ACUTE GI BLEEDING PRACTICE GUIDELINE ICU ADMISSION (HIGH RISK PATIENT) ACUTE GI BLEEDING PHYSICIAN INFORMATION - SEE BACK Complete top portion with each Level of Care change. Indicate order with a Check Mark. □ Outpatient Procedure:
□ Place in Outpatient Observation Services for
INITIAL ORDERS
□ Upper □ Lower gastrointestinal hemorrhage
□ Dr. contacted by covering medical resident
□ Dr. contacted by covering medical resident
Every 1 hour, including postural pulse and blood pressure until stable, then every 4 hours
□ NPO until bleeding controlled, then clear liquid diet
Hemoglobin, hematocrit every 6 hours x 24 hours
Normal Saline @ □ 200 mL/hour □ 250 mL/hour □ 300 mL/hour
□ Type & screen □ Type & cross for units packed RBCs.
□ Foley or □ Condom catheter to monitor urinary output
□ NG tube (only to determine presence of active UGI bleeding)
□ Endotracheal intubation (if ongoing hematemesis or suspect variceal hemorrhage)
ADDITIONAL THERAPY FOR UNIQUE CIRCUMSTANCES WITH ACTIVE BLEEDING
□ Administer platelets - 4 units; recheck platelet count following
□ Administer 2 units FFP; recheck INR and correct to INR of less than
3. Uremia (Creatinine greater than 4.0): □ Administer 2 doses of Desmopressin at 0.3 mcg/kg. IV every 12 hours 4. Advanced Liver Disease:
□ Administer Octreotide - 100 mcg IV bolus followed by infusion @ 50
□ With ongoing bleeding, administer erythromycin 250 mg IV 1 hour
PROHIBITED ABBREVIATION REQUIRED TERM PROHIBITED ABBREVIATION REQUIRED TERM WriteMicrogram Write 1. Do not use zero after decimal point Write Daily Write Every Other Day or Write Morphine Write Magnesium sulfate or Morphine sulfate Write Units Write International units Write 0.5 - make sure you Write Left or right eye or both eyes Write Left or right ear or both ears PATIENT LABEL MR.ORDER ACUTE GI BLEEDING PRACTICE GUIDELINE ICU ADMISSION (HIGH RISK PATIENT) PHYSICIAN INFORMATION SUGGESTED TRANSFUSION TRIGGERS
In patients with cardiovascular disease: Maintain Hgb. greater than 9.0 gm/dl or Hct. greater than 27%.
In Jehovah’s Witness patients: no transfusion of any blood product.
In all other patients: maintain Hgb. greater than 7.0 gm/dl or Hct. greater than 21% in other patients. POST-ENDOSCOPY MANAGEMENT
If upper endoscopy shows ulcer, start Protonix 40 mg. PO BID for 8 weeks. Use IV route ONLY if patient cannot tolerate oral intake.
For patients with an ulcer who are H. pylori positive, consider Protonix 40 mg PO BID, PLUS clarithromycin 500mg po BID PLUS amoxicillin 500mg 1gm po BID for 14 days, followed by Protonix 40mg po daily for 8 weeks.
For patients with ulcers who do NOT have a visible vessel or active bleeding at endoscopy, consider discharge at 24 hours if clinical condition permits.
For patients with Mallory-Weiss tear, consider discharge the same day or in a.m. of following day if clinical condition permits.
For patients with ulcer, counsel patient above avoiding future use of aspirin or NSAIDs unless absolutely necessary.
For patients with esophageal varices, treatment may include octreotide, endoscopic variceal banding, monitoring for and treatment of encephalopathy with lactulose and initiation of beta blocker therapy the day after cessation of bleeding.
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