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A 72-year-old man suffers from a recent left middle cerebral artery stroke. His lungs are mechanically ventilated. He develops progressive hypotension and tachycardia. His hemoglobin level has decreased from 10 mg/dL to 7.5 mg/dL over 24 hours. After several fluid boluses, the patient's blood pressure is 80/65 mm Hg. His heart rate is 120 bpm. The patient's nurse reports that the patient's stool is melenic.

What should be the first step in managing this patient?

The patient is suffering from a gastrointestinal bleed (GIB). Two large-bore intravenous catheters (16 gauge or larger) are necessary to initiate resuscitation with crystalloid and colloid fluids or blood products. When peripheral venous access cannot be obtained, a central venous line such as a Cordis catheter (Cordis Corp, Bridgewater, NJ) should be inserted. An arterial line should be inserted for beat-to-beat monitoring of systemic blood pressure. Four units of packed red blood cells (PRBCs) and 4 units of fresh-frozen plasma should be typed and crossed. Bedside assessment of end-organ perfusion and serial laboratory testing (basic metabolic profile, hemoglobin level, coagulation studies) guide transfusions and prevent delayed resuscitation and hypoperfusion. Vasoactive agents are administered during fluid resuscitation to maintain an adequate perfusion pressure.

This patient has a protected airway, but endotracheal intubation should be considered in patients with massive hemoptysis, shock, or obtundation. A nasogastric tube (NGT) should be placed to assess the site and rate of bleeding. If the abdomen is distended or if the patient complains of abdominal pain, a KUB (kidneys, ureters, and bladder) film should be performed and evaluated.

Two large-bore intravenous catheters, an arterial line, and an NGT are placed. The stomach is lavaged and 300 mL of bright red blood with coffee grounds appearance are observed. The patient's blood pressure has decreased to 70/55 mm Hg and his heart rate is 137 bpm. The gastrointestinal medicine service has been consulted.

What is the differential diagnosis for GI bleeding in this patient?

The differential diagnosis of GI bleeding in critically ill patients is broad (Table 28-1). Observation of bright red blood with coffee grounds appearance on NGT lavage suggests an upper gastrointestinal (UGI) source (originating proximal to the ligament of Treitz). UGI bleeding accounts for approximately 75% of GI bleeds and has a mortality rate of 20% to 30% in hospitalized patients.1 Intensive care unit (ICU) patients whose lungs are mechanically ventilated for more than 48 hours have coagulopathy, a history of GI ulceration, or bleeding within the last 12 months or two of the following risk factors: sepsis, ICU admission longer than 7 days, occult bleeding of 6 days or longer, or daily use of 250 mg of hydrocortisone or an equivalent are at risk for stress-related mucosal damage.2 A history of alcoholism, cirrhosis, or portal hypertension is often elicited in patients with variceal bleeding. ...

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