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===Recommendation for Revascularization for CLI:===
__NOTOC__


{| class="wikitable"
{{CMG}}; {{AE}}
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.'''In patients with CLI, [[revascularization]] should be performed when possible to minimize tissue loss.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.'''An evaluation for [[revascularization]] options should be performed by an interdisciplinary care team before amputation in the patient with CLI.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-EO]])''<nowiki>"</nowiki>
|-
|}


====Recommendations for Endovascular Revascularization for CLI:====
== Demographic / Medical history ==
{| class="wikitable"
* '''Demographic''': 77, M
|-
* '''Past Medical History:''' HTN, BPH, CAD w CABG, MI, AVR
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
* '''Past Surgical History:'''  
|-
** AVR (#25 magna ease valve) on 12/14/17
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.'''Endovascular procedures are recommended to establish in-line blood flow to the foot in patients with nonhealing wounds or [[gangrene]].''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''<nowiki>"</nowiki>
** Stent on 10/10/2017
|-
** CABG in 2007
|}
** Appendectomy in 1957


== Pre-endoscopic medical therapy ==
* '''Medications:'''
{| class="wikitable" style="width:82%"
** Metoprolol
|-
** DAPT
| colspan="1" style="text-align:center; background:LemonChiffon" |Conditional recommendation ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]])
** Tamsulosin
|-
| bgcolor="LemonChiffon" |1. Intravenous infusion of erythromycin (250 mg ~ 30 min before endoscopy) should be considered to improve diagnostic yield and decrease the need for


repeat endoscopy. However, erythromycin has not consistently been shown to improve clinical outcomes
== Procedure ==
* '''Index Procedure Date/Time''':
** mm/dd/YYYY at xx:xx  [insert date and time]
* '''Index Procedure Detail''': 
** On mm/dd/YYYY at xx:xx [insert date and time] the subject underwent a [select surgical correction] for [select etiology].  
** Access site details
** The site reported that there were/were not procedural complication(s).


|-
== Event(s) ==
| bgcolor="LemonChiffon" |2. Pre-endoscopic intravenous PPI (e.g., 80 mg bolus followed by 8 mg / h infusion) may be considered to decrease the proportion of patients who have
'''Event (1):'''
* '''Site Reported Event Onset Date: 12/26/2017'''


higher risk stigmata of hemorrhage at endoscopy and who receive endoscopic therapy. However, PPIs do not improve clinical outcomes such as further
* '''Event summary''':
** Symptoms and sign: Subject presented with
*** Right leg collapse,
*** Right arm and right leg weakness
** Episodes lasted approximately  2 -10 minutes and ranged from 1-4/day
** No visual or speech difficulties, no headache or neck pain
** No history of vertigo, syncope, loss of consciousness or seizures
** Other important symptoms related to the chief complaint.
** Physical assessment:
*** Normal neurological exam
*** BP: 124/66
*** HR: 96
== Laboratory data ==
* '''Lab studies list: ('''Date/ name/ value)
** 01/04/2018 / HDLC / 31
** 01/03/2018 / INR / 1.2


bleeding, surgery, or death
== Diagnostic tests ==
|-
* 01/03/2018 '''TTE'''
| bgcolor="LemonChiffon" |3. If endoscopy will be delayed or cannot be performed, intravenous PPI is recommended to reduce further bleeding.
** Mild left ventricular hypertrophy with normal systolic function and left ventricular diastolic dysfunction
|-
** Moderate left atrial enlargement
|}
** Bioprosthetic aortic valve peak vel 2 m/s and mean grad 6.4 hg, no AI
 
* 01/03/2018 '''MR Brain'''
== Gastric lavage ==
** NO evidence of vascular occlusion
{| class="wikitable"
** No evidence of restricted diffusion to suggest infarction
|-
* 01/03/2018 '''MRA H/N'''
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Conditional recommendation (Class IIa)]]
** Eccentric filling defect in the left internal carotid artery just distil to the bifurcation that may be from calcification / nonocclusive thrombus
|-
* 01/03/2018 '''Carotid US(Preliminary)'''
| bgcolor="LemonChiffon" |1. Nasogastric or orogastric lavage is not required in patients with UGIB for diagnosis, prognosis, visualization, or therapeutic effect
** Right: 1-49% stenosis of right internal carotid
|-
** Left: 1-49% stenosis of left internal carotid
|}
** Bilateral vrtebral arteries patent with antegrade flow
 
* 01/03/2018 '''EEG'''
== Timing of endoscopy ==
** Normal awake EEG
{| class="wikitable" style="width:82%"
** No epilitiform discharges, focal changes or other abnormalities
|-
==Consults==
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Conditional recommendation (Class IIa)]]
*Neurology consult : 01/03/2018
|-
*Recommendations:  
| bgcolor="LemonChiffon" |Timing of endoscopy
**CBC,CMP
1. Patients with UGIB should generally undergo endoscopy within 24 h of admission, following resuscitative efforts to optimize hemodynamic parameters and
**Admission to neurology service
 
**MRI brain with or without contrast
other medical problems.
**MRA of the extracranial and intracranial circulation
|-
**Carotid duplex US
| bgcolor="LemonChiffon" |2. In patients who are hemodynamically stable and without serious comorbidities endoscopy should be performed as soon as possible in a non-emergent
**EEG
setting to identify the substantial proportion of patients with low-risk endoscopic fi ndings who can be safely discharged.
*Date and time of consult
|-
*Suggested treatments:  
| bgcolor="LemonChiffon" |3. In patients with higher risk clinical features (e.g., tachycardia, hypotension, bloody emesis or nasogastric aspirate in hospital) endoscopy within 12 h may
**Aspirin 81mg chew tab
 
**Clopidogrel 75 mg tab
be considered to potentially improve clinical outcomes.
**Enoxaparin 40mg inj
|-
**Metoprolol succinate 25mg extended release
|}
==Clinical course==
 
*
==Endoscopic diagnosis==
*Date and time of events,
 
*Patient condition got worse or better.
{| class="wikitable"
==Treatment and outcome==
|-
*List of relevant medical treatments
| colspan="1" style="text-align:center; background:LightGreen" |Strong recommendation ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]])
**Aspirin 81mg chew tab
|-
**Clopidogrel 75 mg tab
| bgcolor="LightGreen" |1. Stigmata of recent hemorrhage should be recorded as they predict risk of further bleeding and guide management decisions. The stigmata, in descending
**Enoxaparin 40mg inj
risk of further bleeding, are active spurting, non-bleeding visible vessel, active oozing, adherent clot, fl at pigmented spot, and clean base .
**Metoprolol succinate 25mg extended release
|-
*Out come - Discharged home
|}
 
== Endoscopic therapy ==
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |Strong recommendation [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |1. Endoscopic therapy should be provided to patients with active spurting or oozing bleeding or a non-bleeding visible vessel.
|-
| bgcolor="LightGreen" |2. Endoscopic therapy should not be provided to patients who have an ulcer with a clean base or a fl at pigmented spot .
|-
| bgcolor="LightGreen" |3. Epinephrine therapy should not be used alone. If used, it should be combined with a second modality.
|-
| bgcolor="LightGreen" |4. Thermal therapy with bipolar electrocoagulation or heater probe and injection of sclerosant (e.g., absolute alcohol) are recommended because they
reduce further bleeding, need for surgery, and mortality.
|-
|}
{| class="wikitable" style="width:82%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Conditional recommendation (Class IIa)]]
|-
| bgcolor="LemonChiffon" |1. Endoscopic therapy may be considered for patients with an adherent clot resistant to vigorous irrigation. Benefi t may be greater in patients with clinical features
potentially associated with a higher risk of rebleeding (e.g., older age, concurrent illness, inpatient at time bleeding began).
|-
| bgcolor="LemonChiffon" |2. Clips are recommended because they appear to decrease further bleeding and need for surgery. However, comparisons of clips vs. other therapies yield
variable results and currently used clips have not been well studied .
|-
| bgcolor="LemonChiffon" |3. For the subset of patients with actively bleeding ulcers, thermal therapy or epinephrine plus a second modality may be preferred over clips or sclerosant
 
alone to achieve initial hemostasis .
|-
|}
 
== Medical therapy after endoscopy ==
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |Strong recommendation ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]])
|-
| bgcolor="LightGreen" |1. After successful endoscopic hemostasis, intravenous PPI therapy with 80 mg bolus followed by 8 mg/h continuous infusion for 72 h should be given to
patients who have an ulcer with active bleeding, a non-bleeding visible vessel, or an adherent clot.
|-
| bgcolor="LightGreen" |2. Patients with ulcers that have fl at pigmented spots or clean bases can receive standard PPI therapy (e.g., oral PPI once daily).
|-
|}
 
== Repeat endoscopy ==
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |Conditional recommendation ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa)]]
|-
| bgcolor="LemonChiffon" |1. Routine second-look endoscopy, in which repeat endoscopy is performed 24 h after initial endoscopic hemostatic therapy, is not recommended.
|-
| bgcolor="LemonChiffon" |2.If further bleeding occurs after a second endoscopic therapeutic session, surgery or interventional radiology with transcathether arterial embolization is
generally employed
|-
|}
 
== Hospitalization ==
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |Conditional recommendation ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa)]]
|-
| bgcolor="LemonChiffon" |1.Patients with high-risk stigmata (active bleeding, visible vessels, clots) should generally be hospitalized for 3 days assuming no rebleeding and no other
reason for hospitalization. They may be fed clear liquids soon after endoscopy.
|-
|}
 
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |Strong recommendation [[ACC AHA guidelines classification scheme#Classification of Recommendations|(Class I]])
|-
| bgcolor="LightGreen" |1.Patients with clean-based ulcers may receive a regular diet and be discharged after endoscopy assuming they are hemodynamically stable, their hemoglobin
is stable, they have no other medical problems, and they have a residence where they can be observed by a responsible adult.
|-
|}
 
== Long-term prevention of recurrent bleeding ulcers ==
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |Strong recommendation ([[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]])
|-
| bgcolor="LightGreen" |1.Patients with H. pylori -associated bleeding ulcers should receive H. pylori therapy. After documentation of eradication, maintenance antisecretory
therapy is not needed unless the patient also requires NSAIDs or antithrombotics.
|-
| bgcolor="LightGreen" |2. In patients with NSAID-associated bleeding ulcers, the need for NSAIDs should be carefully assessed and NSAIDs should not be resumed if possible. In
patients who must resume NSAIDs, a COX-2 selective NSAID at the lowest effective dose plus daily PPI is recommended.
|-
|}
 
===References===
{{Reflist|1}}

Latest revision as of 16:44, 18 June 2018


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Demographic / Medical history

  • Demographic: 77, M
  • Past Medical History: HTN, BPH, CAD w CABG, MI, AVR
  • Past Surgical History:
    • AVR (#25 magna ease valve) on 12/14/17
    • Stent on 10/10/2017
    • CABG in 2007
    • Appendectomy in 1957
  • Medications:
    • Metoprolol
    • DAPT
    • Tamsulosin

Procedure

  • Index Procedure Date/Time:
    • mm/dd/YYYY at xx:xx [insert date and time]
  • Index Procedure Detail:
    • On mm/dd/YYYY at xx:xx [insert date and time] the subject underwent a [select surgical correction] for [select etiology].
    • Access site details
    • The site reported that there were/were not procedural complication(s).

Event(s)

Event (1):

  • Site Reported Event Onset Date: 12/26/2017
  • Event summary:
    • Symptoms and sign: Subject presented with
      • Right leg collapse,
      • Right arm and right leg weakness
    • Episodes lasted approximately 2 -10 minutes and ranged from 1-4/day
    • No visual or speech difficulties, no headache or neck pain
    • No history of vertigo, syncope, loss of consciousness or seizures
    • Other important symptoms related to the chief complaint.
    • Physical assessment:
      • Normal neurological exam
      • BP: 124/66
      • HR: 96

Laboratory data

  • Lab studies list: (Date/ name/ value)
    • 01/04/2018 / HDLC / 31
    • 01/03/2018 / INR / 1.2

Diagnostic tests

  • 01/03/2018 TTE
    • Mild left ventricular hypertrophy with normal systolic function and left ventricular diastolic dysfunction
    • Moderate left atrial enlargement
    • Bioprosthetic aortic valve peak vel 2 m/s and mean grad 6.4 hg, no AI
  • 01/03/2018 MR Brain
    • NO evidence of vascular occlusion
    • No evidence of restricted diffusion to suggest infarction
  • 01/03/2018 MRA H/N
    • Eccentric filling defect in the left internal carotid artery just distil to the bifurcation that may be from calcification / nonocclusive thrombus
  • 01/03/2018 Carotid US(Preliminary)
    • Right: 1-49% stenosis of right internal carotid
    • Left: 1-49% stenosis of left internal carotid
    • Bilateral vrtebral arteries patent with antegrade flow
  • 01/03/2018 EEG
    • Normal awake EEG
    • No epilitiform discharges, focal changes or other abnormalities

Consults

  • Neurology consult : 01/03/2018
  • Recommendations:
    • CBC,CMP
    • Admission to neurology service
    • MRI brain with or without contrast
    • MRA of the extracranial and intracranial circulation
    • Carotid duplex US
    • EEG
  • Date and time of consult
  • Suggested treatments:
    • Aspirin 81mg chew tab
    • Clopidogrel 75 mg tab
    • Enoxaparin 40mg inj
    • Metoprolol succinate 25mg extended release

Clinical course

  • Date and time of events,
  • Patient condition got worse or better.

Treatment and outcome

  • List of relevant medical treatments
    • Aspirin 81mg chew tab
    • Clopidogrel 75 mg tab
    • Enoxaparin 40mg inj
    • Metoprolol succinate 25mg extended release
  • Out come - Discharged home
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