A patient comes in with hypotension. As you gather information, you realize he has urosepsis. He was in the ED yesterday with urinary retention (due to prostate cancer), required a suprapubic tube by GU, and his creatinine rose from a baseline of 2.0 to 2.7. The UA is consistent with infection and the culture has already grown gram negative rods. He was sent home with antibiotics. Today, his creatinine is 6.0 and he has 25% bandemia. He appears well despite his hypotension and the BP came up after 3L of lactated ringers.
Do you say anything to the team that discharged him the day before, and if so, what do you tell them?
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BRBPR answer
Both patients have active UPPER GI bleeds and require emergent endoscopy. Patient 1 has variceal bleeding. Patient 2 has bleeding from an ulcer.
BRBPR (bright red blood per rectum) is rarely caused by upper GI bleeding. Thus, when a surgery consult asks for an NG tube, your answer should be no… most of the time. When upper GI bleeding leads to bright or dark blood from below – the patient will have signs of active bleeding – tachycardia, hypotension, syncope, e.g.
An NGT is life-saving at times because it will get your GI consult to emergently scope the patient. Over the years, endoscopy seems to be delayed more and more in my hospital, leading to patients that bleed to near-death in the ED. Patients look stable and they don’t scope the patient emergently. An NGT will also tell you that you need to transfuse the patient NOW rather than fall behind.
Basically, you’re looking for blood (not coffee grounds) when you put in an NG tube. Coffee-ground emesis is often caused by gastritis due to an illness (e.g. DKA, sepsis) and is not the primary illness that will kill the patient.
If the patient is going to be scoped in the next hour or two, an NGT is unnecessary.
If the patient is actively vomiting blood, an NGT is unnecessary.
An NGT is more likely to be life-saving than a PPI or octreotide, because it may get GI to come in and stop the bleeding.
Patient one was a sign-out to me. The patient was sitting in the ED all day with normal-ish vitals, normal repeat H/H, but apparently had been passing blood from below the entire day. He had coded earlier in the day from his GI bleed but apparently looked so well that critical care refused an ICU bed. He crashed just before sign-out, and of course he lost his lines. It was a mess.
Patient two was my last patient from the same shift. An NGT pulled out red blood, revealing the need for emergent endoscopy and transfusion. GI could not stop the bleeding and the patient had to go to IR for embolization.
When you show your consults blood, they understand the gravity of the situation.
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I must have had a good summer. I didn’t post anything.