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Acute gastrointestinal (GI) bleeding is responsible for as many as 540,000 hospitalizations in the United States each year. Lower GI bleeds account for roughly 20% to 30% of these cases and carry a mortality rate of between 2% to 4%.¹ Early identification and treatment of the source of bleeding and the resulting symptoms is essential for preventing life-threatening complications such as hypovolemic or hemorrhagic shock.

Unstable patients with active GI bleeding who display signs of hemorrhagic shock often require rapid volume resuscitation with crystalloid fluids and/or blood products. However, traditional methods for rapid blood transfusion, including pressure bags and rapid infusers, can be difficult to set up, require extensive staff training for competency, and delay care.²

The following case explores a positive outcome for a patient with severe GI bleeding when a novel handheld rapid infuser was used to efficiently administer blood products.

Case Presentation

A 77-year-old female patient arrived in the emergency department (ED) with complaints of generalized weakness and red blood in the stools as well as decreased appetite and nausea over the past several weeks. The patient’s extensive medical history includes numerous cardiovascular diagnoses and hypothyroidism.  The patient arrived to the ED with vital signs indicative of hypovolemic shock, including a blood pressure (BP) of 92/61 mmHg and a heart rate (HR) of 113.³ Lab results showed a hemoglobin level of 10.2, hematocrit of 32.8, and platelet count of 488. Bright red blood was found during a rectal exam and the patient’s stool guaiac test was also positive.

Given these findings, the patient was taken to interventional radiology (IR) for a CT angiogram to further investigate a suspected gastrointestinal (GI) bleed. In IR, the patient was found to have active extravasation in the lower colon. The IR team attempted to embolize the bleed but was unsuccessful.

The patient was then admitted to the intensive care unit (ICU) for further monitoring and treatment ahead of planned surgical intervention that evening.

Management

In the ED, the patient received a 1000mL bolus of normal saline in response to her poor vital signs. However, upon arrival in the ICU, the patient’s vital signs had further deteriorated to BP 75/44 mmHg and HR 114. The provider ordered four units of packed red blood cells (PRBCs) to be administered as well as one unit of platelets.

The nursing team used the handheld LifeFlow PLUS rapid infuser to administer the PRBCs through the patient’s peripheral IV (PIV). Each unit of PRBC’s was administered over approximately five to seven minutes. Between each unit, the nursing staff reassessed the patient’s vital signs, which remained stable and showed gradual improvement as each unit was administered. Following the fourth unit of PRBCs, the patient’s blood pressure had risen to 106/68 mmHg and her heart rate was 104. The blood was not warmed during the transfusion and the patient complained of feeling cold, however, the team carefully monitored her temperature, which stayed within a range of 97.5-98.8 degrees Fahrenheit throughout the process. The ICU physician at the bedside and the OR general surgeon were in constant communication with the nursing team and ordered continued administration of the blood products as tolerated by the patient.

Based on assessment findings and to further prepare the patient for surgery later that evening, an additional four units of PRBCs were ordered for rapid infusion. These were administered with the LifeFlow device through the patient’s right brachial PICC line over roughly five to seven minutes each. Between each unit, the nursing team continued to reassess the patient’s vital signs, which remained stable.

After a total of eight units of PRBCs had been administered, the patient’s vitals improved to BP 135/85 mmHg and HR 98. Her lab values also improved, with a post-infusion hemoglobin of 13.5 and hematocrit of 38.7.

The patient went on to have two surgeries in the OR to identify and stop the source of the bleeding before being discharged home.

Discussion

In cases of severe GI bleeding, correcting hemodynamic imbalances is imperative. Rapid infusers are complex to set up and many nurses lack the necessary training to feel comfortable with their use in critical situations. Pressure bags are often too slow and require constant attention to maintain faster flow rates.

By contrast, the nursing staff in this case said the LifeFlow device was “a lot simpler and easier to set up and utilize to get the blood products in.” The team also highlighted the importance of one nurse being able to operate the handheld device while another retrieved the next unit of blood from the blood bank to allow for rapid sequential administration.

When patients presenting with GI bleeding need a rapid blood transfusion, traditional methods are often ineffective. LifeFlow’s speed and easy set-up let providers begin infusing blood products in seconds to correct the patient’s hemodynamic imbalance and prepare her for surgery.