This document summarizes guidelines for treating acute medical problems in gastrointestinal practice, including hypovolumic shock, septic shock, coagulopathy, and stress ulcer prophylaxis. It discusses early goal directed therapy for septic shock, fluid resuscitation for hypovolemic shock, use of blood products for coagulopathy, and recommendations for stress ulcer prophylaxis in the ICU.

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!