GI (January 2018)

9 comments

1. Here’s a nice concise summary of HUGS for gastroparesis along with another study as part of our AIR module this month.

   http://foamcast.org/wp-content/uploads/2017/08/Screen-Shot-2017-08-31-at-7.02.47-PM.png

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2. Here are the links to the UGIB scores for your reference:

   https://www.mdcalc.com/aims65-score-upper-gi-bleeding-mortality

   https://www.mdcalc.com/glasgow-blatchford-bleeding-score-gbs

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3. Ramirez at al.
   Strengths:
   Statistically significant finding suggests an alternative to narcotics for gastroparesis induced by DM.

   Weaknesses:
   Retrospective chart review, single center, interpretation of chart notes may not accurately reflect management.

   Outcomes:
   Reduced hospital admission rate and morphine equivalent dose in patient’s who received HP. No sig difference in ED or hospital LOS.

   Change Practice:
   I feel like we have been administering low dose haldol in our ED for gastroparesis for a while now. In my experience its fairly effective in reducing the need for narcotics and admissions for pain control. I will continue to administer haldol in this group.

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4. HP in pts w/ GP, n/v
   1. Study addresses a common complaint that is at times difficult to symptomatically control. Good attempt to study an intervention that is more commonly being used. Nice review of HP in discussion.
   2. Retrospective analysis. Small sample size. No attempt to record or control for self-administered meds PTA. Providers not blinded.
   3. Rate of admission and morphine equivalents were found to be significantly reduced in pts with GP 2/2 DM who received HP.
   4. I started doing this last year and have anecdotally seen better sxs control. However, I’m likely introducing my own bias into the matter (ie, I think it works better, therefore I give more effort into trying to dispo pts home).

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5. UGIB Scoring System
   1. Strengths? Nice attempt to help identify scoring systems that may assist in risk stratification, resource allocation, interventions, etc. We know the resus game well downstairs but if we’re able to separate sick from very sick, we might be more aggressive in management. And given the associated mortality rate (approx. 10%) and frequency seen w/in ED, anything thing to help guide quicker decision making is welcome.
   2. Limitations? Retrospective. Single center. Did not take into account several subgroups of pts with different UGIB etiologies. Unclear of external validity in the US holds up given different practice patterns/protocols used at research site (ie, China).
   3. In pts with acute UGIB, AIMS65 and the Blatchford scores are clinically more useful for predicting 30-day mortality vs pre-endo Rockall, Baylor scores.
   4. It’s never really occurred to me to use these scores in the ED. I’m typically in resus game when it comes to UGIB – 18 gauges x2, PPI, ?octreotide, and crystalloids/blood. Perhaps it’s because the majority of UGIB we see are stable. I recently left the MICU and took care of my fair share of very sick UGIB pts and spent A LOT of time resuscitating them. I’d have to think long and hard to determine if applying these scores downstairs would’ve changed management. I’ll def give it a shot next time a sick UGIB rolls in and calculate an AIMS65 score to risk stratify, determine interventions, etc.

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6. 1. HUGS
   – Internal control group given patients given haldol were compared to prior ED visits without haldol. Compared patient oriented outcomes like need for morphine and admission to hospital. Run like an ITT study where providers were just doing routine care.
   – Restrospective, did not control for other interventions or different providers at different stays (ex. providers that used haldol may have a lower threshold for discharge).For those discharged from ED, no data on repeat visits.
   – Less morphine (6.75 vs 10.75mg) and less admissions (10% vs 27%) in haldol group. Although ED LOS was not significantly different, 9 vs 25hrs definitely trended towards haldol group. Low side effect profile of haldol (although unlikely accurately capture by EMR review).
   – GP patients should receive haldol alongside opiates. Better monitoring and recording of potential side effects on a larger scale need to be established for more routine use of haldol, but given the known downsides of opiates, I think it’s reasonable at this time to use haldol routinely for this ED presentaton

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7. 2. Scores for UGIB mortality prediction
   – Compared multiple scoring systems. Had 30d follow up for all patients.
   – UGIB allcomers so does not include known history of PUD/varices/cirrhosis or prior EGD results to stratify (great if we get an unknown patient to ED2.5pts. +LR of AIM65 was 16.69 and -LR 0.31. There was some improvement in sens to 90% when Blatchford score was combined.
   – Undifferentiated patients with GIB who score >2.5 on AIM65 should be treated more emergently and definitely admitted, however, the scoring misses patients with a sensitivity of 70% which is of much less utility if it is being used as a screening tool. AIM65+Blatchford is a bulky way to improve the sensitivity, but I think gestalt and prior EMR knowledge of patients would superseded use of this tool. Perhaps the one use would be to type and cross AIM65+ patient’s earlier.

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8. Ramirez
   What are some strengths of the study?
   Although small study, statistically significant results: decrease in opioids, admissions
   What are the limitations?
   -retrospective observational study
   -small sample
   What are the main outcomes of the study?
   -a reduction in amt of opioids administered
   -a reduction in hospital admission
   Changes
   -We have a similar pt population to UCSF Fresno and clearly similar clinical practices. Although I have found we usually throw in an IV and give IV haldol. Interesting to avoid line/labs and just give it IM like in the study. Also good to note that no dystonic reactions, akasthesia, torsades de pointes or dysrhythmias were observed amongst patients who received HP.

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9. How has reading the article changed your practice?
   I don’t think it has. Not super practical to think about in the ED. We can usually differentiate sick vs non-sick GIB without these scores. Plus the AIMS65 score is based on things we already consider when evaluating a GIB…what’s their liver function, could this be variceal, and are they old and not perfusing sufficiently. Kinda like the qSOFA in sepsis…are they altered or hypotensive…don’t need a score to tell me these measures indicate a pt is sick.
   What information had you believed in previously that were debunked by reading this article?
   Nothing debunked really. Just reaffirming score is not super helpful in evaluating GIB pts in ED.
   What new information did you learn from reading this article?
   Learned what AIMS65 and Glasgow-Blatchford
   score were. Glasgow-Blatchford score also includes hx of cardiac disease, BUN, syncope and tachycardia into their scoring

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