): 3957–3963.)

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20  UGI Endoscopy identified a small bleeding ulceration which was cauterized.  The patient continued to be transfused with RBCs and FFP. He failed to respond appropriately, as his HCT came up to 23.8, after a total of 4 Units.  The SBP went up to 180 systolic with an episode of ventilator asynchrony, and 300cc of bright red blood was suctioned out his OGT.

21  Angiography and angioembolization:  Surpassing Tagged RBC scan-  Greater Utility, may also be useful in evaluating Mesenteric Ischemia if abdominal pain with elevated lactate.  Tagged RBC Scan  Requires a large volume of active blood loss to be read as positive.  Always weigh the utility of various studies, as some may be both diagnostic and therapeutic.

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24  The patient underwent angioembolization, of a bleeding branch of the gastro-duodenal artery, which was localized secondarily after his varices were banded.  He was stabilized, had his Warfarin restarted, and was later referred to a specialized center for a TIPS procedure to definitively control his portal hypertension and varices.

25  A 67 year old female S/P bare metal stenting presents with recurrent angina. She has been loaded with Plavix 300mg and has developed hematochezia. She has an IABP in place and is pre-op for CABG.  HCT is 24.7, INR is 1.2, PLT 94,000. PRU (P2Y12 assay) shows 80% inhibition.

26  Physical Exam is the first step.  External hemorrhoids are often overlooked.  LLQ pain may be indicative of diverticulitis, another common cause.

27  External Hemorrhoids  Colonic polyps  Diverticulitis  Colitis (Ischemic, Ulcerative, Crohn’s)  Infectious Diarrhea (E.Coli H7:0157, Shiga toxin, Salmonella)  Anal Fissures  Neoplasm/Radiation Proctitis

28  The patient is stabilized, receives OPCAB x 3, and remains with IABP in place post op.  On POD 2, her HCT falls to 21.3 and PLT to 55,000. She develops abdominal pain and is presently NPO. Lactate is 4.1, Creatinine is 1.7.  What is your next priority?

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30  Patient’s with reduced Ejection Fractions who are not intubated may require more restrictive transfusion strategies.  The TRICC trial excluded patients with ACS and maintains a transfusion target HCT of 30.  Reduced splanchnic flow to the kidneys and mesentery warrant increased suspicion of renal failure and mesenteric ischemia.

31  The patient is given 3 units PRBCs and 6 units Platelets- LGI bleeding continues.  CXR reveals IABP with the tip migrated just above the renal arteries; it is repositioned and the tip is now at 4 th ICS.  Judicious fluid resuscitation is an important element of care as the patients EF is 30%; she receives 20mg IV Lasix between the 2 nd and 3 rd unit of RBCs.

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33  Nexium and Octreotide have been validated, but mainly in UGI bleeding, they are class B/C in LGI bleeding.  If patients are receiving anticoagulants, Risk/Benefit must be carefully weighed before using their respective antidotes.  Sucralfate enemas have been shown to reduce rebleeding in patients with radiation proctitis.

34  The patient is stabilized from a cardiac perspective, but continues to pass bloody stools.  Lactate remains elevated at 3.4, and HCT does not respond appropriately to an additional 3 units RBCs- it remains low at  What are additional strategies that can be employed prior to GI surgery?

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37  The patient is taken to IR for superselective angioembolization.  Bleeding is stabilized temporarily, but the patient rebleeds.  She receives another 2 units RBCs (total in last 24 hours is 8 units).

38  She is taken to the OR for sigmoid colectomy and colostomy and does well post op.  Although angiograhic embolization did not stop the bleeding, the surgeon was able to localize the site more expeditiously and provide a more definitive resection.

39  In patients with primary re-anastamosis vs colostomy, the suture line may dehisce.  Sepsis/Intra-abdominal abscess may present ~ POD 5, if fecal spillage occurs intra-op (peritonitis)  Abdominal Compartment Syndrome  Renal Failure  Respiratory Failure

40  Two of the biggest series on GI complications in cardiac surgery come from the Texas Heart Institute Journal in 2000 and  The first is retrospective, the follow up paper is prospective.

41  N=4,463 patients; Retrospective Analysis. 113 GI Diagnoses in 86 patients. Prevalence 1.9%, Mortality 30%.  Risk Factors:  Age >70  Duration of CPB  Need for Blood transfusions  Reoperation  Triple Vessel CAD  PVD  NYHA Class IV CHF  Use of IABP/Inotropic Support post operatively (Tex Heart Inst J 2000;27:93-9)

42  N=11,058 patients; Prospective Analysis. Prevalence 1.2%, Mortality 22.5%  Complications:  UGI Hemorrhage (28.6%)  Gastroesophagitis (12.2%)  Intestinal Ischemia (11.5%)  Mixed Gastrointestinal complications (9.5%)  Pancreatitis (8.8%)  Cholecystitis (6.8%)  Perforated Peptic Ulcer (4.7%) (Tex Heart Inst J 2003;30:280-5)

43  The cohort from the second study included CABG, Valve, Combination surgery, and Adult Congenital patients.  Multivariate Analysis showed six independent predictors:  Prolonged mechanical ventilation  Postoperative renal failure  Preoperative renal failure  Sepsis  Sternal wound infection  Valve surgery (Tex Heart Inst J 2003;30:280-5)

44  Meta-analysis of 200 articles from Evidence Graded A, B, or C.  Incidence for LGI bleeds = 0.03% and for UGI bleeds ~1.5-3%.  For coffee ground emesis and heme (+), NG aspirate- UGI should be performed when a concomitant LGI bleed is present.  For UGI bleeds, TC-99 scanning can detect bleeding rates of 0.1ml/min; however-active bleeding is required for an effective test.  It may be prudent to electively intubate patients prior to UGI endoscopy. (Aliment Pharmacol Ther 2005;21: )

45  For LGI bleeds, unless emergent, a bowel prep should take place. Non-prepped bowels increase the risk of colonic perforation of the endoscope.  It may be prudent to electively intubate patients prior to UGI endoscopy.  For LGI bleeding, angiography may be therapeutic and diagnostic, but requires bleeding rates of ~1ml/min.  Diverticular bleeds and angiodysplasia account for 50-80% of bleeding when the SMA is the bowel source.  Vasopressin infusions may control 91% of these sources (Grade B), but 50% rebleed upon cessation of the drip. (Aliment Pharmacol Ther 2005;21: )

46  Transcatheter embolization using alcohol or microcoils reduces bleeding by 44-91%, however 7-40% with angiodysplasia required emergency surgery for failure or rebleed.  When angiography is successful in localizing the site, limited resection has a lower morbidity than surgery in historic controls without angiographic localization (8.6% vs 37%-Grade B).  Surgery is required when: hemodynamic instability persists, patients require >6 units RBCs, or severe bleeding recurs (Grade B/C). (Aliment Pharmacol Ther 2005;21: )

47  If in doubt, protect the airway.  Be vigilant for renal insufficiency and volume overload.  Be mindful in patients who don’t exhibit an appropriate response to RBCs- trend HCTs q6h.  Patients on anticoagulants may pose special challenges.  Be wary of contrast nephropathy in patients who have had CTA or Angiography.  Multidisciplinary care is key: engage GI and General Surgery early on and create a clear plan with clear accountabilities.

48 I would like to extend a special thanks to Dr. Yuka-Marie Vinagre for your review.


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