People on twitter absolutely hate the concept of using a central line to resuscitate a GI bleeder. This comes up a couple times per year.

I think the source of this hatred is largely three-fold:

1. A central line alone is garbage (without a Level-1 or Belmont infuser). I'll admit that.  So if you're working in a place without immediate access to a fancy pressure infuser then yeah – don't use a central line.
2. The approach to GI bleeding is based on the approach to massive hemorrhage in trauma – which is a different disease process that involves different treatments (e.g., emergent open surgery).
3. Machismo (“when I admit a GI bleeder, I crack open the chest and sew a garden hose directly into the right atrium”).

I work at a GI bleed center of excellence and I've resuscitated a lot of severe GI bleeders using a central line plus a Belmont infuser.  This can get in one round of massive transfusion (6 PRBC, 6 FFP) in roughly five minutes. And that's completely fine for nearly all severe GI bleeders:

• Hypotension in GI bleed is usually because the patient has been slowly losing blood for several hours and they're way behind.  You need to catch up, but whether you catch up over 2 minutes or five minutes doesn't really matter.
• Infusing blood products at a much faster rate isn't necessarily a great thing. I've seen some patients deteriorate after running massive transfusion through dialysis catheters. There is a risk of over-pressurizing the venous system, leading to venous congestion and endothelial damage. Slamming in ginormous amounts of blood at lightning speed is flashy, but I'm skeptical about whether it actually helps the patient.
• If the patient is truly losing blood at such a fast rate that a central line plus Belmont can't keep up (ongoing hemorrhage at >~1 unit/minute), it's dubious whether any intervention in the ICU will be able to manage this. For example, the patient could easily exhaust the entire hospital's blood supply en route to the angio suite. This is an incredibly rare situation that I've seen maybe once (aortoenteric fistula with exsanguination over minutes).

A central line has the following advantages, which almost no other line has:

1. It's secure (will not fall out during transport, or kink off if the patient bends their neck).
2. Gives you multiple lumens (to run pressors, calcium, products) – we love our quad-lumen lines in ICU.
3. Combined with a Belmont infuser it achieves an adequate flow rate.
4. It's readily available (doesn't require rummaging around in the supply room).
5. It is pressure injectable, allowing for the performance of CT angiography.

This last point is really important. If the gastroenterologist fails to control the bleed, the next step is often CT angiography in preparation for interventional radiology intervention. This involves pressurized injection of contrast dye – which must be performed via an 18g peripheral IV or a device that is specifically rated as pressure injectable (so it won't explode under pressure):

• Ideally, all central lines at your shop will be pressure injectable.
• Cordis catheters/sheaths aren't pressure injectable (I once insisted on doing a CT angio through one and… yeah, it completely exploded).
• MAC catheters don't appear to be pressure injectable (at least they aren't labeled as such).

So in conclusion, I feel like a quad-lumen pressure-injectable central line is the Toyota Accord of GI bleed resuscitation.  It's not the fastest nor the flashiest option.  But it's a solid option that gets the job done.

I'm sure that this post won't end the debate about vascular access for GI bleeds. Maybe it doesn't apply to the context where you practice critical care. But I do think that we need to be more open-minded about using different access approaches for gastrointestinal hemorrhage.

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Josh Farkas

Josh is the creator of PulmCrit.org. He is an associate professor of Pulmonary and Critical Care Medicine at the University of Vermont.

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