每日一题_2022.08.28

A 55-year-old man with a history of hepatitis C and alcoholic cirrhosis is admitted to the ICU from the emergency department (ED) with suspected upper gastrointestinal bleeding. He has a history of esophageal varices requiring banding in the past year. He was started on a proton pump inhibitor and octreotide in the ED, and gastroenterology was consulted. Soon after arrival to the ICU, he decompensates with copious hematemesis and becomes hypotensive. An upper endoscopy for source control is not available for at least one hour.

In addition to continued resuscitation while awaiting gastroenterology, which of the following is the most appropriate management for this patient?

A. Place a nasogastric tube, start antibiotics for spontaneous bacterial peritonitis (SBP) prophylaxis, and start a low-dose beta-blocker to decrease portal venous pressure.

B. Intubate for airway protection, and place a Blakemore tube for hemorrhage control.

C. Place a Blakemore tube for hemorrhage control, and start antibiotics for SBP prophylaxis.

D. Intubate for airway protection, place a Blakemore tube for hemorrhage control, and start antibiotics for SBP prophylaxis.

答案解析：

患有食管静脉曲张的肝硬化患者会很快失代偿，需要熟练的复苏以最大限度地提高生存机会。该患者在 ICU 到达前发生了出血，并在急诊科开始接受适当的治疗。到达重症监护室后，他的病情恶化了；由于上消化道出血严重，气道管理至关重要。任何胃肠道手术都需要插管，就像在食道中放置 三腔二囊管以避免在等待胃肠病学时放血一样。经常被忽视但对改善结果至关重要的是预防性抗生素以预防肝硬化静脉曲张出血患者的自发性细菌性腹膜炎。已显示开始使用第三代静脉注射头孢菌素可降低全因死亡率、感染相关死亡率、再出血事件和住院时间。插入鼻胃管并不是不正确的，因为它从未被证明会加重静脉曲张出血，但在急性低血压情况下开始使用 β 受体阻滞剂是不正确的，因为它可能会恶化血流动力学。

正确答案：D