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GI Bleeding: Critical Care Management and High-Risk Clinical Decisions Managing GI bleeding
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🎙️ New Podcast Episode | IVPN Voice x IVPN-Critical Care Listserv
GI Bleeding: Critical Care Management and High-Risk Clinical Decisions
Managing GI bleeding in critical care requires rapid decision-making, interdisciplinary coordination, and strong clinical judgment.
In this episode, we explore the key considerations clinicians must navigate when treating high-risk patients.
Join May Gamal as she hosts Dr. Naglaa Aly, Consultant in Tropical Diseases and Gastroenterology, for a deep discussion on:
🔹 Initial assessment and stabilization of GI bleeding
🔹 Risk stratification in critically ill patients
🔹 Pharmacologic management and clinical pearls
🔹 When to escalate care and involve endoscopy or surgery
🔹 Real-world critical care decision making
This episode is brought to you in collaboration with the IVPN Critical Care Listserv, highlighting interdisciplinary perspectives in acute care.
🎧 Tune in here:
Osama Tabbara Ahmad El Ouweini, Majd El Hazar,
#IVPN #IVPNVoice #CriticalCare #Gastroenterology #GIBleeding #ClinicalPharmacy #PharmacyEducation #MedicalPodcast #HealthcareEducation
Acute GI bleeding is one of those ICU situations where everything happens quickly. Patients can deteriorate within minutes, and the team has to act fast. Managing these cases isn't only about procedures. Medication decisions and supportive care are just as critical. In today's episode, we will explore how critical care pharmacists and gastroentrologists work together to manage these life-threatening situations in the ICE. So today I'm joined by Dr. Nagle Marzou, a tropical disease and gastroentrology consultant. Hello, Dr. Nagle Ramadan Karim. Thanks a lot for being with us at the IVP and Critical Care Podcast.
SPEAKER_01Hello, my Ramadan Karim, to you too. Thank you for inviting me. Actually, GIT bleeding is multidisciplinary emergency, and pharmacists play a bigger role than many people realize.
SPEAKER_00Yeah, absolutely. I totally agree. So in the ICU, we really see how every discipline contributes to stabilizing the patient. So let's start from the very beginning of the clinical scenario. A patient arrives to the ICU with hematempsis, with melina, unstable vitals, and maybe a rapidly dropping hemoglobin. So from your perspective as a gastroenterologist, what are the first priorities at that moment?
SPEAKER_01When a patient present with acute gastrointestinal bleeding, the first priority is rapid stabilization using the ABC approach, which is airway, breathing, and circulation. In practice, circulation and early preparation for hematemes are especially critical. First, we should assess the airway if the patient has massive hematemesis, altered consciousness, or cannot protect their airway. Early help should be called and intuition should be considered immediately. Provide oxygen support if needed and place the patient on continuous monitoring. The focus on circulation, which is often the most urgent issue, look for signs of shock, such as tachycardia, hypotension, or altered mental status. Once initial stabilization is underway, urgent endoscopy should be arranged, particularly in unstable GIT reading, often within hours. And at this critical point, I usually not the pharmacist ensuring that all medication given are clearly documented. And that electronic orders are updated, and the entire health care team is working from the same treatment plan.
SPEAKER_00Yeah, exactly. And that moment is usually where form seasons end very early. So yeah, we immediately start reviewing the medication history of the patient because many ICU bleeds are actually medication triggered or medication worsened. So we usually quickly review the anticoagulants, the antiplatelets, maybe the non-steroidal drugs, any recent thrombolytics, any recent TPA altiplasis the patient had taken, any drug interactions that can worsen or increase the bleeding risk. And sometimes that medication review completely changes the management plan. So, from your experience, how often do you find that drug-related risk factors are underrecognized before pharmacy intervention?
SPEAKER_01Actually, it is very frequently many clinicians focus mainly on procedures to control the source of bleeding, but the pharmacological issues are often underestimated. In my experience, reviewing hundreds of gastro-intestinal leading causes in ICU, drug-related risk factors such as monesteroidal anti-inflammatory drugs, anti-coagulant, anti-platelet, SSRI are either under recognized or not addressed. In about 60 to 80 percentage of the patients before pharmacy intervention. Clinical pharmacists play a key role in preventing EGI bleeding by identifying and intervening early on high-risk medication and inappropriate prophylaxis in ICU sitting.
SPEAKER_00Yeah, that's a very important point. Because once endoscopic control is achieved, the next question often becomes pharmacologic management moving forward. So one of the ongoing discussions in critical care is the optimal PPI dosing strategy after endoscopic hemostasis. So there has been a lot and there has been increasing debate about continuous infusion versus the intermittent polous therapy. So how do you personally interpret the evolving literature surrounding those PPI dosing strategies?
SPEAKER_01Yes, you are right. The evolving literature supports intermittent polous DBI therapy as non-inferior to continuous infusion after endoscopic hemostasis for high-risk group in ARGI bleeding ulcers. This shift is supported by meta-analysis on the current guidelines showing that similar clinical outcomes can be achieved while using few or health care resources. High dose BBI therobic is recommended for the first three days after successful hemostasis. This can be given either continuous infusion, for example, 80 milligram bolus followed by 8 milligrams per hour, or intermittent dosing, such as 40 IV every 12 to 24 hours. Evidence suggests that in selected low-risk patients, intermittent high dose of BBI after successful endoscopic hemostasis can provide outcomes comparable to continuous infusion. However, for patients with high-risk lesions, such as active bleeding ulcer or visible visals during endoscopy, I still prefer continuous infusion during the first 72 hours. Actually, pharmacists provide valuable patient-specific assessment by evaluating bleeding severity, comorbid conditions, and medication absorption reliability in clinical ear in critical ill patient. Additionally, ICU pharmacist monitoring BBI associated complications, such as uh cholesteridium deficiel infection, um ventilator associated pneumonia, VAB, risk, particularly in prolonged ICU steps.
SPEAKER_00Yeah, exactly. Yeah. And we usually also review the medication for it, not only for the acute treatment, but we also look for the longer treatment or the long-side effects of the longer uh duration of PPO therapy. So um now I would like to move to the discussion for another very challenging scenario, which is the varicyl hemorrhage. So uh because of varicyl bleeding, um, multiple pharmacologic decisions often need to happen simultaneously, like all at once. So in our ICU practice, initiating a vasoactive therapy, uh, an antibiotic prophylaxis, hemodynamic monitoring often all occurs almost at the same time. So, um, from a gastroenterology standpoint, which medication decision most significantly influences the survival rate in varicel bleeding?
SPEAKER_01Actually, in acute varicelle bleeding, vasoactive therapy plays a major role in improving survival. Currently, guidelines recommend starting a vasoactive medication such as teleprison or somatostatin, as soon as varical bleeding is suspected. These uh drugs help by lowering portal pressure, controlling the bleeding and improving short-term outcomes. Antibiotics, secondary antibiotics, also has an essential part of management. Their main role to prevent infections and the scobi, which are common in these uh patients.
SPEAKER_00Yeah, and that and actually that leads us to the one of the most clinical complex decisions we usually face in ICU patients, which is the anticoagulant reversal. So reversing anticoagulation can reduce, of course, the hemorrhage progression, but at the same time, it increases the risk of thrombosis. So in multidisciplinary discussions, pharmacists often lead the you know the pharmacokinetic interpretation of these medications. But how do you approach the timing of anticoagulant or maybe of an antiplatelet reversal relative to the endoscopy, of course?
SPEAKER_01Yes. Um when managing the bleeding in patients on anticoagulant, timing of reversal should be guided by pharmacokinetis. Reversal agents should be generally reserved for life-threatening the bleeding or severe ongoing hemorrhage. And importantly, they should not delay urgent endoscopy. Yes. Current guidelines, hemodynamic stabilization and early endoscopic evaluation, ideally. Within, for example, within uh 12 hours for suspected paracelin or within 24 hours for other cases. Initial management should be focused on resuscitation, targeting hemoglobin living between 7 to 9 grams. At the same time, we start uh appropriate pharmacological therapy such as vasoactive agents for suspected perical bleeding, BBI for non-periceal bleeding, antibiotic, as mentioned before. Lapt is to guide reversal decisions such as INR ABTT levels, depend on anticoagulant involved. After successful hemostasis, anticoagulant is usually restart within three to seven days. Although patients with a very high thrombotic risk may require early resumes within less than uh three days.
SPEAKER_00Yeah, exactly. So because delaying anticoagulation, of course, increases the stroke and thrombosis risk. So, particularly in those patients with a high CHADS bask score.
SPEAKER_01Yes, yes, the balance between bleeding and the thrombosis is one of the most challenging parts of managing these patients. This is where collaboration of the pharmacists become extremely bad.
SPEAKER_00Oh, thank you. Yes. So um before we close, um, can we summarize um maybe three high-impact clinical pairs in acute GI bleeding?
SPEAKER_01Yes, okay. Um first, um stabilization comes first. In acute GI bleeding, rapid resuscitation, hemodynamic stabilization, and the timely endoscopic evaluation are essential to prevent deterioration and improved outcomes. Secondly, medication plays a major role in both uh the cause and the treatment of bleeding. Carefully, anticoagulant, antiplatelet, and other high risk drugs such as nanisteroidal anti-inflammatory drugs is crucial, while appropriate pharmacologic therapy, including BBI, vasoactive agents, antibiotics, and transfusion strategies support successive bleeding control. Number three, multidisciplinary collaboration, improve patients' outcome. Managing VGIT bleeding and ICU required coordination care between gastroenterologists, inter civilists, pharmacists, and the wider healthcare team to balance bleeding control from both risk and overall patient safety.
SPEAKER_00Yeah, we usually all focus on the uh overall patient safety, and I totally agree. So, um, Dr. Najla, uh, thank you for sharing your expertise with us today. I have now no doubt that managing the acute GOI bleeding patients is one of the clearest examples of um why ICU care must be a multidisciplinary.
SPEAKER_01Yes, yes, totally agree. Thank you, Umai. It's my pleasure.
SPEAKER_00Yes, thank you to our listeners for joining us today on the IVPN Critical Care podcast. Stay tuned for our next episode where we continue exploring critical care topics.