Acute medical/ critical care issues facing the GI doctors

1. Acute medical problems in
GI practice
Krishnadas
MMM-IGLD

2. Overview
• Hypovolumic shock
• Early goal directed therapy in septic shock
• The bleeding coagulopathic patient & blood
product use
• Stress ulcer prophylaxis in the ICU

3. Hypovolumic shock

4. Hypovolumic shock resuscitation
• Shock reversible initially (vascoconstrictive) but rapidly
becomes irreversible (vasodilatation)
• Early rapid correction of Hypovolumic shock prevents the
development of irreversible shock
• Treat it like door to fluid time!!

5. Hypovolumic shock resuscitation
• Always consider 1-2L of isotonic saline STAT to restore tissue
perfusion
• The above may not be appropriate in the cirrhotic pt

6. Which fluid?
• Blood/PRCs are the fluids of choice in the bleeder
• Try not to raise hematocrit more than 30-35%
• Choices available: Colloids including hyperoncotic
starch, RL, NS, DNS. 5%D etc

7. Colloid vs Crystalloid
• Colloids not better than crystalloids & also costly
• Large volumes of crystalloids may be required( x 3 times) due
to interstitial distribution
• Saline also corrects interstitial fluid deficit
• Hyperoncotic starch solutions increase AKI, Coagulopathy &
mortality!!
• ? RL better than NS as it is buffered solution

8. How to give fluids rapidly?
• How good is our humble venflon?
• Is central line necessary for rapid fluids ?
• Answers: wide bore venflon has excellent flow rates; Central
line is not always necessary for volume resuscitation alone
• Mandatory to insert 2 X 16 G venflons in shock

9. Venflon flow rates
• 20g :40ml/minute
• 18g :75ml/minute
• 16g :150ml/minute
• 14g :300ml/minute
• For equal diameters, peripheral cannulas of shorter lengths
can achieve almost twice the flow rates!
• 16G CVC of 16cm length has flow rate of 50mL/minute only!!

10. Central venous catheterization
• Mandatory when shock not reversed with early resus or
when 2 X 16G cannula access is not feasible
• CVC is mandatory in the co-morbid patient for better
hemodynamic assessment
• Which CV vessel access is safer?

11. Central venous catheterization
• Which is easiest?
• Would you put it in a patient with coagulopathy?
• Is femoral any good for CVP monitoring?

12. Central venous catheterization
• USG guided versus landmark technique.
• Pronovost checklist adherence proven to reduce infection
related mortality: CDC recommendation
• Hand washing
• Full barrier precautions during insertion of CVCs
• Chlorhexidine for skin disinfection
• Avoidance of the femoral insertion site
• Removal of catheters when no longer indicated

13. Pulmonary artery catheterisation
• Useful when CVP is unreliable i.e DCM, pulmonary HTN etc
• No mortality benefit shown; falling out of favor
• Still widely used though.

14. Vasoactive agents
• Always “fill up” the hypovolumic patient adequately before
vasoactive agents are started
• Nor epinephrine : agent of choice in warm sepsis- DB-RCT of
32 pts ( NE vs Dopamine, 93 vs 31 % MAP response)
• Cold sepsis: NE better than dopamine
• SOAP study-Observational study which suggested inferior
outcome in dopaminised ICU patients-? dysrhythmias

15. Buffer therapy in shock
• Bicarbonate therapy is controversial in hypo perfusion lactic
acidosis
• Current recommendation-Treat underlying pathology i.e.
Shock; Use bicarb to keep pH>7.15 only

16. Septic shock & EGDT
• Septic shock = SIRS + SBP< 90 after fluid challenge at
30min/lactate>4mmol/L
• SIRS: Temp>38 or<36--- HR >90---RR>20 or paCO2<32—WBC>12K or<4K
or>10% immature bands ( 2 of these 4 is SIRS)

17. Septic shock & EGDT
• EGDT is a globally accepted intense hemodynamic monitoring based
resuscitation protocol for septic shock published by Dr.E.Rivers in NEJM
2001
• The protocol starts in ED not ICU!!
• EGDT is a part of sepsis bundle including broad spectrum Abx, glycemic
control, steroid etc

18. Typical EGDT protocol

19. Management of bleeding in a
patient with coagulopathy

20. Use of Vitamin K
• Vit K- PO safest; IV only for rapid correction
• Use lowest possible vit K dose (5-25mg)
• Vit k iv to be given over 30 min
• Vit k can take 6- 24 hours to correct INR!

21. Fresh Frozen Plasma
• FFP dose-10-15ml/kg
• Formula exists for exact dose calculation of FFP to achieve
target INR
• Amount of FFP needed (ml) =
(target level as % - present level as %) x Wt.(kg)

22. FFP dose calculation
• % of prothrombin complex at various INR
ranges:
• INR 1 = 100 (%)
• INR 1.4 - 1.6 = 40
• INR 1.7 - 1.8 = 30
• INR 1.9 - 2.1 = 25
• INR 2.2 - 2.5 = 20
• INR 2.6 - 3.2 = 15
• INR 4.0 - 4.9 = 10
• INR > 5 = 5 (%)

23. FFP dose calculation
• Please calculate the FFP dose required to correct INR of a pt
(70Kg) to 1.4;He is bleeding & INR is 7.5.
• FFP in mL=(40-5)X70= 2450mL
• This was published in NEJM August 2003
• FFP helps but volume may be problem in the DCLD patient

24. Platelet transfusion
• Transfuse in a bleeding pt below 0.5 X1011/L, non bleeding febrile pt < 0.2
X1011/L, non bleeding afebrile pt < 0.1 X1011/L.
• UK blood services: 1 Adult therapeutic dose- 75% of it should contain at
least 2 .4 X 1011 PLTs
• Choose single donor apheresis platelet than pooled to reduce
alloimmunisation/ multi donor exposure
• Check for PLT refractoriness: counts @ 1&24hours post

25. Platelet transfusion
• 1 U Whole blood PLT concentrate may contain 0.55 to 0.8 x 1011 only
• 1 U apheresis PLTs has 3 to 6 x 1011
• 1 ATD increases count by 0.3 X1011 /L in 10-60 min post-transfusion
• Splenic sequesters with thrombocytopenia-optimal target not agreed
upon; ? Treat when bleeding alone/ prophylaxis for high risk procedures

26. Prothrombin complex concentrates
• They are Vit K dependant factors-2,7,9 &10
• Currently licensed for use in warfarin associated severe
bleeding only
• But has been successfully used to reduce INR in bleeding CLD
pts including variceal
• Dose 50U/kg
• ? Available in Chennai

27. Recombinant activated Factor VII
• rVIIa works by causing thrombin burst & can cause powerful coagulation
• Coagulopathy is corrected instantly & lasts for 2 hours
• rVIIa (novoseven) may help in life threatening bleed when all else has
failed/Useful in volume intolerant patients
• Novoseven is available in Chennai

28. Recombinant activated Factor VII
• In Cirrhosis it may supplement FFP , to reduce volume required to correct
INR
• FDA approved indication in acute liver failure pts requiring invasive
procedures
• Dose 5-120 mcg/kg; average dose used 40mcg/kg

29. Prevention of GI bleed in the ICU
STRESS ULCER PROPHYLAXIS

30. The American Society of Health System
Pharmacists-Major Risk Factors
• Mechanical Ventilation for 48 hours or more
• Coagulopathy-PLT<50K, INR>1.5, PTT 2 X control
• GI Bleed in the last year
• Traumatic brain/spinal injury
• Burns>35% of BSA

31. Minor Risk Factors
• Sepsis
• ICU admission > 1 week
• Occult GI bleed> 6 days duration
• Glucocorticoid therapy-250mg of hydrocortisone or
equivalent
• Need 2 or more of the above

32. Why SUP is important?
• Overt GI bleed with Stress Ulceration increases mortality
• A prospective cohort study showed that mortality was higher
among ICU patients with clinically important GI bleeding than
among those without bleeding (49 vs 9 %)

33. Which agent to use?
• PPI only slightly better than H2RA -difference very small.
• Level A evidence is for H2RA/sucralfate only
• PPI/H2B better than sucralfate / antacids.
• Early Enteral nutrition appears effective SUP but drug therapy
still recommended

34. Which agent to use?
• Continuous infusion of H2RA better than bolus
• H2RA/PPI associated with nosocomial pneumonia than
sucralfate-more research needed
• Choose patient/drug in a case-by-case basis

35. Any questions?

36. Thank you & have a great day!