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An Approach to GI Bleeding in the Cardiac Surgery patient

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1 An Approach to GI Bleeding in the Cardiac Surgery patient
Ryan O’Gowan, MBA, PA-C FAPACVS FCCM St. Vincent Hospital, Worcester, MA

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

3 Objectives 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 Patient scenario 1 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.

5 Perspectives on management
All Bleeding Stops Eventually!

6 Patient scenario 1 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? Risks for bleeding: Drug-drug interactions with Coumadin-Amiodarone-Levofloxacin. Question of Alcohol abuse.

7 Approach to GI Bleeding-shock
Image credit: lifeinthefastlane.com American College of Surgeons Committee on Trauma- ATLS Course Guidebook

8 Next steps in management
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. Circulation: Per the 2008 revisions of ACLS- ABCD has been supplanted by CAB. Discuss options for fluid management and temporizing measures of crystalloid fluid replacement. For airway management: discuss GCS assessment of LOC as well as the LEMON criteria- L=Look externally (facial trauma, large incisors, beard or moustache, and large tongue) E=Evaluate the rule (incisor distance <3 fingerbreadths, hyoid/mental distance <3 fingerbreadths, thyroid-to-mouth distance <2 fingerbreadths) M=Mallampati (Mallampati score 3) O=Obstruction (presence of any condition that could cause an obstructed airway) N=Neck mobility (limited neck mobility). CITATION(S): Reed MJ et al. Can an airway assessment score predict difficulty at intubation in the emergency department? Emerg Med J 2005 Feb; 22: Breathing: assess for tachypnea, use of accessory muscles, pulse oximetry, and ABG if possible.

9 Localizing the site of bleeding
Not all bleeding is created alike: Above the Ligament of Treitz- Hematemesis Melena Below the Ligament of Treitz- Hematochezia Image credit: Be sure to discuss definitions of hematemesis, melena, and hematochezia. A majority of CTS patients receive iron supplementation, which can be misinterpreted as melena (dark, heme + stools). Ensure that all patients receiving anticoagulation have orders to heme all stools.

10 Initial Management 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. Ice water lavage: no evidence supports ice water vs. tap water. Ensure that a fixed amount of lavage is used so that I/Os will be precise. Patients with variceal bleeding may have a Sengstaken Blakemore tube placed to tamponade bleeding vessels. S-B tubes are not definitive management and need to be followed by GI consultants and UGI endoscopy. Labs: trend labs, posit question to audience: how frequent, how often, should ABGs be performed, what about Lactate. When should serial labs be stopped? When 2 HCTs are stable. Fluid resuscitation: in largest trial of trauma patients: SAFE study, no benefit of colloids vs. crystalloids in mortality. However, in CTS patients, need to be wary of CHF and increased extra-pulmonary lung water.

11 Initial Management Image credit:
https://www.jhmicall.org/GDL_Disease.aspx?CurrentUDV=31&GDL_Cat_ID=AF793A59-B736-42CB-9E1F-E79D2B9FC358&GDL_Disease_ID=FE B B-3256E859CD01

12 Calculating the extent of bleeding
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. Class 1: < 15% Class 2: 15-30% Class 3: 30-40% Class 4: >40% VD= Blood Volume (BV) x Percent Loss. The ICU Book, 3rd Edition. Marino, et. Al.

13 Pharmacologic Adjuncts
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) IV Omeprazole 20mg q12h. Omeprazole infusion 8mg/hr.

14 Pharmacologic Adjuncts-special circumstances
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. Abx:Indicated for cirrhotic patients Amicar: don’t bother.

15 Differential Diagnosis of UGI Bleeding
Barret’s esophagus Esophageal cancer Esophagitis Gastric Cancer Gastric Ulcer Gastrinoma Mallory Weiss Tears Variceal Disease

16 Patient scenario 1-continued
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. Query audience with significance of base deficit.

17 Diagnostic Evaluation
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. 2010 August 21; 16(31): 3957–3963.) Emphasis on utility of UGI in patients whose histories clearly point to variceal bleeding. N.B., these patients may be turned down for routine CT surgical interventions based on higher baseline MELD scores.

18 UGI-electrocautery Image credit:

19 Ugi-Variceal banding Image credit:
https://www.jhmicall.org/GDL_Disease.aspx?CurrentUDV=31&GDL_Cat_ID=AF793A59-B736-42CB-9E1F-E79D2B9FC358&GDL_Disease_ID=FE B B-3256E859CD01

20 Patient scenario 1-continued
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 Diagnostic Evaluation
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. Tagged RBC scan requires a large volume of active blood loss to be read as positive. Angiography may be more sensitive; however, it may also require a significant amount of active bleeding.

22 Positive tagged rbc scan
Image credit:

23 Positive Angiographic study
Image credit:

24 Patient scenario 1-continued
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. Emphasis on following points: Large amount of bleeding needs to be present for adequate visualization. Cautery of ulcers may lead to a false sense of security. Re-bleeding typically occurs when patients “stabilize”; i.e.- high normal blood pressures may dislodge clot. Based on 2009 SCCM surgical critical care paper, permissive hypotension may have a role in preventing re-bleed in post op bleeding patients. Create a smooth transition point between upper and lower GI bleeding.

25 Patient scenario 2 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 Identification of lower GI bleeding
Physical Exam is the first step. External hemorrhoids are often overlooked. LLQ pain may be indicative of diverticulitis, another common cause.

27 Differential diagnosis- lgi bleeding
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 Patient scenario 2-continued
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?

29 Colonoscopy- IschEmic Sigmoid colitis
Image credit:

30 resuscitation 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 Patient scenario 2-continued
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 4th ICS. Judicious fluid resuscitation is an important element of care as the patients EF is 30%; she receives 20mg IV Lasix between the 2nd and 3rd unit of RBCs.

32 LGI Algorithm Image credit:

33 Pharmacologic Adjuncts
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 Patient scenario 2-continued
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 22.1. What are additional strategies that can be employed prior to GI surgery?

35 Ima angiography Image credit:

36 Superselective angioembolization
Image Credit:

37 Patient scenario 2-continued
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 Emergent surgery 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 Post operative complications
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 Cardiac Surgery literature review
Two of the biggest series on GI complications in cardiac surgery come from the Texas Heart Institute Journal in 2000 and 2003. The first is retrospective, the follow up paper is prospective.

41 Cardiac Surgery literature review
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 Cardiac Surgery literature review
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%) Gastroesophagitis (12.2%) UGI Hemorrhage (28.6%) Perforated Peptic Ulcer (4.7%) Cholecystitis (6.8%) Pancreatitis (8.8%) Intestinal Ischemia (11.5%) Mixed Gastrointestinal complications (9.5%) (Tex Heart Inst J 2003;30:280-5)

43 Cardiac Surgery literature review
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 GI literature review 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 GI literature review 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 GI literature review 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 Summary points 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 Thank you for your time and attention.
I would like to extend a special thanks to Dr. Yuka-Marie Vinagre for your review.


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