What are the initial orders for a patient with an upper gastrointestinal (GI) bleed?

Initial Orders for Upper Gastrointestinal Bleeding

For patients presenting with upper GI bleeding, immediate resuscitation with two large-bore IV cannulae and rapid fluid replacement should be initiated, followed by risk stratification to determine the timing of endoscopy and appropriate level of care. 1

Initial Assessment and Resuscitation

• Establish two large-bore venous cannulae in the antecubital fossae for hemodynamically compromised patients 1
• Infuse normal saline to achieve hemodynamic stability (fall in pulse rate, rising blood pressure, adequate urine output) - typically 1-2 liters initially 1
• If patient remains shocked after initial fluid resuscitation, administer plasma expanders as this indicates at least 20% blood volume loss 1
• Insert urinary catheter and monitor hourly volumes in severe cases 1
• Continuously monitor pulse and blood pressure using automated monitoring 1
• Consider central venous pressure monitoring in patients with significant cardiac disease 1

Blood Transfusion Criteria

• Transfuse red cell concentrate when:
  • Active bleeding with hemodynamic instability (active hematemesis with shock) 1
  • Hemoglobin concentration less than 100 g/L in acute bleeding (although this threshold may be adjusted for patients with chronic anemia) 1

Risk Stratification

• Classify severity based on:
  • Age (>60 years increases risk) 1
  • Vital signs (pulse >100 beats/min, systolic BP <100 mmHg indicate severe bleeding) 1
  • Hemoglobin level (<100 g/L indicates severe bleeding) 1
  • Presence of significant comorbidities 1

Laboratory Tests

• Complete blood count 2
• Basic metabolic panel 2
• Coagulation panel 2
• Liver function tests 2
• Type and crossmatch 2

Pharmacologic Management

• Initiate proton pump inhibitor therapy upon presentation 1, 2
• Consider high-dose IV PPI for the first 72 hours post-endoscopy in high-risk patients 2
• For patients with liver disease/suspected varices, administer antibiotics and vasoactive drugs 3
• Consider erythromycin as a prokinetic agent before endoscopy 3

Endoscopy Timing and Preparation

• Perform endoscopy within 24 hours of presentation for most patients 1
• Consider urgent endoscopy after resuscitation for high-risk patients (hemodynamically unstable) 3
• Important caveat: Endoscopy should only be performed after adequate resuscitation has been achieved 1
• Keep patient fasted until hemodynamically stable 1
• For severely bleeding patients, consider endotracheal intubation before endoscopy to prevent pulmonary aspiration 1
• Ensure endoscopy is performed by experienced endoscopists capable of therapeutic interventions 1

Special Considerations

• Identify patients with significant liver disease early as they require specific management protocols 1
• In very low-risk young patients with minor bleeding and no hemodynamic compromise, hospital discharge without endoscopy may be reasonable 1
• Adequately resuscitated patients should have a urine output of >30 ml/h and a central venous pressure of 5-10 cm H₂O 1

Post-Endoscopy Management

• Patients who are hemodynamically stable 4-6 hours after endoscopy can start drinking and eating a light diet 1
• For high-risk endoscopic findings (active bleeding, non-bleeding visible vessel), continue high-dose PPI therapy 3
• For variceal bleeding, continue antibiotics and vasoactive drugs 3
• Monitor for rebleeding with continuous observation of pulse, blood pressure, and urine output 1