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GI/Hepatic > SUP and Bleeding > Flashcards

SUP and Bleeding Flashcards

1
Q

What is the pathophysiology of stress ulcers?

A

decreased splanchnic blood flow secondary to hypovolemia, reduced cardiac output, proinflammatory mediator release, increased catecholamine release, and visceral vasoconstriction

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2
Q

What are additional factors contributing to the pathophysiology of stress ulcers?

A

decreased gastric mucosal bicarbonate production, decreased gastric emptying of irritants and acidic contents, acid back-diffusion, reperfusion injury follow restoration of blood flow after hypoperfusion

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3
Q

What is the most common cause of GI bleeds in the ICU?

A

Stress ulcers

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4
Q

When does superficial mucosal damage generally begin to occur after ICU admission?

A

within 1-2 days

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5
Q

When is stress ulcer prophylaxis not recommended?

A

in the non-ICU setting

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6
Q

What are the major risk factors for SUP?

A
  1. mechanical ventilation ≥ 48 hours
  2. Platelets < 50,000 and/or INR > 1.5
  3. Hx of GI ulceration or bleeding within past year
  4. burns > 35% BSA
  5. severe head or spinal cord injury
  6. multiple trauma
  7. perioperative transplant period
  8. low intragastric pH
  9. surgery lasting > 4 hours
  10. acute lung injury
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7
Q

What are the other risk factors?

A
  1. sepsis
  2. ICU stay > 1 week
  3. occult bleeding
  4. ≥ 250 mg/day of hydrocortisone or equivalent
  5. hepatic failure
  6. acute kidney injury
  7. hypotension
  8. anticoagulation
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8
Q

What are the treatment goals for SUP?

A
  1. prevent any bleeding

2. reduce acid secretion (pH > 4) or increase protective factors

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9
Q

What factors determine which agents to give for SUP?

A
  1. functioning GI tract
  2. adverse effects
  3. cost
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10
Q

What is the MOA of sucralfate?

A

forms a complex with positively charged proteins to form a substance that coats the stomach to protect gastric mucosa

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11
Q

In which patients should sucralfate not be used?

A

Renal dysfunction (it can cause aluminum toxicity)

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12
Q

What is sucralfate’s role in therapy?

A

Not a first line option

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13
Q

Which two treatment options require a functioning GI tract?

A

sucralfate and antacids

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14
Q

What is the MOA of antacids?

A

neutralize stomach acid

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15
Q

How often are antacids dosed?

A

q1-2h

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16
Q

What are the ADRs associated with antacids?

A

constipation, diarrhea, electrolyte abnormalities

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17
Q

What are antacids’ role in SUP?

A

Avoid use - last line option

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18
Q

Which two products can lead to toxicity in renal failure patients?

A

aluminum and magnesium

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19
Q

What is a major concern with antacids and an NG tube?

A

It can clog the NG tube

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20
Q

Which two H2RAs are available via IV?

A

Ranitidine and famotidine

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21
Q

What is the MOA of H2RAs?

A

inhibits histamine receptors of the gastric parietal cells to ultimately inhibits gastric acid secretion

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22
Q

What is the typical dosing of H2RAs?

A

BID dosing with renal adjustments

23
Q

What are the major ADRs of H2RAs?

A

mental status changes and thrombocytopenia

24
Q

Which H2RA should be avoided due to a high number of drug interactions>

A

cimetadine

25
Q

Which PPIs are available via IV?

A

Esomeprazole and pantoprazole

26
Q

What is the MOA of PPIs?

A

suppress the parietal cells H+/K+ ATP pump to raise gastric pH

27
Q

What are the major ADRs of PPIs?

A

diarrhea, constipation, nausea, nosocomial pneumonia, and c-diff

28
Q

What is the role of therapy for PPIs?

A

first line

29
Q

Which sign/symptom indicates treatment failure of SUP?

A

hematemesis

30
Q

What are the monitoring parameters for SUP?

A

signs and symptoms of bleeding

31
Q

When should SUP therapy be discontinued?

A
  1. when risk factors resolve

2. before transferring to the general floor

32
Q

What are the four categories of GI bleeds?

A
  1. upper
  2. lower
  3. occult
  4. obscure
33
Q

What is an upper GI bleed?

A

pharynx to ligament of Treitz

34
Q

What is the most common GI bleed?

A

Upper (4 times more common than lower)

35
Q

What is an occult GI bleed?

A

unknown to the patient

36
Q

What is an obscure GI bleed?

A

unknown location in GI tract

37
Q

What are the two types of GI bleeds?

A

variceal and non-variceal

38
Q

What is a variceal bleed?

A

esophageal or gastric varices that rupture

39
Q

What is non-variceal bleeding caused by?

A

peptic ulcers (H. pylori), stress ulcers, aspirin, NSAID use, and Mallory-Weiss tears

40
Q

What are the signs and symptoms of a GI bleed?

A
  1. hematemesis
  2. melena
  3. hematochezia
  4. N/V
  5. anemia
  6. tachycardia
  7. hypotension
  8. fatigue
  9. weakness
  10. abdominal pain
  11. hemodynamic instability
41
Q

What is the initial priority in a GI bleed?

A

hemodynamic status/stability

42
Q

When should fluids or a blood transfusion be given?

A

when Hg falls below 7

43
Q

What are the two diagnostic exams for GI bleed?

A

esophagogastroduodenoscopy for upper GI bleed and colonoscopy for lower GI bleed

44
Q

When should the EGD or colonoscopy be performed

A

When the patient is stable (ideally in the first 24 hours)

45
Q

What treatments can be performed during the EGD or colonoscopy?

A
  1. sclerotherapy (high saline drug)
  2. thermal coaptive therapy
  3. hemostatic clip placement
46
Q

What is the most efficacious therapy for GI bleed?

A

sclerotherapy + copative therapy

47
Q

What is the pharmacological treatment of a GI bleed?

A
  1. remove contributing meds
  2. give fluids or transfusion
  3. discontinue anticoagulants and use reversal agents
  4. acid suppression therapy
48
Q

What is the goal pH to prevent clot dissolution?

A

≥ 6

49
Q

What medications should be used for acid suppression?

A

PPIs (IV options: esomeprazole and pantoprazole)

50
Q

What is the typical dosing for IV PPIs?

A

80 mg bolus, followed by 8 mg/hr infusion x 72 hours

51
Q

How long should PPI therapy be continued post-endoscopy?

A

72 hours

52
Q

How long should oral PPI therapy be continued for a non-H. pylori bleed?

A

6-8 weeks

53
Q

What happens if you can’t stop NSAID therapy?

A

Switch to COX-2 selective agent like celecoxib

54
Q

When can aspirin be resumed for a secondary prevention?

A

as soon as possible after bleeding stops (usually 7 days)

GI/Hepatic (4 decks)

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