Burst Mode. Blood Transfusion in Acute GI Hemorrhage. Victor Tseng, MD Internal Medicine Emory University School of Medicine

Transcription

1 Coached by Roshan Patel, MD Burst Mode Blood Transfusion in Acute GI Hemorrhage Victor Tseng, MD Internal Medicine Emory University School of Medicine

2 WHAT S SPECIAL ABOUT ACUTE GI BLEEDING? It s the bleeding that our specialty (IM) takes care of! Other considerations Mucosa are uniquely susceptible to platelet and coagulation dysfunction No tamponade effect within hollow lumen Only vague estimation of bleeding rate is possible 10% coincidence with acute thrombotic disease (DVT, ACS) 10% chance of obscure bleeding

3 YOU SHOULD KNOW 1. Is acute isovolemic (aka hemodilutional) anemia dangerous to my actively bleeding patient? 2. What is the hemoglobin target, and does it matter? 3. What s the deal with large bore IVs?

4 51 F Grady, March 2015 Essential Hypertension + LVH, Peripheral Atherosclerotic Disease with Chronic Claudication, Alcoholism complicated by Hepatic Steatosis and Accelerated Osteopenia In the ER with melena and maroon stools x 8 episodes over 2 days. Called by floor team after active witnessed melena. She is otherwise asymptomatic. Medications: ASA 81, Naproxen PRN, Lipitor 40, Norvasc 10, Chlorthalidone 25, Ca/D 2 VS: T 35.8, P 112 sinus, BP 112/54, R 22 manual, SpO2 = 99% ambient Exam: thin female, AO x 4, psychomotor slowing, pallid face and palpebrae, cool and clammy skin, icy cold distal extremities, hyperdynamic precordium, JVP supraclavicular, normal radial pulses, right femoral bruit, clear lungs, soft and nontender abdomen with hyperactive bowel sounds, DRE melanic stool Labs: Hb 6.8 (10.2 in Feb), creatinine 1.4, BUN 42, protime 19 (INR 1.5), platelet 236, lactate 1.6

5 RBCs typed and cross-matched. They will be ready in around 90 minutes. IV access = 20 g x 3. Intravenous PPI infusion is begun. Intern: We need to prioritize the circulation. Let s give a bolus of 2 liters crystalloid (plasma-lyte A) while waiting for the blood Student 1: No, we can t risk the hemodilution. She could become unstable from the anemia Student 2: Let s get GI to scope her right now so we can get hemostasis while waiting for blood

6 Delivery of O 2 (DO 2 ) CO x [1.39 Hb S p O P a O 2 ] Oxyhemoglobin Gas (Dissolved)

7 Effects of Acute Isovolemic Anemia No change in preload (volume) status CVP and PCWP remain constant Increase in Cardiac Output by 2-fold This is mediated by equally tachycardia (HR) and stroke volume index (SVI)

8 Effects of Acute Isovolemic Anemia At Hg < 7, a net decrease in DO 2 by 25% This is due to overwhelming dependence of oxygen transport on oxyhemoglobin Delivery but no deleterious physiologic effects ST depression in 2/32 patient No lactic academia No chance in anaerobic threshold, VO 2 Even when DO 2 reduced even further by addition of esmolol and diltiazem! Consumption Mixed Venous O 2

9 Is hemodilution dangerous to my actively bleeding patient? i.e. can I resuscitate acutely with RBC-free IVFs? Hb 7 Hb < 7 No acute ischemia No issues Fluids reduce DO 2 but well-tolerated physiologically Acute ischemia present (e.g. primary ΔST, oliguria, lactic acidosis) IVF will help DO 2 Wait for blood Start vasopressors/inotropes for shock and maximize P a O2 in this situation Exception: some patient are dependent on DO 2 (sepsis, cellular respiratory chain poisoning CN, salicylates)

10 Estimating Bleed Rate MANIFESTATION If UGIB (ml/hr) If LGIB Coffee-Ground Emesis (CGE) 10 None Blood-Streaked Browns None 10 Melena 25 Rare (Cecal) Maroonic Stool Hematochezia (BRBPR) > 200 Anything > 5 Frank Hematemesis Anything > 20 None

11 Barcelona UGIB Transfusion Trial of 7 vs 9 NEJM 2013 Hb goal > 7 associated with survival benefit Driven largely by reduced rebleeding risk in class B cirrhotic patients Patients with recently symptomatic arterial ischemia were excluded

12 TANK UP Deficit from Target + CATCH UP Ongoing Bleeding Hb 7 Hb 8 Hb 10 Hb? General goal Including NDHF, sepsis, ICU Compensated chronic ischemia or Urgent non-cardiac surgery Acute ischemia (TIA, ACS) Hemorrhagic shock Ongoing Exsaguination RBC x 1 per 400 ml Melena 300 ml Hematochezia 200 ml Hematemesis

13 What is the hemoglobin target, and does it matter? Goal Hb 7 generally and especially in portal hypertensive bleeding Goal Hb 10 for acute cardiac or cerebral ischemia. Hemorrhage-induced ischemia has never been studied in a randomized fashion 400 ml melena = 1 unit RBC transited through GI tract over 8 hours All ongoing GI bleeding requires admission to ICU Numeric thresholds are irrelevant in a rapidly exsanguinating patient.

14 BACK IN THE ED 3 units RBC are now at bedside. Patient s hemodynamics have deteriorated: P 130 and BP 92/55. Another episode of maroon stool occurs. The ED resident has just placed a subclavian central venous triple lumen line due to hypotension. Lactated Ringers (LR) is being infused through one PIV. Intern 1: Alright, we need to give the blood through the central line right away No. Blood cannot be transfused rapidly through a central line. Intern 2: The patient is shocky. Let s give three units simultaneously through each PIV No. Units must be given sequentially per RN and hospital protocol. Student: Yeah, they are crashing. We need to pressure-bag the blood, one unit through each infusion port of the central line No. For the two reasons listed above.

15 ORANGE GRAY/TLC GREEN PINK BLUE YELLOW

16 Flow L ΔP r Flow = π ΔP r 4 8 η L viscosity Cutting the radius by half is the same as multiplying the length by a factor of 16! It takes 16 times as much pressure to get the same flow through half the radius!

17 Small Bore Large Bore COLOR Gauge Maximum RBC Flow (ml/hr) Hrs per RBC Unit Units/Hr CORDIS ~ ORANGE GRAY GREEN PINK BLUE YELLOW Cannot Use

18 What s the deal the large bore IVs? IV access is the limiting factor in rapidly bleeding patients, not blood availability It takes 1 hour to transfuse 1 RBC unit with an 18-g PIV Units must be given sequentially, unless O-neg massive transfusion protocol Central line lumen is 16-g. Only indicated for pressor administration Pressurized blood can only be given through IV 16-g Place a cordis for brisk bleeding or hemorrhagic shock

19 SUMMARY 1. Is acute isovolemic (hemodilutional) anemia dangerous to my actively bleeding patient? Only if Hb < 7 + active ischemia Fluids reduce DO 2 overall, but it is usually inconsequential Wait for blood if ischemia is due to anemia 2. How much blood to give? Hb > 7 and INR 1.5 for endoscopy Hb > 10 for cardiac ischemia Use bleeding manifestation to ballpark ongoing loss Excessive transfusion leads to increased mortality

20 SUMMARY 3. What are the advantages of large bore PIVs? Faster flows under lower pressures less hemolysis Transfuse one unit at a time, unless activating MTP A central venous line is ineffectual for rapid transfusion IV access, not blood availability, is the limiting factor 1 unit, 1 hour, 18 guage

21 REFERENCES 1. Weiskopf et al. Human cardiovascular and metabolic response to acute, severe isovolemic anemia. JAMA Jan 21;279(3): Leiberman et al. Critical oxygen delivery in conscious humans is less than. Anesthesiology Feb;92(2): Villaneuva et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med Jan 3;368(1): Cooper et al. Conservative versus liberal red cell transfusion in acute myocardial infarction (the CRIT Randomized Pilot Study). Am J Cardiol Oct 15;108(8): Carson et al. Liberal versus restrictive transfusion thresholds for patients with symptomatic coronary artery disease. Am Heart J Jun;165(6): An environment that does not nurture one's sense of purpose will only dull it over time. George Mathew, M.D

22 Appendix Massive Transfusion Protocol

23 Threshold in Acute Coronary Syndrome: Unresolved CRIT Trial AJC 2011 vs New Brunswick Trial AHJ 2013 KEY POINT: Effect of active bleeding not studied. Are these data applicable to unstable coronary disease that is specifically provoked by GIB?

24 Ooze 1 2 units per day Frank Non-Brisk 3 6 units per day Brisk Hemorrhage > 3 units in 6 hours > 10 units per day Stage 1 Asymptomatic Anemia PIV + Sequential PIV + Sequential PIV or Cordis + MTP Stage 2 Tachycardia PIV + Sequential PIV + Sequential Cordis + MTP Stage 3 Acute Hypotension PIV + MTP Cordis + Sequential Cordis + MTP Stage 4 Acute Hypotension and Organ Failure Cordis + MTP Cordis + MTP Cordis +MTP

25 Dilutional Coagulopathy: At 8 units RBC, plasma coagulation factor content decreases to 25% Dilutional Thrombocytopenia: At 10 units RBC, platelet count decreases by half. Products are given in ~ 1:1:1 ratio Each MTP cooler contains: 6 RBC: 4 FFP: 1 x 5 Platelet

26 HOW TO ACTIVATE MASSIVE TRANSFUSION 1. Call the Blood Bank 1. Arrange ICU Transfer 2. Fill out Emergent Blood Products Consent for Uncrossed Units 3. Obtain Adequate IV Access 20G x 3 18G x 2 Cordis + 20G

27 Other complications of MTP (RBC > 10 units) Coagulopathy and Thrombocytopenia Acute Pneumonitis (TRALI) Hydrostatic Pulmonary Edema (TACO) Hyperkalemia (+ 5 7 meq per unit) Free Hypocalcemia and Tetany Hypothermia Acute Metabolic Alkalosis (citrate converted to 23 meq HCO 3 per unit)