What is the treatment for gastrointestinal (GI) bleed-induced cardiac arrest?

From the Guidelines

The treatment of cardiac arrest due to a gastrointestinal (GI) bleed requires immediate resuscitation following standard ACLS protocols while simultaneously addressing the underlying hemorrhage, with a focus on restoring volaemia and administering antibiotic prophylaxis as soon as possible, as recommended by the EASL clinical practice guidelines 1. The initial management involves high-quality CPR and early defibrillation if indicated, as well as establishing large-bore IV access for rapid fluid resuscitation using crystalloids like normal saline or lactated Ringer's solution.

• Blood product administration is crucial, starting with 2 units of packed red blood cells and considering massive transfusion protocol if bleeding is severe, typically using a 1:1:1 ratio of PRBCs, fresh frozen plasma, and platelets.
• Correct coagulopathy with vitamin K 10mg IV, prothrombin complex concentrate (25-50 units/kg), or fresh frozen plasma.
• If the patient is on anticoagulants, consider reversal agents: protamine for heparin, idarucizumab for dabigatran, or andexanet alfa for factor Xa inhibitors. Once return of spontaneous circulation is achieved, perform urgent endoscopy to identify and treat the bleeding source, with vasoactive drug therapy initiated as soon as AVH is suspected, using either terlipressin, somatostatin, or octreotide 1.
• The recommended dose of terlipressin is 2 mg/4 h during the first 48 h, followed by 1 mg/4 h thereafter.
• The recommended dose of somatostatin is a continuous infusion of 250 µg/h with an initial bolus of 250 µg.
• The recommended dose of octreotide is a continuous infusion of 50 µg/h with an initial bolus of 50 µg. Pharmacologic adjuncts include IV proton pump inhibitors (although their efficacy in AVH is not established 1), vasopressors like norepinephrine to maintain perfusion, and tranexamic acid to help stabilize clots.
• Prevention of complications, such as bacterial infections, hepatic encephalopathy, and deterioration of renal function, should run simultaneously to haemostatic therapies from admission of patients with cirrhosis and acute GI bleeding 1.
• Antibiotic prophylaxis is recommended, with ceftriaxone (1 g/24 h) for up to seven days being the first choice in patients with advanced cirrhosis 1.

From the Research

GI Bleed Cardiac Arrest Treatment

• The treatment of gastrointestinal (GI) bleeding in patients with cardiac arrest is a complex issue, and there is limited research available on this specific topic 2, 3.
• However, studies suggest that cardiac arrest can induce severe mesenteric ischemia, leading to gut dysfunction and endoscopic lesions, including GI hemorrhage 3.
• In patients undergoing cardiac surgery, proton-pump inhibitors appear to be the superior agent for prophylaxis against GI bleed, although rigorous comparative data are sparse 4.
• Cardiac patients are at risk of GI bleeding due to their use of antithrombotic medications, and the magnitude of gastrointestinal risk in this vulnerable patient population is still relatively unexplored 5.
• Gastrointestinal bleeding is a hemorrhagic complication after primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction (STEMI), and is associated with longer intensive care unit stay and higher in-hospital and overall mortality rate 6.

Risk Factors and Prevention

• Previous gastrointestinal bleeding, impaired renal function, and Killip class IV at presentation are associated with a higher incidence of GI bleeding in patients with STEMI 6.
• The use of proton-pump inhibitors may help prevent GI bleeding in patients undergoing cardiac surgery, but its effectiveness in preventing GI bleeding in patients with cardiac arrest is unclear 4.
• A multidisciplinary approach to the care of cardiac patients, involving active patient participation and collaboration between cardiologists and gastroenterologists, may help minimize the risk of GI bleeding 5.

Treatment and Outcomes

• The treatment of GI bleeding in patients with cardiac arrest typically involves resuscitation, stabilization, and management of the underlying cause of the bleeding 2.
• The outcomes of patients with GI bleeding and cardiac arrest are generally poor, with high mortality rates and prolonged intensive care unit stays 3, 6.
• Further research is needed to better understand the epidemiology and management of GI bleeding in patients with cardiac arrest, and to develop effective strategies for prevention and treatment 5.