morbidity & mortality conference department of internal medicine catherine a. chu, m.d monina...

MORBIDITY & MORTALITY CONFERENCEDepartment of Internal Medicine

Catherine A. Chu, M.DCatherine A. Chu, M.DMonina Clauna, M.D.Monina Clauna, M.D.

OBJECTIVES

To discuss the case of a strong elderly patient who had continuous active gastrointestinal bleeding.

To discuss the role and timing of endoscopy or surgical intervention in such cases.

To discuss the appropriate fluid replacement to maintain hemodynamics in hemorrhagic shock

•E.R. •71 YEAR OLD•MALE•FILIPINO•CATHOLIC•MEYCAUAYAN, BULACAN

PATIENT

Chief Complaint

Hematemesis and

Hematochezia/ Melena

History of Present Illness

1 month PTA motorcycle accident muscular lower

extremity trauma

- Diclofenac 25mg 1 tab TID, Omeprazole 40mg 1 tab OD

1 week PTA shifted to Meloxicam 15mg BID-TID

History of Present Illness

3 days PTA hematemesis followed by hematochezia (~100ml each)

(+) dizziness no abdominal pain or no retching local hospital Hgb:5mg/dl

4 units of PRBC transfusion Endoscopy was not done Pending CP clearance Symptoms persisted

Admission

What is the duration of NSAID use that will cause bleeding?

16.3 % during the first 30 days of use20.9 % over the next 31-180 daysFor long-term users (180 days or more of

continuous NSAID use), the ulcer hospitalization rate remained elevated at 26.3

Griffin, F.R., Smalley, W.E., Ray, W.A., and Daugherty, J.R. Nonsteroidal anti-inflammatory drugs and the incidence of hospitalizations for peptic ulcer disease in elderly persons.

Am J Epidemiol 2005 Mar 15;141(6):539-45.

Review of Symptoms

No fever, headache, weight lossNo chest pain, palpitation, orthopnea,PNDNo cough, colds, dyspneaNo dysuria, hematuria, low back painNo easy bruisabilty

Past Medical History

(+) HTN – for 10 years; takes Nifedipine as needed for BP elevation up to 160/100 mmHg.

ASA taken intermittently(+) Gouty Arthritis - on Diclofenac prn(+) PUD secondary to chronic NSAID (15-20 years

ago) – reason for a previous hospital admission; previously on PPI for sometime; asymptomatic since then

(-) DM (-)Bronchial Asthma (-) liver cirrhosis (-) blood dyscrasia (-) history of surgeries

Family Medical History

(+) HTN and Coronary Artery Disease – parents

(-) bleeding dyscrasia nor oncologic diseases(-) Bronchial Asthma, DM, PTB

Personal Social History

previous smoker - stopped about 40 years ago- 3 sticks of cigarette per day non alcoholic beverage drinker

Physical Examination

Weak-looking, conscious, coherent, not in cardio respiratory distress

Vital Signs:BP :110/60mmHg, HR: 88 bpm, RR:20cpm, T

36ºC. Weight: 90 kgDry and pale skin, pale palpebral conjunctivae,

anicteric sclerae, neck vein not distendedEqual chest expansion, no retractions, clear

breath sounds

Physical Examination

Adynamic precordium, normal rate and regular rhythm, no murmur

flabby abdomen,soft, nontender, no muscle guarding, no palpable mass, no organomegaly, normoactive bowel sounds,

slightly cyanotic nail beds on lower extremities with faint pulses, (+) grade 2 bipedal edema

black tarry stool per rectum

SALIENT FEATURES

• 71 year old, Male• motorcycle accident (Diclofenac and Meloxicam)hematemesis ,hematochezia /melenaNazareno Hospital Hgb = 5mg/dlS/P 4 units of PRBC transfusion(+) Gouty Arthritis - on Diclofenac prn(+) PUD secondary to chronic NSAID(15-20 years

ago)Stable VSDry,pale, (+) cyanotic nail bed,faint pulses, grade II

bipedal edemaBlack tarry stool per rectum

Admitting Impression

•Upper Gastrointestinal Bleeding probably secondary to Peptic Ulcer Disease due to Chronic NSAID use

•S/P 4u PRBC transfusion

COURSE IN THE WARDS

0200Hawake, conversant

BP 110/60, HR 88 bpm, RR 20cpm, T36C

Skin: pale

Lungs: clear BS

Heart: NRRR

Abdomen: flabby, soft and nontender

Extremity: pale nail beds , (+),GrII peripheral edema

Rectum; black tarry stool

Patient Status

On Arrival…..

Ongoing 5th unit PRBC with700ml PNSS at KVO -right arm peripheral lineO2 at 2-3lpm Foley catheter -about 200ml yellow amber urine

0200HPatient StatusINTERVENTIONS:

NPOContinuation of BT and OxygenationPNSS 1L KVO to 80cc/hr.stat dose of Esomeprazole IV then Esomeprazole drip at 8mg/hrMetoclopramide 10mg every 8 hrs PRNDiagnostics: STAT5 and Blood typing 12-L ECG CXR

awake, conversant

BP 110/60, HR 88 bpm, RR 20cpm, T36C

Skin: pale

Lungs: clear BS

Heart: NRRR

Abdomen: flabby, soft & nontender

Extremity: slightly pale nail beds , (+) grII peripheral edema

Rectum: black tarry stool

Are we dealing with a hemorrhagic shock despite good dynamic parameters ?

Hemorrhagic shock- a condition of reduced

perfusion of vital organs leading to inadequate delivery of oxygen and nutrients necessary for normal tissue and cellular function secondary to blood loss

Krausz, M.,initial Resuscitation of Hemorrhagic shock,World journal of Emergency Surgery 2006

Hemodynamic Parameters:

•BP•PR/HR•RR•Urine output•Mentation

ATLS guidelines 2004, American College of Surgeons

Massive Hemorrhage

- Loss of total estimated blood volume(EBV) within a 24 hour period or loss of half of the total EBV in a 3 hour period

- EBV: 7% of body weight 0r 70ml/kg body weight

ex: 70kg man = 4.9L

Krausz, M.,initial Resuscitation of Hemorrhagic Shock, Journal of Emergency Surgery 2006 1:14

Are we dealing with a hemorrhagic shock despite good dynamic parameters ?

Primary goals:1. To find the source of bleeder and

prevent rebleeding (Issues: When and How?)

2. To maintain adequate hemodynamic parameters by fluid resuscitation

(Issues: Rate/Type of fluid, Roles of vasopressor)

YESHemorrhagic Shock Class I

0245H

awake, conversant

BP 110/60, HR 88 bpm, RR 20cpm, T36C

+ hematemesis (est. 10-20ml)

+ melena

Patient StatusINTERVENTIONS:

Another peripheral line was inserted at the left arm,3 units PRBC ordered for transfusion Referred to Gastroenterology service and agreed with present management.

0300H

Awake, conscious

110/60 to 80/50 80s to 120s

BP 90/50

HR 120s

BP 90/60,HR 110s

Patient StatusINTERVENTIONS:

.

200ml PNSS

200ml PNSS

Regulated to 120cc/hr Dopamine 5mcg

On going BT 1st0330

STAT5 & Blood type(extracted ()320H)STAT5 & Blood type(extracted ()320H)

Stat 5 0345HHgb 5.4 g/dlHct 16%Na 138 mmol/LK 4.4 mmol/LGlu 145 mg/dl

Blood type Type O+

RESULTS

ECG 03:17HECG 03:17H CXR 0342HCXR 0342H

RESULTS

0400H

80/60, 110s

O2 sat 69%

(+) melena 2x

BP 70/50- dizzy

(+) Chest Pain

Patient Status INTERVENTIONS:

.

0410H600ml PNSS then 120ml/hr

NC shifted to MVM 50%

0450HRegulated to 120cc/hr

0420HAnother 2u PRBC ordered

Tranexamic acid

Diagnostics: PT,PTT, Triage Panel

PT/PTTPT/PTT Triage PanelTriage Panel

0535HCKMB <1.0Myoglob. 44.2Trop I <0.05BNP 5.4d Dimer 362

RESULTS

PTT 0525HPx 23Control 27.6

PT 0525HActivity 83.1INR 1.17

5-800H

BP 70/50

HR 130s

BP 90/60

HR 130s

Initial CVP:O


0500HHaesteril 500 free flowPNSS then 120ml/hr

0750Central line inserted right arm

0645Brought to regular room

Diagnostics: CXR post intubation

RATE Since the time of World War II, the accepted

therapeutic dogma has been to restore blood volume rapidly and achieve normal physiologic parameters

Generations of physicians have been trained to reverse shock within the ‘golden hour’ in order to preserve organ function and prevent death

Early correction of the volume deficit is essential t0 prevent irreversible shock

How do we go about fluid restoration?

Gutierrez et.al. Clinical Review: Hemorrhagic Shock, Critical Care 2004


It is not possible to precisely predict the total fluid deficit in a given patient particularly if fluid loss is continous

initial resuscitation should be at least 1 to 2 liters of isotonic saline which is given as rapidly as possible

Fluid repletion should continue at the initial rapid rate as long as the systemic blood pressure remains low (guide: BP, UO, Mental Status, Periph.Perfusion)

- An arterial line: placed in all patients who fail to respond promply to initial fluid resuscitation

- CVP help direct therapy

Rose et.al. Treatment of Severe Hypovolemia in Adults,www.uptodate.com Feb 2009

8-10H

BP palp 60

HR 130s

dyspneic


0800HHaesteril 500ml free flow

Endotracheal intubation /NGT insertion

Diagnostic: ABGABG 0910HpO2 55.9pH 7.04pCO 2 30.3HCO3 7.4O2 sat. 73.1B.E. 22.9

0930H: NaHCO3 2 amps given

8-10HBP palp 60

dyspneic

BP palp 80

HR 130


0800HHaesteril 500ml free flow

Endotracheal intubation /NGT insertion

0845H500cc PNSS/Dopamine

10mcg/kg/min

Diagnostic: ABG

0930H: ReferralsCardiology,/Pulmonology/Nephrology.

1000HBP 100/60 from palp 80

HR120s

RR17

CVP O

-on dopamine of 10mcg/kg/min

Patient Status

Fluid hydration of 200ml PNSS 2d echocardiography

Cardiology Assessment:Hypovolemic shock secondary to GI bleed; Tachycardia secondary to Anemia

What fluid should we use?

What fluid should we use?

Choice depends in part upon the type of fluid that has been lost

- blood components are initially indicated in patients who are bleeding but hematocrit should not be raised above 35%*Further increase of hct is not necessary for oxygen transport.*May increase blood viscosity leading to stasis in the already compromised capillary circulation

* crystalloids/colloids are used to replace the extracellular fluid


1010HBP 100/60

HR120s

RR 28

CVP0


Patient StatusInterventions:

Results of ABG & Blood Chem reviewed by Nephrology service.

Blood Chemistry

0345H 0720HGlucose 145.04 H 236.79BUN H 69Creatinine H 1.9K 4.4 4.3Na 147Ca L 6.9Total protein L 3Albumin L 1.5Globulin 1.5A/G ratio 1Alk.Phos. 28AST 10Total Bili. 0.17Uric acid 7ALT 21Triglyceride 92.65Cholesterol 72.99HDL 13.15ALDL 41.01

1010HBP 100/60

HR120s

RR 25-30s

CVP0



Nephrology Assessment:Acute renal failure secondary to acute blood loss

Left Femoral line insertedAnother 2 amps of NaHCO3

50meqs IV and another 1 amp every 2 hours for 4 doses

fast drip of 500ml Voluven Another 2 units available PRBC

were ordered for transfusion and hematology referral suggested

Stat CBC was ordered

1040HBP 100/60

HR120s

O2 sat 98-100% from 60s


Pulmonology Assessment:

Hypoxemic Acute Respiratory Failure

•Mechanical Ventilator set at:TV 630FiO2 100RR 20AC mode

12-13H

BP 120/8 0

HR 124

BP 140/80


At 1205HDopamine dec to 8mcg/kg/min

Norepinehrine 50ng/kg/hr

Gastroenterology Service:Octreotide 100mcg SC every 8 hours Piperacillin at 2.25gm every 6HDiagnostic: CBC (then q6H)Referral to HematologyReferral to Surgery

Cleared for endoscopy

When do we use vasopressors?

Vasopressors( eg.norepinephrine and dopamine) generally should NOT be administered since they do not correct the primary problem and tend to further reduce tissue perfusion


When do we use vasopressors?

Hypovolemia should be corrected prior to the institution of vasopressor therapy

Vasopressors are indicated for a decrease of >30 mmHg from baseline systolic blood pressure, or a mean arterial pressure <60 mmHg when either condition results in end-organ dysfunction due to hypoperfusion.

Nalaka et al, Use of vasopressors and inotropes. www.uptodate.com Mar 2009

12-13HBP 140/8 0

HR 120s

O2sat 98-100%


• Result of CBC reviewed by Hematology service

CBC 0345H 1135HHgb 5.4 3.7Hct 16 11.3WBC 18.83Segm 75Lympho 16Platelet 80,000

12-13HBP 140/8 0

HR 124

O2sat 98-100%


Hematology Assessment:Anemia of acute bleeding; dilutional thrombocytopenia and coagulopathy

• 7th unit PRBC ordered for transfusion•Transfusion will be subsequently followed up with 2 units of FWB.•2 units PRBC, 4 units FFP and 1 unit platelet apheresis secured for standby.

CBC

CBC 0345H 1135H 1415HHgb 5.4 3.7 3.4Hct 16 11.3 10.4WBC 18.83 12.83Segm 75 73Lympho 16 20Platelet 80,000 45,000

14-16HConscious

Communicates by sign language

BP 140/8 0

HR 120s

95-98%

(+) continouos bleeding per rectum


1600H Patient was seen by the surgery resident yet the consultant was out of the country

1400H Three 500ml Voluven; Two 500ml Haesteril Calcium Gluconate 2g SIVP Human Albumin 25% 100 FD Two free flowing PNSS lines

1630H

Patient restless

Bp 140/80

HR 130s

BP NA

HR NA

Flatline by cardiac monitor


1630H

Self extubation

•Reintubation attempted immediately but patient arrested after about 3 minutes extubation•CPR •Meds:Total of 5 doses of Epinephrine, 2 doses of Calcium Gluconate and 2 doses of NAHCO3

•expired after 25minutes CPR.

Cardiopulmonary Arrest secondary to Multiple Organ

Failure secondary to Hypovolemic Shock from

NSAID Induced UGIB

DIAGNOSIS

Urgent Endoscopy Vs. Surgery in Massive GI

Bleeding

A Study of Jensen et al. on Severe hematochezia with an unknown

cause

Objectives: to prospectively evaluate(a) the evaluate the diagnosis and treatment of 80 consecutive patients with severe, ongoing hematochezia from unknown source(b) the effectiveness and safety of urgent endoscopy after oral purge.

Jensen, D.M., and Machicado, G.A. Diagnosis and treatment of severe hematochezia. The role of urgent colonoscopy after purge.

Gastroenterology 2004 Dec;95(6):1569-74.


cause

Fifty-two men and 28 women (mean age, 64.5 yr) received a mean of 6.5 U of blood and had negative endoscopy, rigid sigmoidoscopy, and nasogastric tube aspiration before our evaluation.

Emergency panendoscopy was performed before purge.




causeUrgent endoscopy was performed in the

intensive care unit after patients received oral purge and their gut was cleared of blood, clots, and stool.

Final diagnosis: 74% colonic lesions (30% angiomata, 17% diverticulosis, 11% polyps or cancer, 9% focal ulcers, 7% other), 11% UGI lesions and 9% presumed small bowel lesions.

Jensen, D.M., and Machicado, G.A. Diagnosis and treatment of severe hematochezia. The role of urgent colonoscopy after purge. Gastroenterology 2004 Dec;95(6):1569-74.


cause

No lesion site was identified in 6%.64% of patients had intervention for control of

bleeding: 39% had therapeutic endoscopy, 24% surgery, and 1% therapeutic angiography.

For 22 pxs who also had emergency visceral angiography, the diagnostic yield was 14% & the complication rate was 9%.

Jensen, D.M., and Machicado, G.A. Diagnosis and treatment of severe hematochezia.

The role of urgent colonoscopy after purge. Gastroenterology 2004 Dec;95(6):1569-74.


cause

Conclusions: (a) Before urgent colonoscopy and purge, emergency

panendoscopy was indicated to exclude an upper gastrointestinal bleeding source.

(b) Urgent colonoscopy after purge was effective, safe, and often diagnostic.




cause

Conclusion:(c) Compared with urgent endoscopy, urgent visceral angiography was often nondiagnostic

(d) Hemostasis via colonoscopy has a definitive role in the treatment of some focal colonic lesions such as bleeding angiomata


Gastroenterology 2004 Dec;95(6):1569-74

Non-Variceal Upper Gastrointestinal Hemorrhage: Guidelines

Endoscopy is done urgently in patients who have sustained major bleeding but it was emphasized that it should only be done when resuscitation has been achieved.

Ideally blood pressure and CVP should be stable but in patients who are actively bleeding this is not always possible.

Palmer, K.R. Non-Variceal Upper Gastrointestinal Hemorrhage: Guidelines. Gut. 2002: 51 (Suppl IV): iv1-iv6.

Endoscopic therapy for Acute Non-Varicial Hemorrhage: a Meta-Analysis

Endoscopic therapy reduces rebleeding, need for surgical intervention&mortality. (Grade A)

A range of endoscopic treatments are available for treating patients who have major stigmata of recent hemorrhage like injection of adrnaline, application of heater probe/ multipolar coagulation or mechanical clips.

Cook, D.J., Gayatt, Gayatt, G.H., Salena, B.J., et al. Endoscopic therapy for Acute Non-Varicial Hemorrhage: a Meta-Analysis. Gastroenterology 1992; 102: 139-

148

Endoscopic retreatment compared with surgery in patients w/ recurrent bleeding after

initial endoscopic control of bleeding ulcers

Patients whose rebleeding is treated by further endoscopic therapy have at least as good a prognosis as those randomised to urgent/emergent surgery without repeat endoscopic therapy. (Grade A)

Lau, J.Y.W., Lam T., et al. Endoscopic retreatment compared with surgery in patients w/ recurrent bleeding after initial endoscopic control of bleeding

ulcers. New England Journal of Medicine. 1999. 340; 751-6

Take Home Message

Hemorrhagic shock can be rapidly fatal. Uncertainties remain regarding the best

method for resuscitation, what type of fluid, how much,when, and how fast

Resuscitation may well depend on estimated severity of hemorrhage

Endoscopy must be done urgently in patients who have sustained massive bleeding but in patients who are actively bleeding this is not always the case; thus, taking the risk of performing endoscopy must be considered.

ATLS guidelines 2004, American College of Surgeons

Aggressive resuscitation of hemorrhagic shock however raises the concern on the scenario that

“ raising the blood pressure in a bleeding patient would eliminate the clot and increase bleeding’


Cannon WB, Fraser J, Cowell EM: The preventive treatment of wound shock. JAMA 1918, 70:618-621.34.


A total of 598 matched control patients with SBP of 60mmHg were included in the study group

immediate resuscitation group received an average of 900 ml fluid- 62% were discharged

Delayed resuscitation group 100 ml fluid in the delayed - 70% were discharged, as compared with of the immediate

- trended to have fewer complications.

Bickell WH, et al.: Immediate versus Delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl JMed 1994, 331:1105-1109.


systematic review of the animal studies also showed an increased risk for death from aggressive resuscitation in animals with less severe hemorrhage

- suggesting that excessive fluid resuscitation can be instituted when there is the presence of severe hemorrhage

Mapstone J, Roberts I, Evans P: Fluid resuscitation strategies: a systematic review of animal trials. J Trauma 2003, 55:571-589.

Colloid vs Crystalloid

- Some advocated to colloid containing solution due to 2 possible advantages:

1. More rapid plasma vol expansion since colloid remains in the vascular space2. Lesser risk of pulmonary edema since dilutional hypoalbuminemia will not occur


Colloid vs. Crystalloid

Although colloid prevent pulmonary edema, it is not effective in preserving pulmonary function.

Several studies showed that saline solutions are equally effective in expanding plasma volume

Although 1.5-3x as much saline must be given because of its extravascular distribution. - not deleterious since fluid loss also leads to an interstitial fluid deficit

Acute saline-induced hypoalbuminemia can lead to peripheral edema (cosmetic but not life threatening)


Colloid vs Crystalloid

Saline solutions are generally preferred in patients with severe volume depletion

- safe and effective, less expensive


What is the role of buffer therapy?

Patients with marked hypoperfusion may develop lactic acidosis leading to reduction in extracellular pH below 7.10.

Marked acidemia may contribute to continued tissue hypoperfusion by decreasing cardiac contractility via a reduction in myocardial cell pH

- administration of NaHCo3 may be of benefitHowever, variety of problems may be

encountered in Na HCO3 infusion- Fluid overload, postrecovery metabolic

alkalosis, hypernatremia


Utility of bicarbonate administration to patients with severe metabolic acidosis remains controversial

In general, bicarbonate should be given at an arterial blood pH of </=7.0.

The amount given should be what is calculated to bring the pH up to 7.2.

- Bicarbonate can also prevent improvement in cardiac function by inducing a fall in the ionized calcium due to increased protein binding

- Cautious administration of Calcium may be necessary

Sabatini et al, Bicarbonate Therapy in Severe Metabolic Acidosis ,J Am Soc Nephrol 20: 692-695, 2009


The urge to give bicarbonate to a patient with severe acidemia is apt to be all but irresistible. Intervention should be restrained, however, unless the clinical

situation clearly suggests benefit

Sabatini et al, Bicarbonate Therapy in Severe Metabolic Acidosis J Am Soc Nephrol 20: 692-695, 2009

When and how much to transfuse?

The use of blood and blood products is necessary when the estimated blood loss from hemorrhage exceeds 30% of the blood volume (class III hemorrhage)

a hypotensive patient who fails to respond to 2 lcrystalloid in the face of probable hemorrhage should be treated with blood and blood products.

Guillermo etal, Clinical Review: Hemorrhagic Shock, Critical Care 2004


American College of Physicians, the American Society of Anesthesiology, and the Canadian Medical Association Guidelines for blood transfusion

- recommend a hemoglobin level between 6 and 8 g/dl as a threshold for transfusion in patients without known risk factors

- They also agree in their disapproval of prophylactic blood transfusion, because patients with hemoglobin levels greater than 10 g/dl are unlikely to benefit from blood transfusion.

Guillermo etal, Clinical Review: Hemorrhagic Shock, Critical Care 2004


A study conducted by Wu and coworkers indicated that a substantial number of people who present to the hospital with acute myocardial infarction and a hematocrit of 24% or lower may benefit from blood transfusion.

Wu etal, Blood transfusion in the Elderly Patients with Acute Myocardial Infarction,N eng J Med 2001,345: 1230-1236


In a restrospective analysis of data from 78,974 patients aged 65 years or older and who were hospitalized with acute myocardial infarction

those with lower hematocrit values (<24%) on admission had higher 30-day mortality rates.

Blood transfusion was associated with a reduction in 30-day mortality among patients whose hematocrit on admission was in the 5–24% range.

Blood transfusion did not improve survival among those whose hematocrit values fell in the higher ranges.

Wu etal, Blood transfusion in the Elderly Patients with Acute Myocardial Infarction,N eng J Med 2001,345: 1230-1236

Emergency Angiography

50 pxs with massive gastrointestinal bleeding were initially managed with emergency angiography.

The average age was 67.2; mean hematocrit, 23.7; and average transfusion, 7.6 units.

36 pxs (72%) had bleeding site located.

Browder , W., Cerise, E.J. and Litwin, M.S. Impact of emergency angiography in massive lower gastrointestinal bleeding. Ann Surg 2006 Nov;204(5):530-6.

Impact of emergency angiography in massive gastrointestinal bleeding

20 of 22 (91%) pxs receiving selective intra-arterial vasopressin stopped bleeding

50% rebled on cessation of vasopressin.35 of 50 (70%) patients underwent surgery,

with 57% operated on electively after vasopressin therapy.

17 pxs had surgery, with no rebleeding.


Impact of emergency angiography in massive gastrointestinal bleeding

9 of the 17 patients had diverticular disease in the remaining colon.

Operative morbidity in these 35 patients was significantly improved when compared to previously reported patients undergoing emergency surgery without angiography (8.6% vs. 37%) (p less than 0.02).


Impact of emergency angiography in massive gastrointestinal bleedingConclusion:Emergency angiography successfully locates the

bleeding site, allowing surgery. Vasopressin infusion transiently halts bleeding,

permitting elective surgery in many instances.


morbidity & mortality conference department of internal medicine catherine a. chu, m.d monina...

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