Protocol For Treating Upper GI Bleeding
1) Resuscitation: confirm airway patency. Make sure that patient is not likely to aspirate blood especially if the patient is comatose. Put the patient in left lateral position with head towards the floor. Take TWO peripheral lines with 16/18G venflon. If IV fluids are required always use blood set. Collect blood samples for CBC, group and cross match at least FOUR units of blood. Also collect blood for urea, electrolytes, liver function tests and prothombine time as required.
2) Confirm upper g.i. Bleeding: Coffee ground or frank red blood. Preserve samples: vomiting or after coughing. Melena: tarry black or very dark red
3) Assess blood loss: Resting pulse and blood pressure = normal means less than 500 ml. Of blood loss. Resting tachycardia + postural drop of blood pressure means about 2.00 liters of blood loss. Shock: more than 2.00 liters of blood loss. If more than 500ml.of blood is lost start N-saline and/or plasma expanders till haemoglobin results are available and transfusion requirements are decided. If patient is in shock, elevate foot end of the bed. Start haemacele or other plasma expanders till blood is available. Dopamine in renal dose and dobutamine in pressor dose may be used to maintain perfusion along with plasma expanders and blood. If time permits and availability is not a problem use Packed cell volume (PCV) only. Whole blood to be used only in exceptional circumstances. In dire emergency used unmatched group "O" negative blood.
4) Indications for central line: Massive bleed Above 60 yrs.of age. Patients with CCF or poor ejection fraction or COPD Rebleed during the same admission. Never use femoral. First preference to Internal jugular as it is in area where sterility could be easily observed and no major organs are nearby that could be damaged. Easier to maintain once inserted. No need for IITV or X-ray to confirm its location for CVP measurement. Second preference is Subclavian. Needs confirmation of its proper placement by IITV or X-ray. Lookout for pneumothorax or haemothorax.
5) Insert Nasogastric tube in patients who are continually bleeding or who have had moderate to severe blood loss. Use no.20 or18 as clots could be easily removed. Give wash with simple tap water, no need for cold saline etc. Give wash in left lateral, right lateral and in supine position to aspirate totally. Remember, incomplete evacuation of clots could lead to aspiration at endoscopy and may impair proper visualization.
6) Prepare for endoscopy: Early endoscopy helps to establish correct diagnosis, therapeutic intervention and thereby reduces the chance of further bleed. Emergency endoscopy is indicated if bleeding continues or there is a rebleed during the same admission or emergency surgery is contemplated
7) If patient is known to have portal hypertension than IV Sandostatin or somatostatin is started to control bleeding. In a known case of portal hypertension and massive bleed Sangstaken tube may be used to control bleeding while endoscopy is being arranged.
8) Monitor Pulse, B.P. half hourly till the patient is stable. Monitor hourly urine output and central venous pressure.
9) Daily or twice a day Hb, daily electrolytes
High risk patients are:
1) > 60yrs.of age
2) Fresh haemetemesis with melena
3) N-SAID drug induced
4) Continued bleeding or rebleed in hospital
5) Advanced heart, lung or liver disease
6) Bleeding in a patient admitted for other reason
7) Massive bleed
8) With endoscopic stigmata of rebleed; like active arterial bleeding, visible vessel in ulcer base, fresh adherent clot or oozing or black dots in ulcer base
Common causes of bleeding:
1) Portal hypertension
2) Peptic ulcer
3) N-SAID drugs
4) Mellory-Weiss tear
Indications for surgery:
1) Inform surgical team about all bleeding patients.
2) Age > 60yrs. >4 units in 24 hrs.
3) One rebleed in hospital
4) Continued bleeding
5) Spurting vessel
6) Age < 60yrs . >8 units in 24 hrs.
7) O Rebleed in hospital
8) O Continued bleeding
9) O Spurting vessel at endoscopies
Upper g.i. bleed
1) assess severity
2) assure airway patency resuscitate
3) ascertain the cause by endoscopy monitor
4) decide if safe to continue medically or to surgically intervene