What is the recommended anesthetic management for a patient with a gastrointestinal (GI) bleed?

Anesthetic Management of GI Bleed Patients

For patients with gastrointestinal bleeding requiring anesthesia, prioritize airway protection in those with ongoing hematemesis and altered mental or respiratory status, use restrictive transfusion thresholds (Hb 70 g/L targeting 70-100 g/L, or Hb 80 g/L targeting ≥100 g/L for cardiovascular disease), and ensure immediate hemodynamic stabilization before proceeding with endoscopy or surgery. 1

Immediate Assessment and Stabilization

Hemodynamic Evaluation

• Calculate shock index (heart rate ÷ systolic blood pressure) immediately upon presentation—a value >1 defines hemodynamic instability requiring urgent intervention rather than routine endoscopy 2, 3
• Place at least two large-bore intravenous catheters to allow rapid volume expansion 2, 3
• Initiate fluid resuscitation with crystalloids to restore hemodynamic stability before anesthetic induction 1

Risk Stratification

• Identify high-risk features: age >65 years, shock, comorbid illness, low hemoglobin, melena, fresh red blood in emesis/nasogastric aspirate, or on rectal examination 3
• Recognize that mortality in GI bleeding (10% for upper GI, 3.4% for lower GI overall, rising to 18-20% in specific high-risk groups) is primarily related to comorbidity rather than exsanguination 1, 2

Airway Management Considerations

Indications for Intubation

• Provide airway protection for patients with ongoing hematemesis combined with altered mental status or respiratory compromise 1
• Consider early intubation in hemodynamically unstable patients requiring urgent endoscopy, as aspiration risk is substantially elevated 1
• An experienced consultant anesthetist should assess the patient's fitness for operation and decide whether to perform the anesthetic personally or delegate appropriately 1

Anesthetic Technique

• For sedation during endoscopy in stable patients, use midazolam with careful titration: patients age 60 or older require approximately 50% less midazolam than younger patients, with initial doses no greater than 1.5 mg given over at least 2 minutes 4
• Wait an additional 2 or more minutes after each increment to fully evaluate sedative effect, as peak effect takes longer in elderly and chronically ill patients 4
• For general anesthesia induction in unpremedicated patients over age 55, use reduced initial doses of 0.3 mg/kg midazolam; those with severe systemic disease require only 0.2-0.25 mg/kg 4

Transfusion Management

Restrictive Transfusion Strategy

• Use a hemoglobin threshold of 70 g/L with target range 70-100 g/L for patients without cardiovascular disease (this is high certainty evidence) 1
• For patients with cardiovascular disease, use a higher threshold of 80 g/L targeting ≥100 g/L 1
• Avoid over-transfusion: nearly one-third of lower GI bleeding patients receive RBC transfusion, but up to 80% may be inappropriate or unnecessary 1

Coagulopathy Correction

• Correct INR >1.5 with fresh frozen plasma and platelet count <50,000/μL with platelet transfusion before proceeding with anesthesia 2

Anticoagulation and Antiplatelet Management

Warfarin Reversal

• For unstable gastrointestinal hemorrhage in patients on warfarin, reverse immediately with prothrombin complex concentrate AND vitamin K 1, 5
• Do not use fresh frozen plasma as first-line reversal agent 6
• For patients with low thrombotic risk, restart warfarin at 7 days after hemorrhage 1

Direct Oral Anticoagulant (DOAC) Management

• Interrupt DOAC therapy immediately at presentation 1
• For life-threatening hemorrhage, use targeted reversal agents: andexanet alfa for apixaban, rivaroxaban, or edoxaban; idarucizumab for dabigatran 1
• Do NOT use prothrombin complex concentrates routinely in patients taking DOACs prior to emergency surgery 1
• Restart DOAC therapy at maximum 7 days after hemorrhage 1
• Note that andexanet alfa carries approximately 10% risk of thrombotic events within 30 days, but this risk is eliminated with prompt resumption of anticoagulation 1

Antiplatelet Management

• For patients on aspirin for secondary prevention, do NOT routinely stop it; if stopped, restart as soon as hemostasis is achieved 1
• Aspirin for primary prophylaxis should be permanently discontinued 1
• For dual antiplatelet therapy with coronary stents, do NOT routinely stop; manage in liaison with cardiology 1
• If P2Y12 receptor antagonist must be interrupted in unstable hemorrhage, continue aspirin 1
• Reinstate P2Y12 receptor antagonist within 5 days maximum 1
• Do not give platelet transfusions to patients on antiplatelet agents during acute GI bleeding 6

Timing and Coordination of Procedures

Surgical Timing

• Avoid operating during midnight to 7am hours when possible, as mortality correlates with timing 1
• A consultant surgeon should be informed about possible need for surgery and make the decision to operate or delegate 1
• No patient should proceed to emergency laparotomy unless every effort has been made to localize bleeding by radiological and/or endoscopic modalities 1

Endoscopy Timing

• For upper GI bleeding, perform endoscopy within 24 hours in high-risk patients 3
• For lower GI bleeding in stable patients, colonoscopy should be performed within 24 hours after adequate bowel preparation 1, 5
• For hemodynamically unstable patients (shock index >1), perform CT angiography immediately BEFORE colonoscopy to localize bleeding 2, 3, 5

Common Pitfalls to Avoid

• Do not assume hematochezia indicates lower GI source in unstable patients—always consider upper GI bleeding, which may present with bright red rectal bleeding 2, 3, 5
• Do not delay definitive airway management in patients with ongoing hematemesis and altered mental status 1
• Do not use excessive sedation doses in elderly patients—they require 50% less midazolam and have delayed peak effects 4
• Do not proceed with colonoscopy in hemodynamically unstable patients (shock index >1)—this delays definitive localization and treatment 5
• Do not give fresh frozen plasma for warfarin reversal when prothrombin complex concentrate is available 1
• Do not stop cardiac aspirin for secondary prevention in the setting of GI bleeding 1, 7