Improved outcomes and reduced complications were associated with a restrictive transfusion strategy in patients with upper gastrointestinal bleeding. Note that patients with “massive exsanguinating bleeding” were excluded from the study so this shouldn’t be extrapolated to such presentations.
The benefit seemed to be most marked in patients with variceal haemorrhage, but not those with the most severe Child-Pugh class. In portal hypertensive-related bleeding, transfusion may increase portal pressure and exacerbate bleeding.
The patients were ‘scoped within 6 hours, and less than 10% received FFP or platelets. Both groups averaged over 5 litres of crystalloid in the first 72 hours. Transfusion Strategies for Acute Upper Gastrointestinal Bleeding N Engl J Med. 2013 Jan 3;368(1):11-21
BACKGROUND: The hemoglobin threshold for transfusion of red cells in patients with acute gastrointestinal bleeding is controversial. We compared the efficacy and safety of a restrictive transfusion strategy with those of a liberal transfusion strategy.
METHODS: We enrolled 921 patients with severe acute upper gastrointestinal bleeding and randomly assigned 461 of them to a restrictive strategy (transfusion when the hemoglobin level fell below 7 g per deciliter) and 460 to a liberal strategy (transfusion when the hemoglobin fell below 9 g per deciliter). Randomization was stratified according to the presence or absence of liver cirrhosis.
RESULTS: A total of 225 patients assigned to the restrictive strategy (51%), as compared with 61 assigned to the liberal strategy (14%), did not receive transfusions (P<0.001) [corrected].The probability of survival at 6 weeks was higher in the restrictive-strategy group than in the liberal-strategy group (95% vs. 91%; hazard ratio for death with restrictive strategy, 0.55; 95% confidence interval [CI], 0.33 to 0.92; P=0.02). Further bleeding occurred in 10% of the patients in the restrictive-strategy group as compared with 16% of the patients in the liberal-strategy group (P=0.01), and adverse events occurred in 40% as compared with 48% (P=0.02). The probability of survival was slightly higher with the restrictive strategy than with the liberal strategy in the subgroup of patients who had bleeding associated with a peptic ulcer (hazard ratio, 0.70; 95% CI, 0.26 to 1.25) and was significantly higher in the subgroup of patients with cirrhosis and Child-Pugh class A or B disease (hazard ratio, 0.30; 95% CI, 0.11 to 0.85), but not in those with cirrhosis and Child-Pugh class C disease (hazard ratio, 1.04; 95% CI, 0.45 to 2.37). Within the first 5 days, the portal-pressure gradient increased significantly in patients assigned to the liberal strategy (P=0.03) but not in those assigned to the restrictive strategy.
CONCLUSIONS: As compared with a liberal transfusion strategy, a restrictive strategy significantly improved outcomes in patients with acute upper gastrointestinal bleeding. (Funded by Fundació Investigació Sant Pau; ClinicalTrials.gov number, NCT00414713.).
Two recent studies evaluate the use of a novel ingestable camera to diagnose upper gastrointestinal bleeding in emergency department patients.
The potential advantages of video capsule endoscopy over traditional endoscopy could include immediate availability, avoidance of sedation, patient tolerance, and the ability to rule out active bleeding in the emergency department.
The device used was the PillCam ESO2 – shown here in this animation:
Further research is needed. These small interesting studies demonstrate the potential for this imaging technology to be used in stable patients presenting to emergency departments. Since it can only diagnose rather than treat, it would not appear to have any role in unstable patients. Video capsule endoscopy in the emergency department: a prospective study of acute upper gastrointestinal hemorrhage. Ann Emerg Med. 2013 Apr;61(4):438-443
STUDY OBJECTIVE: Video capsule endoscopy has been used to diagnose gastrointestinal hemorrhage and other small bowel diseases but has not been tested in an emergency department (ED) setting. The objectives in this pilot study are to demonstrate the ability of emergency physicians to detect blood in the upper gastrointestinal tract with capsule endoscopy after a short training period, measure ED patient acceptance of capsule endoscopy, and estimate the test characteristics of capsule endoscopy to detect acute upper gastrointestinal hemorrhage.
METHODS: During a 6-month period at a single academic hospital, eligible patients underwent video capsule endoscopy (Pillcam Eso2; Given Imaging) in the ED. Video images were reviewed by 4 blinded physicians (2 emergency physicians with brief training in capsule endoscopy interpretation and 2 gastroenterologists with capsule endoscopy experience).
RESULTS: A total of 25 subjects with acute upper gastrointestinal hemorrhage were enrolled. There was excellent agreement between gastroenterologists and emergency physicians for the presence of fresh or coffee-ground blood (0.96 overall agreement; κ=0.90). Capsule endoscopy was well tolerated by 96% of patients and showed an 88% sensitivity (95% confidence interval 65% to 100%) and 64% specificity (95% confidence interval 35% to 92%) for the detection of fresh blood. Capsule endoscopy missed 1 bleeding lesion located in the postpyloric region, which was not imaged because of expired battery life.
CONCLUSION: Video capsule endoscopy is a sensitive way to identify upper gastrointestinal hemorrhage in the ED. It is well tolerated and there is excellent agreement in interpretation between gastroenterologists and emergency physicians.
BACKGROUND AND STUDY AIMS: Capsule endoscopy may play a role in the evaluation of patients presenting with acute upper gastrointestinal hemorrhage in the emergency department.
METHODS: We evaluated adults with acute upper gastrointestinal hemorrhage presenting to the emergency departments of two academic centers. Patients ingested a wireless video capsule, which was followed immediately by a nasogastric tube aspiration and later by esophagogastroduodenoscopy (EGD). We compared capsule endoscopy with nasogastric tube aspiration for determination of the presence of blood, and with EGD for discrimination of the source of bleeding, identification of peptic/inflammatory lesions, safety, and patient satisfaction.
RESULTS:The study enrolled 49 patients (32 men, 17 women; mean age 58.3 ± 19 years), but three patients did not complete the capsule endoscopy and five were intolerant of the nasogastric tube. Blood was detected in the upper gastrointestinal tract significantly more often by capsule endoscopy (15 /18 [83.3 %]) than by nasogastric tube aspiration (6 /18 [33.3 %]; P = 0.035). There was no significant difference in the identification of peptic/inflammatory lesions between capsule endoscopy (27 /40 [67.5 %]) and EGD (35 /40 [87.5 %]; P = 0.10, OR 0.39 95 %CI 0.11 - 1.15). Capsule endoscopy reached the duodenum in 45 /46 patients (98 %). One patient (2.2 %) had self-limited shortness of breath and one (2.2 %) had coughing on capsule ingestion.
CONCLUSION:In an emergency department setting, capsule endoscopy appears feasible and safe in people presenting with acute upper gastrointestinal hemorrhage. Capsule endoscopy identifies gross blood in the upper gastrointestinal tract, including the duodenum, significantly more often than nasogastric tube aspiration and identifies inflammatory lesions, as well as EGD. Capsule endoscopy may facilitate patient triage and earlier endoscopy, but should not be considered a substitute for EGD.
The UK’s National Institute for Health and Clinical Excellence has issued updated guidance on the management of acute upper gastrointestinal bleeding.
The initial resuscitation section recommends haemostatic blood product resuscitation for unstable patients in line with massive transfusion practice in trauma.
A risk assessment is recommended using the Blatchford score pre-endoscopy at first assessment, and the full Rockall score after endoscopy.
Consider early discharge for patients with a pre-endoscopy Blatchford score of 0.
In non-varicesal haemorrhage, acid-suppression drugs (proton pump inhibitors or H2-receptor antagonists) before endoscopy are not recommended.
Terlipressin should be given to patients with suspected variceal bleeding at presentation and continued until definitive haemostasis has been achieved, or after 5 days, unless there is another indication for its use.
Prophylactic antibiotic therapy should be offered at presentation to patients with suspected or confirmed variceal bleeding.
Critically ill patients may receive cardiovascular, respiratory, and renal support, but systems that perform some of the functions of the liver are less routinely used. Extracorporeal liver support can be provided by artificial systems or bioartificial systems:
Artificial liver support systems aim to replace the detoxification functions of the liver, based on albumin dialysis, and consist of membrane separation associated with columns or suspensions of sorbents, including charcoal and anion or cation exchange resins.
Bioartificial systems incorporate either human hepatoblastoma cells or porcine hepatocytes into bioreactors that are intended to perform both liver detoxification and synthetic functions. A porous barrier between the patient’s blood or plasma isolates cells from immunoglobulins and leucocytes, avoiding immune rejection. Smaller particles such as toxins, metabolites and synthesized proteins are free to cross the barrier.
Three artificial liver support system types and two bioartificial liver systems have undergone randomised controlled trials. A meta-analysis examined the effect of extracorporeal liver support on mortality
BACKGROUND: Extracorporeal liver support (ELS) systems offer the potential to prolong survival in acute and acute-on-chronic liver failure. However, the literature has been unclear on their specific role and influence on mortality. This meta-analysis aimed to test the hypothesis that ELS improves survival in acute and acute-on-chronic liver failure. METHODS: Clinical trials citing MeSH terms ‘liver failure’ and ‘liver, artificial’ were identified by searching MEDLINE, Embase and the Cochrane registry of randomised controlled trials (RCTs) between January 1995 and January 2010. Only RCTs comparing ELS with standard medical therapy in acute or acute-on-chronic liver failure were included. A predefined data collection pro forma was used and study quality assessed according to Consolidated Standards of Reporting Trials (CONSORT) criteria. Risk ratio was used as the effect size measure according to a random-effects model. RESULTS: The search strategy revealed 74 clinical studies including 17 RCTs, five case-control studies and 52 cohort studies. Eight RCTs were suitable for inclusion, three addressing acute liver failure (198 participants) and five acute-on-chronic liver failure (157 participants). The mean CONSORT score was 14 (range 11-20). Overall ELS therapy significantly improved survival in acute liver failure (risk ratio 0·70; P = 0·05). The number needed to treat to prevent one death in acute liver failure was eight. No significant survival benefit was demonstrated in acute-on-chronic liver failure (risk ratio 0·87; P = 0·37). CONCLUSION: ELS systems appear to improve survival in acute liver failure. There is, however, no evidence that they improve survival in acute-on-chronic liver failure.
The prognosis of cirrhotic patients with multiple organ failure is not universally dismal. A retrospective French study examined predictive factors of mortality and concluded: In-hospital survival rate of intensive care unit- admitted cirrhotic patients seemed acceptable, even in patients requiring life-sustaining treatments and/or with multiple organ failure on admission. The most important risk factor for in-hospital mortality was the severity of nonhematologic organ failure, as best assessed after 3 days. A trial of unrestricted intensive care for a few days could be proposed for select critically ill cirrhotic patients. Cirrhotic patients in the medical intensive care unit: Early prognosis and long-term survival Crit Care Med. 2010 Nov;38(11):2108-2116
When assessed against CT as gold standard, ultrasound diagnosis of small bowel obstruction by emergency physicians compared favourably with abdominal radiographs.
US exams were performed using a phased array probe in the bilateral colic gutters, epigastric and suprapubic regions to assess for (1) the presence of fluid-filled, dilated bowel (defined as >25mm) proximal to normal or collapsed bowel, and (2) decreased or absent bowel peristalsis (defined as back and forth movements of spot echoes inside the fluid-filled bowel). Either finding was considered ‘positive’ for small bowel obstruction. Bedside ultrasonography for the detection of small bowel obstruction in the emergency department Emerg Med J. 2010 Aug 22. [Epub ahead of print]
Transjugular intrahepatic portosystemic shunt (TIPS) is often used as a rescue therapy in cirrhotic patients with variceal haemorrhage after vasoactive drug therapy and endoscopic ligation have failed. A randomised study compared this standard management with earlier TIPS within 72 hours after randomisation (and randomisation occurred within 24 hours of admission). The early use of TIPS was associated with significant reductions in treatment failure and in mortality.
Not sure what TIPS is? This video I found on YouTube explains it nicely..
[youtube]http://www.youtube.com/watch?v=pGA6KUgq7AI&feature=related[/youtube] Early Use of TIPS in Patients with Cirrhosis and Variceal Bleeding NEJM 2010;362:2370-2379
Guidelines for preventing, detecting, and treating Clostridium Difficile infection from the Infectious Diseases Society of America have been published. Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) Infect Control Hosp Epidemiol 2010;31:431–455 Full Text
International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding have been published. Here is a summary of the recommendations; a link to the full text document is at the bottom of this page.
Prognostic scales are recommended for early stratification of patients into low- and high-risk categories for rebleeding and mortality.
Blood transfusions should be administered to a patient with a hemoglobin level of 70 g/L or less.
In patients receiving anticoagulants, correction of coagulopathy is recommended but should not delay endoscopy.
Promotility agents should not be used routinely before endoscopy to increase the diagnostic yield.
Selected patients with acute ulcer bleeding who are at low risk for rebleeding on the basis of clinical and endoscopic criteria may be discharged promptly after endoscopy.
Preendoscopic PPI therapy may be considered to downstage the endoscopic lesion and decrease the need for endoscopic intervention but should not delay endoscopy (the observed lesion downstaging attributable to PPI therapy before endoscopy may be even more beneficial in situations in which early endoscopy may be delayed or when available endoscopic expertise may be suboptimal).
Early endoscopy (within 24 hours of presentation) is recommended for most patients with acute upper gastrointestinal bleeding.
A finding of a clot in an ulcer bed warrants targeted irrigation in an attempt at dislodgement, with appropriate treatment of the underlying lesion.
The role of endoscopic therapy for ulcers with adherent clots is controversial. Endoscopic therapy may be considered, although intensive PPI therapy alone may be sufficient.
Epinephrine injection alone provides suboptimal efficacy and should be used in combination with another method.
Clips, thermocoagulation, or sclerosant injection should be used in patients with high-risk lesions, alone or in combination with epinephrine injection
Routine second-look endoscopy is not recommended.
An intravenous bolus followed by continuous-infusion PPI therapy should be used to decrease rebleeding and mortality in patients with high-risk stigmata who have undergone successful endoscopic therapy.
Patients should be discharged with a prescription for a single daily-dose oral PPI for a duration as dictated by the underlying etiology.
Most patients who have undergone endoscopic hemostasis for high-risk stigmata should be hospitalized for at least 72 hours thereafter.
Where available, percutaneous embolization can be considered as an alternative to surgery for patients for whom endoscopic therapy has failed.
Patients with bleeding peptic ulcers should be tested for H. pylori and receive eradication therapy if it is present, with confirmation of eradication.
Negative H. pylori diagnostic tests obtained in the acute setting should be repeated
In patients with previous ulcer bleeding who require an NSAID, it should be recognized that treatment with a traditional NSAID plus PPI or a cyclooxygenase-2 (COX-2) inhibitor alone is still associated with a clinically important risk for recurrent ulcer bleeding.
In patients with previous ulcer bleeding who require an NSAID, the combination of a PPI and a COX-2 inhibitor is recommended to reduce the risk for recurrent bleeding from that of COX-2 inhibitors alone.
In patients who receive low-dose ASA and develop acute ulcer bleeding, ASA therapy should be restarted as soon as the risk for cardiovascular complication is thought to outweigh the risk for bleeding.
In patients with previous ulcer bleeding who require cardiovascular prophylaxis, it should be recognized that clopidogrel alone has a higher risk for rebleeding than ASA combined with a PPI.
A child with status epilepticus has been stabilised and intubated and is awaiting admission to the paediatric intensive care unit. You decide to insert a nasogastric tube. The nurse asks the following questions:
1. What size gastric tube would you like?
[EXPAND Answer]A general guide is twice the size of the uncuffed tracheal tube.
A four year old for example would usually need a tracheal tube size of 5.0mm internal diameter (age/4 +4), so would need a 10 Fr gastric tube.
2. To what length are you intending to insert it?
[EXPAND Answer]A formula based on height of the child can be used, so get your tape measure or length chart out:
For neonates < 2 weeks and children >8 years 4 months a method called NEMU (nose-ear-midxiphoid-umbilicus measurement) may be used.
3. How will you confirm placement?
[EXPAND Answer]It is very likely this child will get a post-intubation chest radiograph and the gastric tube tip can be visualised on that. However non-radiological tests should be used and pH testing of the aspirate is recommended, looking for pH<6