Critical Care Mailbag: Upper GI Bleed

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN
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Scott W., M.D. -

Can you point me to the lecture that weingart talked about why we don't need to do a type and screen b/c it doesn't save time

Ben S., Dr -

What is your pre-oxygenatjon strategy for upper GI bleeders?
Specifically ones with ongoing haematemsis
DSI and high flow nasal cannula - does that just cause blood spray? DSI and more typical pre-ox with an understanding you may get poor denitrogenation?
What do you actually do?

Anand S., M.D. -

Scott has discussed this before and I like his approach. https://emcrit.org/dsi/
DSI with ketamine and drop an NGT to empty the stomach out. Then supply NRB +/- NC
Honestly, I find that getting the blood out of the stomach relieves a lot of the issues (they don't vomit and cause blood to go down into the airway)

Sarah M. -

I think bullet points 4 and 5 might be missing the the "octreotide" and "antibiotics" labels, respectively. The statements make sense but it would be more clear if the interventions were listed too! Thanks!

Sarah M. -

Apologies, I found one more similar issue with the third to last bullet point. I think it's talking about TIPS but there's no label. Thank you!

Anand S., M.D. -

Thanks!

Drue O. -

An additional treatment for the Jehovah's witness with a GI bleed ( or any blood loss for that matter) is hyperbaric oxygen. Hyperbaric oxygen in severe anemia is a very good way to continue to provide oxygen to end organs while the body makes more hemoglobin. It is an approved indication and has been done many times in the past. If fact there was actually a very interesting study done on piglets in the 1940's where they removed all of the pigs blood and switched it out for saline while doing a 3 hour hyperbaric treatment on the pigs. There was enough free/dissolved oxygen in the saline via the hyperbaric environment to continue to perfuse the end-organs of the pigs and keep them alive. All this is to say that hyperbaric oxygen is great for anemic patients, especially those such as a Jehovah's witness that wont accept blood products.

Anand S., M.D. -

Interesting idea but I think before I would be calling the hyperbaric center, I would want some human data to drive this. I'd be worried as well because in this scenario, we're talking about a very unstable patient. It's challenging, if not frankly impossible, to manage a patient like this in a chamber.

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