From the Guidelines
For a dialysis patient with dark blood in stool, dizziness, and low blood pressure (115/44), I strongly recommend ordering a complete blood count (CBC) to evaluate for anemia and blood loss, as the patient's hemoglobin level is crucial in determining the need for blood transfusion, with a threshold of 70 g/L or less for transfusion, as suggested by the international consensus recommendations 1. To further assess the patient's condition, the following labs should be ordered:
- Comprehensive metabolic panel (CMP) to assess electrolytes and kidney function
- Coagulation studies including PT/INR and PTT to check for bleeding disorders
- Type and cross for potential blood transfusion
- Fecal occult blood test to confirm GI bleeding
- Iron studies including ferritin, TIBC, and transferrin saturation to evaluate iron stores
- BNP to assess for cardiac involvement
- Blood cultures if infection is suspected The Blatchford score, which includes hemoglobin level, blood urea level, pulse, systolic blood pressure, the presence of syncope or melena, and evidence of hepatic disease or cardiac failure, can be used to predict the risk of rebleeding or mortality in patients with nonvariceal upper gastrointestinal bleeding 1. Given the patient's dialysis status and symptoms, it is essential to closely monitor vital signs and consider fluid resuscitation if appropriate, while awaiting lab results. The patient's hypotension and dizziness suggest significant volume depletion or ongoing blood loss that requires immediate evaluation.