What is the management for a patient with tachycardia and reduced exercise tolerance during a gastrointestinal (GI) bleed?

Management of Tachycardia and Reduced Exercise Tolerance During GI Bleed

Patients with tachycardia and reduced exercise tolerance during GI bleeding require immediate assessment of hemodynamic stability, with prompt resuscitation and stratification based on shock index to guide appropriate management. 1

Initial Assessment and Stratification

• Calculate shock index (heart rate/systolic BP) immediately:

  • Shock index >1: Patient is unstable and requires immediate intervention 1
  • Shock index ≤1: Patient is stable but needs further risk assessment

• For stable patients, use the Oakland score to categorize as major or minor bleed:

  • Score ≤8: Minor bleed, may be suitable for outpatient management
  • Score >8: Major bleed, requires hospital admission 1

Immediate Management for Unstable Patients

1. Resuscitation:

   • Establish large-bore IV access (at least two lines)
   • Initiate crystalloid fluid resuscitation
   • Administer blood products based on restrictive transfusion strategy:
     • Hemoglobin trigger of 70 g/L (target 70-90 g/L) for most patients
     • Hemoglobin trigger of 80 g/L (target 100 g/L) for patients with cardiovascular disease 1

2. Diagnostic Approach:

   • CT angiography is recommended as the first-line investigation for unstable patients to rapidly localize bleeding 1
   • If no source is identified on CTA and patient remains unstable, immediate upper endoscopy should be performed 1
   • For patients who stabilize after initial resuscitation, upper endoscopy may be the first investigation

3. Monitoring:

   • Continuous cardiac monitoring is essential for patients with GI bleeding and tachycardia 1
   • Patients with hemodynamic instability requiring vasopressors should be admitted to ICU 1
   • Patients with tachycardia but hemodynamically stable may be managed in telemetry/progressive care units 1

Management of Antithrombotic Medications

• Anticoagulants:

  • Interrupt warfarin therapy at presentation 1
  • For unstable bleeding on warfarin, reverse anticoagulation with prothrombin complex concentrate and vitamin K 1
  • For patients on direct oral anticoagulants (DOACs) with life-threatening hemorrhage, consider reversal agents (idarucizumab or andexanet) 1

• Antiplatelet Therapy:

  • For primary prophylaxis: Consider permanent discontinuation of aspirin 1
  • For secondary prevention: Do not routinely stop aspirin; restart as soon as hemostasis is achieved 1
  • For dual antiplatelet therapy in patients with coronary stents: Manage in consultation with cardiology 1

Specific Interventions Based on Bleeding Source

• For Lower GI Bleeding:

  • If stable with major bleed: Hospital admission for colonoscopy 1
  • If unstable: CTA followed by catheter angiography with embolization if positive 1

• For Upper GI Bleeding:

  • Consider proton pump inhibitor infusion rather than intermittent administration 1
  • Consider octreotide infusion for suspected or known liver disease 1
  • Consider scheduled antiemetics and correction of coagulopathies 1

Ongoing Management

• Monitor for rebleeding and continued hemodynamic stability
• Address the underlying cause of bleeding once identified
• Consider alternative diagnostic modalities in stable patients where endoscopy may be delayed:
  • CT angiography
  • Capsule endoscopy (in select cases) 1

Pitfalls and Caveats

1. Do not delay resuscitation for diagnostic procedures in unstable patients
2. Avoid over-transfusion - restrictive transfusion strategies improve outcomes 1
3. Do not proceed to emergency laparotomy without attempting to localize bleeding through radiological and/or endoscopic modalities first 1
4. Consider COVID-19 infection as a potential confounder that can mimic or exacerbate hemodynamic effects of GI bleeding 1
5. Be aware that tachycardia may persist even after adequate volume resuscitation due to other factors (pain, anxiety, medication effects)
6. Remember that mortality in GI bleeding is generally related to comorbidity rather than exsanguination 1

By following this structured approach to managing tachycardia and reduced exercise tolerance during GI bleeding, you can optimize patient outcomes while minimizing complications from both the bleeding event and its treatment.