Day #11 - Upper GI Bleed

Today's case was of an acute upper GI bleed.

The essentials on management include:

• Attend to airway and breathing first -- if you need to intubate to protect the airway in massive hematemesis or to facilitate safe endoscopy you should do so
  
• Circulation:
  1) Obtain good peripheral access -- '2 large bore' peripheral IVs (16-18ga), one in each arm. A 3-lumen central line is not as effective as two good peripheral lines -- if central access is required a CORDIS can be inserted centrally and can be used to deliver blood and fluids quickly.
  2) Volume resuscitate the hypotensive patient with crystalloid and blood (ideally cross matched, in an emergency can use un-matched but best not to)
  3) Use vasopressors as required while rescucitating but avoid VASOPRESSIN.
  
• Stop the bleeding:
  1) Reverse coagulopathies -- FFP for INR >1.5, Platelets if <50-100
  2) High dose proton pump inhibitor --> can reduce need for transfusion and downgrade gastroscopy findings
  3) Octreotide for suspected/known variceal bleed
  4) Arrange for urgent endoscopy if appropriate
  5) In variceal bleed where endoscopy will be delayed can use local tamponade with Blakemore or Linton tubes (ICU)
• In "massive" transfusion remember:
  1) Transfuse ~ 1u platelets per 5 of blood
  2) Transfuse ~2-4u FFP and ~10 of cryoprecipitate per 10 of blood
  3) Replete calcium because citrate in blood with chelate it and calcium is required for coagulation
  4) Watch for hypothermia (warm the blood if possible) and hyperkalemia (blood has a high K load)
• Prophylaxis for SBP in cirrhosis --> ciprofloxacin or ceftriaxone IV

Regarding the steroid issue -- steroids are associated with a RR of 2.4 for gastric bleeding which increases to 4 in the context of low dose NSAIDs and 12.7 in the context of high dose NSAIDs.