▪️︎ درباره NG tube گذاشتن:
The routine use of nasogastric tube (NGT) placement in patients with suspected acute upper GI bleeding is not recommended, as studies have failed to demonstrate a benefit with regard to clinical outcomes. We suggest that patients only undergo NGT lavage if particulate matter, fresh blood, or clots need to be removed from the stomach to facilitate endoscopy. An alternative to NGT lavage in this situation is to use a prokinetic such as erythromycin.
▪️Our approach is to perform upper endoscopy within 24 hours for most patients with upper GI
bleeding, but only after adequate resuscitation has been provided. For patients with suspected variceal bleeding, we perform endoscopy within 12 hours of presentation.
▪️Retrospective studies have suggested that emergency
endoscopy (within 12 hours) may be associated with poor outcomes, possibly due to inadequate resuscitation in patients undergoing emergency endoscopy.
▪️Glasgow-blatchford bleeding score for admission/discharge
📝ED order for UGIB or unstable LGIB
#Order
▪️Imp: upper GI bleeding or unstable LGIB#Episode_9
▪️Cond: emergency
▪️Diet: NPO
▪️Act: CBR and bed sides up
▪️Pos: supine and head elevated
▪️C.V.S q1h
▪️CM and POM
▪️oxygen if sat<90
▪️two large bore IV lines fix (16 gauge or larger)
▪️IV fluid 500-1000ml bolus isotonic crystalloid over 30-60 min, repeated if needed.
▫️use smaller boluses and lower total volumes for patients with compromised cardiac function.
▪️ECG stat
*in patients who are at risk for a myocardial infarction, or patients with symptoms such as chest pain or dyspnea, especially if there has been hemodynamic instability.
▪️CXR
*(if suspect perforation)
▪️Foley and I/O chart
▪️Check CBC, BUN, Cr, Na, K, PT, PTT, INR, AST, ALT, Alb, BG, Rh
* initial Hb may be inaccurate with acute severe hemorrhage
▪️check CBC(Hb) q2-8h based on the severity of bleeding
▪️reserve 2 unit pc
▪️Transfusion:
* avoid over-transfusion with possible upper GI bleeding
▫️plasma(FFP) for coagulopathy(INR>1.5) or after transfusing 4 units of RBCs
▫️platelets for thrombocytopenia (platelets <50,000) or platelet dysfunction (eg, chronic aspirin therapy) or after transfusing 4 units of RBCs.
▫️immediately transfusion blood products in 1:1:1 ration of RBCs, plasma, and platelets
*For severe, ongoing bleeding,
▫️transfusion 1 to 2 units RBCs
*For hemodynamic instability despite crystalloid resuscitation,
▫️transfusion 1 unit RBCs and reassess the patient's clinical condition
*For hemoglobin <8 g/dL in high-risk patients (eg, older adult, coronary artery disease)
*For hemoglobin <7 g/dL in low-risk patients,
▪️Amp pantoprazole 80mg IV stat.
* If endoscopy delayed beyond 12 hours, give second dose of esomeprazole or pantoprazole, 40 mg IV.
▪️Pharmacotherapy for known or suspected esophagogastric variceal bleeding and/or cirrhosis:
▫️Give somatostatin or an analogue (eg, octreotide 50 mcg IV bolus followed by 50 mcg/hour continuous IV infusion)
▫️Give an IV antibiotic (eg, ceftriaxone or fluoroquinolone), e.g. Amp Ceftriaxone 1gr/ IV / stat & Daily for 7 days
▪️Amp erythromycin 250mg IV (30 min befor endoscopy )
* (equal endoscopy conditions as NG lavage) so The routine use of nasogastric tube (NGT) placement in patients with suspected acute upper GI bleeding is not recommended.
🔹Appendix:
▪️Our approach is to perform upper endoscopy within 24 hours for most patients with upper GI
bleeding, but only after adequate resuscitation has been provided. For patients with suspected variceal bleeding, we perform endoscopy within 12 hours of presentation.
*Early endoscopy does not necessarily improve clinical outcomes
▪️The routine use of nasogastric tube (NGT) placement in patients with suspected acute upper GI bleeding is not recommended.
▪️in patients with life-threatening bleeding and a coagulopathy (INR> 1.5), warfarin and direct-acting anticoagulants (DOACs) should be withheld.
▫️In general, aspirin should be continued for secondary prophylaxis in patients with high-risk cardiovascular disease
➡️Upper and lower GIB