What are the initial orders for a patient admitted with gastrointestinal (GI) bleeding?

Initial Orders for GI Bleeding Admission

Immediate evaluation and appropriate resuscitation are critical to proper management of patients admitted with gastrointestinal bleeding, with priority given to hemodynamic stabilization before diagnostic procedures. 1

Initial Assessment and Stratification

1. Hemodynamic Assessment

   • Assess shock index (heart rate divided by systolic blood pressure) - unstable if >1 1
   • Establish two large-bore IV access points for fluid and blood administration 2
   • Monitor vital signs closely, targeting mean arterial pressure >65 mmHg 2

2. Risk Stratification

   • Categorize bleeding as upper or lower GI source
   • For lower GI bleeding: Use Oakland score to classify as major (>8 points) or minor (≤8 points) 1
   • For upper GI bleeding: Assess for signs of severe bleeding (systolic BP <100 mmHg, heart rate >100/min, or need for transfusion of >2 units of blood) 1

Resuscitation Orders

1. Fluid Resuscitation

   • Begin crystalloid fluid resuscitation immediately 2
   • Consider permissive hypotension with target systolic BP of 80-100 mmHg until bleeding is controlled 2
   • Avoid excessive fluid resuscitation which may increase bleeding 2

2. Blood Transfusion

   • Implement restrictive transfusion strategy with target hemoglobin >7 g/dL (>9 g/dL in patients with cardiovascular disease) 2
   • Type and cross-match for blood products 3

3. Coagulopathy Correction

   • Order coagulation panel (PT/INR, PTT) 3
   • Correct any coagulopathy if present 2
   • Consider reversal agents for patients on anticoagulants with life-threatening hemorrhage 2

Diagnostic Orders

1. Laboratory Tests

   • Complete blood count with differential
   • Basic metabolic panel
   • Liver function tests
   • Coagulation studies (PT/INR, PTT)
   • Type and cross-match 3

2. Nasogastric Tube Placement

   • Consider nasogastric tube placement in selected patients as findings may have prognostic value 1
   • If very early endoscopy is planned, orogastric or nasogastric lavage may help clear the stomach of blood and clots 1

3. Endoscopic Evaluation

   • For upper GI bleeding: Order urgent upper endoscopy within 24 hours 3
   • For lower GI bleeding: Order colonoscopy within 24 hours after adequate bowel preparation 4
   • For massive lower GI bleeding or hemodynamic instability with hematochezia: Consider upper endoscopy first to rule out upper GI source 2, 4

Medication Orders

1. Acid Suppression

   • For suspected or confirmed upper GI bleeding: Start IV proton pump inhibitor (e.g., pantoprazole 40 mg IV) 5
   • High-dose PPI treatment should be maintained for the first 72 hours post-endoscopy when rebleeding risk is highest 3

2. Temporary Suspension of Antithrombotics

   • Hold anticoagulants during the acute bleeding episode 2
   • Document plan for restarting anticoagulants (typically no more than 7 days after bleeding stops) 2

Monitoring Orders

1. Vital Signs

   • Continuous cardiac monitoring for unstable patients
   • Frequent vital sign checks (every 15-30 minutes initially for unstable patients)
   • Monitor for signs of rebleeding

2. Admission Location

   • High-risk patients should be admitted to a monitored setting for at least the first 24 hours 1
   • If intensive care beds are unavailable, consider wards with more intensive monitoring than standard units 1

Specialty Consultation

1. Gastroenterology Consultation

   • Early involvement of gastroenterologist for endoscopic evaluation and potential hemostasis 1

2. Surgical Consultation

   • Consider early surgical consultation for severe or persistent bleeding 2

Common Pitfalls to Avoid

• Delaying resuscitation while awaiting diagnostic studies
• Overaggressive blood transfusion (aim for restrictive strategy)
• Failing to consider upper GI source in patients presenting with hematochezia and hemodynamic instability
• Inadequate bowel preparation before colonoscopy, reducing diagnostic yield
• Delaying endoscopy beyond 24 hours in high-risk patients

By following this structured approach to GI bleeding management, you can ensure optimal patient outcomes through prompt resuscitation, appropriate risk stratification, and timely diagnostic and therapeutic interventions.