What is the management approach for a gastrointestinal (GI) bleed in the Intensive Care Unit (ICU)?

Management of Gastrointestinal Bleeding in the ICU

Immediate Hemodynamic Assessment and Resuscitation

Calculate the shock index (heart rate ÷ systolic blood pressure) immediately upon presentation, with a value >1 indicating hemodynamic instability that requires urgent CT angiography and interventional radiology rather than routine endoscopy. 1, 2

Initial Resuscitation Protocol

• Initiate crystalloid resuscitation immediately to restore blood pressure and heart rate in hemodynamically unstable patients 3, 2
• Use balanced crystalloids (such as Ringer lactate) over normal saline, as recent evidence shows reduced acute kidney injury and possible mortality benefit 3
• Avoid colloids for routine resuscitation, as they provide no survival advantage over crystalloids and are more expensive 3

Blood Transfusion Strategy

• For patients without cardiovascular disease: Use restrictive transfusion thresholds with hemoglobin trigger of 70 g/L and target range of 70-90 g/L 1, 2
• For patients with cardiovascular disease: Use higher threshold with hemoglobin trigger of 80 g/L and target ≥100 g/L 1, 2

Coagulopathy Correction

• Transfuse fresh frozen plasma or prothrombin complex concentrate for INR >1.5 2
• Transfuse platelets for platelet count <50,000/µL 2
• Consider scheduled clotting factors to correct iatrogenic or acquired coagulopathies 3

Diagnostic Approach Based on Hemodynamic Status

For Hemodynamically Unstable Patients (Shock Index >1)

• Perform CT angiography immediately as the first diagnostic step to localize active bleeding before any therapeutic intervention 1, 4
• CT angiography provides the fastest and least invasive means to localize bleeding, with a positive rate of 94% in hemodynamically unstable patients 4
• Following positive CT angiography, proceed to catheter angiography with embolization within 60 minutes in centers with 24/7 interventional radiology 1, 4
• Do not perform colonoscopy as the initial approach when shock index >1 or patient remains unstable after resuscitation 4

Always Consider Upper GI Source

• Hematochezia with hemodynamic instability may indicate an upper GI source and warrants upper endoscopy 4, 5
• Failure to consider an upper GI source in hemodynamically unstable patients can lead to delayed diagnosis and treatment 1, 4
• In ventilated patients, consider nasogastric tube lavage if blood return would change management, though avoid in unsedated patients due to aerosolization risk 3

For Hemodynamically Stable Patients

• Perform upper endoscopy within 24 hours for suspected upper GI bleeding 2
• Perform colonoscopy within 24 hours after adequate bowel preparation for lower GI bleeding 5

Pharmacologic Management

Upper GI Bleeding

• Consider proton pump inhibitor infusions over intermittent IV administration for suspected upper GI bleeding 3, 2
• Administer erythromycin as a prokinetic agent before endoscopy 6
• For patients with suspected or known liver disease, use liberalized octreotide infusions 3, 2
• Administer scheduled antiemetics to reduce risk of aspiration 3

Variceal Bleeding

• Continue antibiotics and vasoactive drugs in patients with cirrhosis 6
• Maintain these medications after endoscopic therapy 6

Management of Anticoagulation and Antiplatelet Therapy

Warfarin Management

• Interrupt warfarin therapy immediately at presentation for unstable GI hemorrhage 1, 2
• Reverse anticoagulation with prothrombin complex concentrate and vitamin K for unstable bleeding 1, 2
• For patients with low thrombotic risk, restart warfarin 7 days after hemorrhage 1, 4
• For patients with high thrombotic risk, consider low molecular weight heparin therapy at 48 hours after hemorrhage 1

Aspirin Management

• For aspirin used for primary prophylaxis: Permanently discontinue 1, 2, 4
• For aspirin used for secondary cardiovascular prevention: Do not routinely stop; if stopped, restart as soon as hemostasis is achieved 1, 2, 4, 5

Dual Antiplatelet Therapy

• If P2Y12 receptor antagonist is stopped, reinstate within 5 days to prevent thrombotic complications 1

ICU Admission Criteria

Admit patients to the ICU if any of the following are present: 2

• Orthostatic hypotension
• Hematocrit decrease ≥6%
• Transfusion requirement >2 units packed red blood cells
• Continuous active bleeding
• Persistent hemodynamic instability despite aggressive resuscitation

Interventional Management Algorithm

For Positive CT Angiography

• Proceed to catheter angiography with embolization within 60 minutes 1, 4
• Transcatheter embolization provides time to stabilize the patient and prepare the bowel, contributing to better surgical outcomes if surgery ultimately becomes necessary 4

For Failed Endoscopic or Angiographic Intervention

• Consider repeat endoscopy with hemostasis for recurrent bleeding 5
• Reserve surgery only for patients who fail angiographic intervention or continue to deteriorate despite all attempts at localization and intervention 4
• Avoid blind segmental resection and emergency subtotal colectomy, which are associated with rebleeding rates as high as 33% and mortality of 33-57% 4

Special Considerations for COVID-19 or High-Risk Infectious Patients

• Manage all patients as if COVID positive when appropriate 3
• Use negative-pressure rooms whenever possible (endoscopy, OR, ICU) 3
• Limit in-room staff to critical personnel only with full PPE including N95 masks 3
• Consider endotracheal intubation or procedural oxygen mask for all upper endoscopies to reduce aerosolization 3

Critical Pitfalls to Avoid

• Do not pursue aggressive endoscopy in hemodynamically unstable patients without first attempting CT angiography for localization 1, 4
• Recognize that mortality in GI bleeding is generally related to comorbidity rather than exsanguination, with overall in-hospital mortality of 3.4% but rising to 18% for inpatient-onset lower GI bleeding and 20% for patients requiring ≥4 units of red cells 1, 4
• Be aware that critically ill COVID patients may develop prothrombotic disseminated intravascular coagulation, placing them at dramatically increased risk of thrombosis, and many may be on newly prescribed anticoagulants 3
• Avoid physical examination unless findings are expected to impart acute changes in management; use photographic documentation of bleeding by patient or staff to confirm symptoms and guide remote decisions 3