Their conclusions:
Hypotension caused a significant and persistent rise in BUN
Blood feeding caused a small transient rise in BUN
Anemia alone DID NOT cause an elevated BUN
Hypotension AND blood-feeding cause a higher and longer uremia than either alone.
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A wonderful follow up study was done by Cohn and colleagues in 1956. He recruited five healthy men for a series of studies in which they were given either blood, protein concentrate, or beefsteak.pic.twitter.com/XLXkctXhvf
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They found that there was a small rise in BUN (~25%) with blood that rapidly resolved within 24 hours. However, both the protein concentrate and the beefsteak had a considerably higher rise (up to 247%) and lasted greater than 24 hours.
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They concluded that while blood can cause a small, transient increase in urea nitrogen, it’s far less than other sources of protein.
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In 1980, Stellato and colleagues performed a systematic review and concluded that azotemia in gastrointestinal hemorrhage may have a small and transient effect from blood digestion, but that hypovolemia was the major contributing factor (https://www.ncbi.nlm.nih.gov/pubmed/6968509 )
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Since the 1930s, it’s been noted that azotemia in UGIB is associated with sicker patients. In 2017, Kumar and colleagues performed a retrospective cohort study looking at patients with azotemia and nonvariceal UGIB to test this hypothesis (https://www.ncbi.nlm.nih.gov/pubmed/28377105 )
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They found that an elevated BUN was associated with an increased risk of an adverse event, including death. Their conclusion? “Increasing BUN at 24 hours likely reflects under resuscitation and is a predictor of worse outcomes in patients with acute nonvariceal UGIB.”
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So let’s revisit the original question again. Why does the urea nitrogen rise in gastrointestinal hemorrhage?
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I think the most important takeaway here is that if you have a patient with a GIB and azotemia, don’t just think, “oh, that’s interesting.” You should carefully evaluate their need for volume resuscitation.pic.twitter.com/ZwId9i8fi0
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Replying to @AdamRodmanMD
Priority should be blood for resus, right? Crystalloid as well, but if you're in shock or heading that way from bleeding, blood first
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I’ve always told my teams to be wary of giving diluting IV fluids for GI bleeds as an extrapolation of the trauma literature.. which makes sense to me intuitively but is there decent evidence to support this or permissive hypotension in GIB?
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Catrìona Retweeted Karim Brohi
This thread is very helpfulhttps://twitter.com/karimbrohi/status/1084519276332093440?s=19 …
Catrìona added,
Karim Brohi @karimbrohiHave been asked a few times where I got the 60mmHg figure from in this tweet. Should answer this in a long, well-reasoned paper, not Twitter. But here goes... First and most importantly, the number 60 is largely irrelevant, the ethos is far more important than the number. https://twitter.com/karimbrohi/status/1083036811717500929 …Show this thread1 reply 0 retweets 2 likes -
great threads, thanks!- know of any societal position statements to support that practice? Was hoping to forward to my team something higher on that evidence chain that a twitter thread, although it may serve :P
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