UPPER GI BLEED IN ICU PATIENTS: THE POINTS WHICH YOU SHOULD KEEP IN MIND

💥Incidence of overt Upper GI Bleed (UGIB) ranges from 1.5 to 8.5% of all ICU patients but may be as high as 15% if no prophylaxis is used.

💥RISK FACTORS 

☢Mechanical ventilation >48 h 

☢Coagulopathy – INR >1.5 or platelet count <50,000 

☢Others: ✔️ Shock ✔️Sepsis ✔️Hepatic failure ✔️Acute Renal failure ✔️Multiple trauma ✔️Burns >35% of total body surface area ✔️Organ transplantation ✔️Head trauma ✔️Spinal trauma ✔️History of PUD or UGIB

💥SPECIFIC POINTS REGARDING TREATMENT 

🔸Thrombocytopenia can develop in neurosurgical patients on H2 Blockers

🔸The use of H2Bs and PPIs may increase the frequency of nosocomial pneumonia.

💥PROPHYLAXIS IS RECOMMENDED FOR ICU PATIENTS WHO EXHIBIT:

🔸Coagulopathy (platelet count < 50,000 per m 3 , INR > 1.5, partial thromboplastin time (PTT) >2 times the control value) 

🔸Mechanical ventilation >48 h 

🔸History of GI ulceration or bleeding within the past year 

🔸Two or more of the following risk factors: sepsis; ICU stay >1 week; occult GIB ≥6 days; glucocorticoid therapy (>250 mg hydrocortisone).

💥REASONS FOR UGIB IN ICU PATIENTS: 

🔸The glycoprotein mucous layer may be denuded by increased concentrations of refluxed bile salts or uremic toxins common in critically ill. Alternatively, or in addition, mucosal integrity may be compromised due to poor perfusion associated with shock, sepsis, and trauma. 

🔸Excessive gastrin stimulation of parietal cells has been detected in patients with head trauma as oppose to be normal or subnormal in most other ICU patients.

🔸Systemic steroids double the risk of a new episode of UGIB or perforation. Concomitant use with high doses of NSAIDs has been associated with a 12-fold increased risk for upper GI complications.

🔸Helicobacter pylori infection 

💥EMPIRICAL THERAPY

⚛ Start with an IV bolus of 80 mg and continue IV infusion at 8 mg/h for a total of 72 h. If no signs of rebleeding after 24 h, switch to oral PPI. 

⚛Octreotide is used in variceal bleeding. Start with an IV bolus of 50 mcg and continue IV infusion at 50 mcg/h for 3–5 days.

💥 UGIB IN HEAD INJURY & OTHER NEUROSURGICAL PATIENTS:

🔸They are more prone for UGIB because of ✔️ Frequent use of systemic steroids ✔️ Increased gastrin secretion ✔️ Significant gastric intramucosal acidosis is common in severe head injury. ✔️Primary insult to the central nervous system may result in derangement of splanchnic blood flow secondary to neurohumoral mechanisms.

🔸 In head injury, GI dysfunction also may manifest as ✔️gastroparesis✔️ileus, ✔️increased intestinal mucosal permeability, 

🔸 Plasma levels of cortisol and age are independent predictors of stress ulcers following acute head injury.

Reference: Gastrointestinal Hemorrhage in Neurosurgical Critical Care Meghan Bost, Kamila Vagnerova  , Ch:84, Essentials of Neurosurgical Anesthesia & Critical Care 2012 Strategies for Prevention, Early Detection, and Successful Management of Perioperative Complications