g.i. bleed case, how would u manage.

[Painter1]

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80yo woman on coumadin for afib, here for black stools. rectal exam, black/redish stools, guiac +. vitals normal other than afib at 100.orthostatics done, rapid afib goes from 100 to 135 on standing and patient feels dizzy. labs reveal inr of 3. bun elevated. h/h 10/30.

you call gi, they know of patient and will see patient but can't come in right now.

what do u do?

reverse anticougulation? iv vitamin k, subq, oral or not at all. ffps or not at all? do u even give her a unit of prbc even though her h/h is 10/30? lastly, do you get an micu bed for this patient?

i know what i did, but i'm asking as i couldn't find any black or white answers.

 

[BADMD]

Active life threatening bleeding is an indication to reverse anticoagulation. There is no difference between IV vit K and subq vit K, except there is a higher incidence of anaphylactoid reactions to IV. Since we don't know how well the gut is working, I probably wouldn't give any oral. More than 1 mg of K is basically a waste, with a therapeutic INR. That is going to start 6-8 hours from now but likely won't have full effect for 24 hours.

Use FFP or PCC to give back the factors and return anticoagulation to normalcy. An INR of 1.7 is about the best you can expect. For someone who is actively bleeding, I'm giving 1:1:1 platelets, PRBCs and FFP, once I've given enough FFP to get the INR down. I'm also going to give additional platelets if they are on aspirin or plavix.

Hemoglobin lags if the person is actively bleeding. So if there are clinical signs of volume depletion after crystalloid/FFP resuscitation, I'm giving blood, despite an "ok" hemoglobin.

Try to control the bleeding with a PPI (or an H2 blocker if that is what you've got) for an upper bleed or octreotide for an esophageal bleed.

Don't forget to give Calcium to deal with the citrate if the transfusion starts to get big.

 

[Painter1]

Active life threatening bleeding is an indication to reverse anticoagulation. There is no difference between IV vit K and subq vit K, except there is a higher incidence of anaphylactoid reactions to IV. Since we don't know how well the gut is working, I probably wouldn't give any oral. More than 1 mg of K is basically a waste, with a therapeutic INR. That is good to start 6-8 hours from now but likely won't have full effect for 24 hours.

Use FPP or PCC to give back the factors and return anticoagulation to normalcy. An INR of 1.7 is about the best you can expect. For someone who is actively bleeding, I'm giving 1:1:1 platelets, PRBCs and FFP, once I've given enough FFP to get the INR down. I'm also going to give additional platelets if they are on aspirin or plavix.

Hemoglobin lags if the person is actively bleeding. So if there are clinical signs of volume depletion after crystalloid/FFP resuscitation, I'm giving blood, despite an "ok" hemoglobin.

Try to control the bleeding with a PPI (or an H2 blocker if that is what you've got) for an upper bleed or octreotide for an esophageal bleed.

Don't forget to give Calcium to deal with the citrate if the transfusion starts to get big.

thanks for the great response. do u have a reference on how much vitamin k to give in a presumed active bleed and therapeutic inr? tintinali wasn't the clearest, but recommendation in an active bleed was vitamin k 10 IV and ffp (they didn't specify an INR, they only said someone anticougulated and active bleeding). another source said vit k 5mg to 10mg iv.

the case was tough as if i gave the patient vitamin k iv, i was afraid i would be in limbo with a pending stroke.

in this case, eventhough the h/h was as noted, after speaking with the gi attending, considering the orthostatic change in HR, he recommended one unite of prbcs. i had my concerns but he was pretty confident and made it sound as if they do that often.

 

[beriberi]

The risk of stroke is around 1-2% per year in afib patients who are not anticoagulated. The risk of dying of a gi bleed with an 1nr of three is 40%? 50% ? 60% ? Have a conversation with the patient. Let them make informed decision.

 

[BADMD]

tintinali wasn't the clearest, but recommendation in an active bleed was vitamin k 10 IV and ffp (they didn't specify an INR, they only said someone anticougulated and active bleeding). another source said vit k 5mg to 10mg iv..

The 5-10 number comes from the Chest paper on the management of supratherapeutic warfarin use. Pharmacologically, more than a mg probably isn't going to do much with an INR of 3.

It is unusually to have strokes from Vit K (though I have seen an MI that I attribute to overly aggressive vit K). The use of PCC or factor 7 is far more likely to cause a hypercoaguable state.

 

[NateintheED]

Correct me if I'm wrong, but I believe the risk of stroke from a-fib isn't from the rhythm itself, but from the mural thrombus that forms in the atria. Cardiologists will cardiovert out of a-fib without worry about a stroke if therapeutically anticoagulated for a certain length of time (3-4 months?). So I wouldn't worry about an acute stroke in this case.

One thing nobody mentioned, but I suppose you could do to really slam that INR down fast would be Factor VII. I would be happier using it in someone like this than in a coumadin head bleed who's already neurologically devastated.

Oh, and as for that MICU bed... absolutely.

 

[BADMD]

Correct me if I'm wrong, but I believe the risk of stroke from a-fib isn't from the rhythm itself, but from the mural thrombus that forms in the atria.

Yes.

However experience from the war in Iraq/Afganistan and some of the Factor VII trials have shown about a 5% incidence of ischemic complications.

 

[fairwaysngreens]

How about just IV fluids, hold Coumadin dose for a couple days, IV nexium, +/- octreotide depending on liver history and MICU admission. Then let GI scope her. If her H/H drops further would transfuse to keep HgB >10 due to cardiac risk factors/age. Not sure I'm seeing why she needs to be considered an active life threatening bleed and needs reversal right now.

 

[Arcan57]

She has a life-threatening GI bleed because you haven't proved that she does not. The H&H provides a baseline, but she's already tachycardic and you don't know how much blood she's actually lost. The acute stroke risk due to A-fib is going to be negligible (if she was on it for a mechanical valve, reversing is much riskier). We know that transfusing people is not without risks (especially if it becomes a massive transfusion). So if we can minimize the need for transfusion by eliminating the coagulopathy while introducing mininmal additional risk of CVA then why not?

 

[fairwaysngreens]

"She's has a life-threatening GI bleed because you haven't proved that she's not."

I'll buy that, good point. Thanks for clearing that up.

 

[BADMD]

If her H/H drops further would transfuse to keep HgB >10 due to cardiac risk factors/age. Not sure I'm seeing why she needs to be considered an active life threatening bleed and needs reversal right now.

Her hemoglobin is already 10 and she is symptomatic and she is a little old lady. You can start with crystalloid, but the red stuff is indicated.