What is the nursing priority in the management of a patient with an active upper GI bleed?
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Acute upper gastrointestinal (GI) bleeding is a common medical emergency with an estimated incidence of 134 per 100 000 population (Button et al, 2011). It occurs above the ligament of Treitz, the boundary between the duodenum and the jejunum. National guidelines have been produced by the National Institute for Health and Care Excellence (NICE) (2012) and by a collaboration between the Scottish Intercollegiate Guidelines Network (SIGN) and the British Society of Gastroenterology (SIGN, 2008) to improve patient outcomes. However, the 2015 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) (2015) review on patients with acute upper GI bleeding found variable practice and less than adequate standards of care. Consequently, NCEPOD proposed a set of criteria to standardise practice (NCEPOD, 2015: 97-98). Despite these, it is noteworthy that guidance specific to nursing care is lacking, and yet it is essential that nurses caring for patients with acute GI bleeding are aware of the current standards to ensure optimal care. Show
PresentationAcute upper GI bleeding is a medical emergency so early recognition is essential. It may present with haematemesis, coffee-ground vomiting, melaena or as an unexplained fall in haemoglobin levels (Siau et al, 2017). It may also present as fresh rectal bleeding, particularly when accompanied by haemodynamic instability. Assessment and resuscitationThe Resuscitation Council UK (2015) recommends that the ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach is taken for all critically ill or deteriorating patients. This approach provides a systematic structure for assessing patients with suspected acute upper GI bleeding. AirwayThe patient's airway could be compromised with large-volume vomiting. It may be necessary to place the patient in the recovery position to help protect the airway. Suction should be applied orally, as required, to remove excess blood and secretions. If the patient is unconscious, an oropharyngeal or nasopharyngeal airway should be inserted. When the patient is critically ill, the resuscitation/critical care team should be in attendance to intubate the trachea and provide ventilation. BreathingThe patient's respiratory rate and oxygen saturations should be monitored and oxygen given if required; if the patient is vomiting, nasal cannulae may be used. Should breathing be compromised, it will be necessary to initiate basic life support and call the resuscitation team. CirculationThe patient's blood pressure and pulse should be monitored to check for hypovolaemic shock. This will typically present as tachycardia and hypotension. There should be secure intravenous access with a minimum of two large-bore cannulas to allow rapid infusion of fluids and blood. Urine output monitoring may be indicated in haemorrhagic shock. Importantly, blood pressure and pulse should be regularly assessed. Patients should have bloods taken for cross-matching, full blood count, urea and electrolytes, and clotting. Blood gas tests can provide a rapid estimate of haemoglobin levels. In the case of major haemorrhage, most hospitals have a massive transfusion protocol that can be triggered, with empirically prepared group O negative blood, platelets and fresh frozen plasma (FFP) (SIGN, 2008; Association of Anaesthetists of Great Britain and Ireland et al, 2010). Patients with acute upper GI bleeding should be screened for coagulopathy (abnormality in blood clotting), which should be addressed before investigations or treatment such as endoscopy take place. Clotting anomalies may be due to liver problems or other diseases, e.g. haemophilia. Patients with liver disease may be given vitamin K and FFP in order to replace missing clotting factors. Clotting anomalies may also be iatrogenic from antithrombotic therapy, e.g. aspirin, clopidogrel or warfarin. The INR should be less than 1.4 in the case of patients with acute upper GI bleeding (NICE, 2012). INR reversal may require the use of prothrombin complex concentrate or FFP. In patients with high thrombotic risk, e.g. if they have a metal heart valve, deepvein thrombosis or pulmonary embolism, bridging cover with heparin may be required to prevent thrombotic complications. Nurses should also be aware of novel oral anticoagulants, e.g. apixaban, dabigatran, rivaroxaban or edoxaban. The reversal agent for dabigatran is idarucizumab (NICE, 2018). DisabilityThe patient's level of consciousness should be regularly assessed using the Glasgow Coma Scale (GCS). This is particularly relevant in patients with liver cirrhosis, who may develop hepatic encephalopathy triggered by a variceal bleed. Altered consciousness may lead to airway compromise. As hypoglycaemia is also a complication of cirrhosis, capillary blood glucose should be checked. Exposure/examinationIt is important to obtain a full medical and social history, if possible, as this may be relevant to GI bleeding, e.g. a past history of peptic ulcer disease, non-steroidal anti-inflammatory drug use, liver disease or alcoholism. The patient will need to be examined for signs of shock such as pallor and cool extremities. Signs of dehydration should be assessed, including dry mucosa, lack of skin elasticity and sunken eyes. It will also be necessary to note stigmata of liver disease, e.g. jaundice, spider naevi, gynaecomastia, ascites and liver flap. A medical assessment will also include an abdominal examination and a rectal examination. The patient's temperature should be checked because sepsis can lead to complications in patients with cirrhosis and ascites. InvestigationdA diagnosis of acute upper GI bleeding is confirmed by upper GI endoscopy. This is a visual examination of the oesophagus, stomach and duodenum during which biopsies can be taken, if required, and therapeutic interventions to stop bleeding can be carried out. Blatchford and Rockall scoresThe Blatchford and Rockall scores (Tables 1 and 2) are validated scoring systems that can be used to triage for endoscopy (Rockall et al, 1996; Blatchford et al, 2000). A pre-endoscopic assessment can be made using the first three categories in the Rockall score: age, shock and comorbidity. The entire Rockall score can be used to predict patient prognosis following endoscopy. Table 1. Blatchford risk score
Source: Blatchford et al, 2000 Table 2. Rockall risk score
SRH = stigmata of recent haemorrhage Source: Rockall et al, 1996 The Blatchford and Rockall scoring systems are reliant on observations and comorbidity with or without blood results. These could be assessed by nurses and there is a place for specialist nurses to be involved in the entire assessment and preparation for patients with an acute upper GI bleed to attend endoscopy. Individuals with high pre-endoscopic scores (Blatchford >6/Rockall >1) should be prioritised for endoscopy within 24 hours. There is strong evidence to suggest that patients with low scores (Blatchford 0-1, Rockall 0) could be safely discharged (on proton-pump inhibitor (PPI) treatment) and return for urgent outpatient endoscopy. CommunicationEffective communication between health professionals at all stages of the acute upper GI bleeding patient pathway is essential to ensure high-quality care. The use of a framework, such as the SBAR system (Box 1) (Institute for Healthcare Improvement, 2004), provides health professionals with a structured and efficient way to communicate the details of a patient condition. Box 1.The SBAR framework
By using this, the nurse can ensure that information about a patient's condition are communicated effectively to medical staff and other colleagues, e.g. during handover between ward and endoscopy nurses. Endoscopy preparationNil by mouthPatients are usually placed nil by mouth for at least 4 hours before endoscopy to ensure the upper GI tract has emptied of food. However, haemodynamically unstable patients may need to have an endoscopy within that period of time. In these situations, a dose of intravenous prokinetic (e.g. erythromycin or metoclopramide) can be administered to accelerate gastric emptying. ConsentThe nurse should ensure that, where possible, the patient is in agreement with the procedure. This will involve a suitably qualified person explaining the nature of the procedure, the aftercare, the options of sedation such as local anaesthetic spray, the benefits, the risks and the limitations of endoscopy, as well as the alternatives. This process should involve written information being available for patients, and it is important that any barriers to communication are addressed wherever possible. This may mean having access to interpreters for instance (General Medical Council, 2008; Everett et al, 2016). Patients may have anxiety about having upper GI endoscopy so a clear explanation of the procedure may help alleviate this. It is also important to ascertain the source of the anxiety, which may be due to the procedure itself or concerns regarding any possible findings. Endoscopy checklistThere is increasing evidence that use of checklists can reduce errors and improve patient morbidity and mortality (Matharoo et al, 2014). A checklist should be used to ensure the patient is adequately prepared for endoscopy and as a tool for the handover between ward and endoscopy nursing teams. It should consist of details such as past medical history, including details of any heart implants e.g. pacemakers or implantable cardioverter-defibrillators, observations, medications, any special considerations and the patient's ability to give consent. The use of checklists prior to procedures has been advocated by the World Health Organization (WHO), which has produced a surgical safety checklist (Haynes et al, 2009). The principle behind this is that it provides a chance for the entire team to check and share vital information (Walker et al, 2012). A sample checklist is shown in Box 2. Box 2.Endoscopy safety checklist
Endoscopic interventionsEndoscopic management differs depending on whether the bleeding is variceal or non-variceal. Non-variceal upper GI bleedingNon-variceal bleeding is often caused by peptic ulcers. This is when a break in the oesophageal, stomach or duodenal mucosa has eroded, penetrating into a blood vessel. On endoscopy, high-risk ulcers requiring endoscopic treatment are actively bleeding, have a non-bleeding visible vessel or an adherent clot. Using endoscopic techniques to stop bleeding (achieve haemostasis) has been shown to improve survival rates, re-bleeding risk and the need for surgery (SIGN, 2008; Barkun et al, 2010). InjectionA catheter with a needle on the end is placed through the endoscope channel and adrenaline 1:10 000 injected. The adrenaline constricts and applies pressure to blood vessels allowing the bleeding lesion to be viewed better. Injection of adrenaline at and around the bleeding point reduces the rate of re-bleeding (Kahi et al, 2005). It is recommended that adrenaline injection is combined with another haemostatic method (dual therapy) (NICE, 2012) as this reduces the risk of re-bleeding (Shi et al, 2004). Thermal treatmentContact thermal treatments use heat to seal the vessel and cause clotting. There are two types: contact, using diathermy, and non-contact, using argon plasma coagulation. NICE (2012) recommends that thermal treatment is combined with injection treatment. Mechanical treatmentStainless steel clips can be passed though the endoscope and applied directly to the bleeding lesion. This compresses the vessel and stops the bleeding. This therapy should be combined with injection treatment (NICE, 2012). HemosprayHemospray© (Cook Medical) is a powder that is projected through the endoscope onto bleeding lesions. It forms a barrier that stops the bleeding, enhancing the clotting process (Babiuc et al, 2013). It can be used when lesions are difficult to treat or as an adjunct to combinations of mechanical, injection and thermal treatments. Variceal upper GI bleedingVariceal upper GI bleeding occurs from dilated veins (varices), which are typically due to liver disease; a rise in portal pressure diverts blood from the portal system and into the systemic system. In the upper GI tract this occurs through the gastro-oesophageal veins, so varices may be seen in the lower oesophagus and upper stomach. They may be controlled endoscopically through band ligation, injection and Sengstaken tube insertion (Siau et al, 2017). Variceal band ligationVariceal band ligation is the treatment of choice for oesophageal varices (SIGN 2008; NICE, 2012; Hwang et al, 2014). Band ligation involves deploying a small rubber band from the endoscope tip to strangulate the varix and stop the bleeding. A complication can be ulceration, which can be minimised with proton-pump inhibitor (PPI) treatment (Lo, 2015). Glue/thrombin injectionGlue can be injected into bleeding vessels. The glue used is cyanoacrylate, which is a strong instant adhesive, which hardens and occludes the varix. It has been found to be superior to variceal band ligation for gastric and gastro-oesophageal junction varices (Ríos Castellanos et al, 2015). Injection of the clotting agent thrombin is also an alternative treatment for gastric varices (Tripathi et al, 2015). Balloon tamponadeBalloon tamponade may be necessary to control variceal bleeding. The Sengstaken tube is inserted through the mouth and a balloon is inflated once inside the stomach. Traction is applied to the end of the tube, which pulls the balloon into the varices, thereby providing tamponade. Traction is traditionally applied using a pulley system involving a 500 ml fluid bag, but tongue depressors or even a sliced tennis ball are alternative traction mechanisms that can be considered. As this can be poorly tolerated, patients should be under general anaesthesia following placement. Particular attention should be placed on mouth care, as the friction and pressure from the Sengstaken tube can result in mucosal injuries. Complications can include pressure necrosis, misplacement, aspiration pneumonia and oesophageal rupture (Tripathi et al, 2015). Oesophageal stentingOesophageal stenting is an alternative to balloon tamponade (McCarty et al, 2016). This is a self-expanding metal tube that is inserted via the endoscope and used to apply pressure to the varices. Post endoscopyFollowing endoscopy, the endoscopist should produce a report outlining the procedure findings, the therapy undertaken, sedation given, recommendations for further treatment and a plan to be followed in the event of any re-bleeding (NCEPOD, 2015). Endoscopy nurses should also document the observations recorded during the procedure, the drugs administered, the equipment used and any significant events. Additionally, the nursing documentation should include the need for any immediate therapies (such as 72-hour PPI infusion for high risk peptic ulcers or terlipressin), a plan for further care, i.e. whether admission to critical care is required, as well as instructions on when feeding can recommence and how long oxygen therapy should be continued. A comprehensive handover between endoscopy and ward nurses is essential: it should include a full review of the findings and instructions written within the endoscopy report. Ward staff should conduct a full reassessment of the patient, including consciousness level and observations. It may also be necessary to ensure repeat bloods are taken to assess haemoglobin levels. The discharge plan will also need to be considered, as well as a plan to follow should further bleeding become evident. Patients sedated with midazolam should be monitored for potential side effects. These include reduced consciousness and respiratory depression. The benzodiazepine reversal agent, flumazenil, may be administered in case of toxicity. Patients should have continuous monitoring of oxygen saturations, heart rate and consciousness level. They should remain on oxygen, which would usually be given at 2 L per minute through nasal cannulas (Academy of Medical Royal Colleges, 2013). This will depend on their comorbid status and whether critical interventions have been necessary. Re-bleedingRe-bleeding can occur in 13-23% of cases of non-variceal upper GI bleeding (NICE, 2012; Gralnek et al, 2015). NICE (2012) recommends a repeat endoscopy. If endoscopic efforts fail to control the bleeding, radiological methods or surgery may be required. Radiological options in GI bleeding include computed tomography (CT) angiography and transcatheter arterial embolisation. In CT angiography contrast is injected to show up the gastrointestinal blood supply. If a bleeding point is detected, the radiologist can place a catheter via the femoral artery and apply therapy to the bleeding point (Ramaswamy et al, 2014). Surgical treatment will occasionally be the only option to stop bleeding that has not responded to other attempts at haemostasis. Patients with non-variceal upper GI bleeding who re-bleed may require endoscopy and variceal band ligation; or balloon tamponade or stenting may be necessary. If endoscopy fails, a transjugular intrahepatic portosystemic shunt (TIPSS) may be required to control non-variceal upper GI bleeding. TIPSS is a procedure performed in specialist centres by interventional radiologists, who place a shunt through the liver, from the portal vein to hepatic vein, to reduce portal pressure and hence pressure within the varices. Medical therapies for non-variceal bleedingAcid suppressionProton pump inhibitors (PPIs) reduce the acid produced by the stomach, which has been shown to reduce risk of re-bleeding (Scally, 2018). NICE (2012) recommends that patients with non-variceal upper GI bleeding be routinely given PPIs. Helicobacter pyloriHelicobacter pylori (H. pylori) is a Gram-negative bacterium that colonises the mucous layer of the stomach and is a common, treatable cause of peptic ulcer disease (Malfertheiner et al, 2012). H. pylori can be tested for at endoscopy by taking a gastric biopsy and subjecting it to a urease test; the results may be available within 5 minutes, although the presence of blood in the stomach can result in a false negative urease test. Alternatively, a biopsy may be sent for examination under a microscope in the histopathology laboratory; in this case, the result may take several days. H. pylori status can also be tested via a blood (serology test) or stool antigen test. If peptic ulcers are confirmed, H. pylori status should be ascertained prior to hospital discharge (Malfertheiner et al, 2012). The recommended treatment consists of PPI and dual antibiotics (amoxicillin and clarithromycin or metronidazole), administered for at least 7 days (NICE, 2014). Patients should be instructed how to take this regimen of tablets correctly to increase the likelihood of eradication. Additionally, it is essential that the patient is asked about any drug allergies; in the case of penicillin allergy, there is an alternative eradication regimen. The PPI treatment should continue for 4 weeks to help the ulcer to heal (SIGN, 2008). Successful H. pylori eradication should be confirmed with a urease breath test or a stool antigen test (Malfertheiner et al, 2012). PPI should be stopped 2 weeks before the test because this treatment this can lead to a false negative H. pylori test (SIGN, 2008). Iron replacement and blood transfusionsBlood loss from acute upper GI bleeding may require blood transfusion. It is important to ensure that the patient fully consents to blood transfusion or, in cases where consent cannot be given, there are no indications that the patient may object to receiving blood products. Details of the consent process should be documented in the patient's notes (Advisory Committee on the Safety of Blood Tissues and Organs, 2011). Increasing the blood volume by too much can increase pressure and risk a re-bleed. A more conservative approach to blood transfusion has been shown to reduce mortality (Villaneuva et al, 2013). It is therefore recommended that blood transfusion be restricted to achieving a target haemoglobin level of 70-90 g/dl (Gralnek et al 2015). Patients who develop anaemia following an acute upper GI bleed should be considered for iron supplementation, which has been shown to improve haemoglobin levels (Bager et al, 2014). However, identification and management of iron deficiency anaemia is often overlooked (Royal College of Nursing, 2015). It is therefore important that nurses staff ensure that measures are taken to correct any deficiency. AdherencePrevention of further bleeds will be greatly helped by patients' adherence to treatment regimens. WHO defines adherence as: ‘The extent to which a person's behaviour—taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider.’ WHO, 2003NICE (2009) has published guidance on adherence with regard to medicines. Good communication, increasing patient involvement and understanding patients' knowledge, beliefs and concerns are key to ensuring adherence. The nurse should ensure that the patient had been provided with sufficient information about the cause of the GI bleed, and ensure that the patient is in agreement with the treatments prescribed/recommended. These measures can help reduce risks of further bleeds and help ensure that other related complaints, e.g. iron deficiency anaemia, are treated correctly. Follow-up endoscopyThe need for follow-up endoscopy following an acute upper GI bleed should be ascertained. Patients with gastric ulcers should have a follow-up procedure after 6-8 weeks (NICE, 2014) to check healing and identify if there is a need for biopsy. In study by Selinger et al (2016) 6% of gastric ulcers were found to be malignant, leading them to recommend that all gastric ulcers be biopsied. Patients with bleeding oesophageal varices should be booked for repeat endoscopy for rebanding every 2–4 weeks until the varices have been eradicated. Endoscopy should be repeated 3 months later, and then every 6 months to assess and potentially reband, as required (Tripathi et al, 2015). Health educationPatients with variceal bleeding are likely to have underlying cirrhosis. Alcoholic and non-alcoholic fatty liver disease are the commonest causes. Admission with a GI bleed can be an ideal opportunity to discuss a patient's lifestyle. Individuals should be screened for alcohol intake and metabolic risk factors (e.g. diabetes, hypertension, smoking, dyslipidaemia, obesity and lack of exercise). Referral to relevant services, such as the alcohol liaison team or dietitians may be appropriate. Patients should be encouraged to avoid taking non-steroidal anti-inflammatory drugs. Other medication that may cause gastrointestinal bleeding, such as anti-platelet/anti-coagulant drugs, should be identified and stopped, with relevant advice sought from appropriate specialists, such as cardiologists. However, if the patient's cardiovascular risks are high, these drugs may need to be resumed at discharge. Prior to discharge, patients should be given information regarding follow-up procedures and appointments. If repeat endoscopy is required, it is essential that the patient understands the rationale for this, otherwise there is a risk that the patient may not attend the appointment. Training and developmentGI bleed patients should be managed by specialist teams, with experience in this field of work. This applies to nursing as well as medical staff. Nurses should complete competencies related to the care of this patient group and should keep up to date with latest developments and evidence-based practice on the management of acute upper GI bleeding. ConclusionThe treatment options available for patients with GI bleeds have improved considerably, however standards of care require education and sustained implementation to ensure that they remain optimal. Nurses caring for patients with acute upper GI bleeding should be aware of the current guidance to help ensure their patients are managed appropriately. Before the procedure it is essential that nurses work with medical colleagues to ensure that an adequate assessment is undertaken using the risk scoring methods described (Rockall et al, 1996; Blatchford et al, 2000), alongside any necessary resuscitation. If endoscopy is required, this should be arranged and the consent process should be facilitated with the provision of information about the procedure. An understanding of the treatment modalities available during endoscopy is essential for endoscopy nurses; other nurses involved in the patient's care should also be aware of the treatments available. Following the procedure, nurses should ensure that patients are prescribed appropriate medication, and that they understand and are in agreement with the treatment they have been prescribed. Follow up should be arranged in line with NICE guidance and the patient should be provided with appropriate health education. Finally, it is essential that, when further guidance is published on the care of patients with acute upper GI bleeding, there is a greater focus on the ways in which nurses can contribute to high-quality care, In this way, patients with acute upper GI bleeding can be assured of the highest standards of care from both the medical and nursing standpoints. KEY POINTSCPD reflective questionsWhat are the priority nursing interventions for someone with a GI bleed?Whatcha gonna do about it?. Serial H/H (typically q 4 or q 6 hours). Monitor PLTs, INR, PTT.. Watch for signs of bleeding.. Monitor BP and check for orthostatic hypotension.. Perform occult blood test on stool.. Assess abdominal pain.. What should a nurse do for a GI bleed?A step-by-step approach to managing gastrointestinal bleeding. Assess severity of GI bleeding and stabilize.. Take a patient history.. Perform a physical exam.. Perform a risk assessment.. Treat the source of the bleeding.. What are the effective nursing management of upper gastrointestinal bleeding?Patient Management
Maintain a patent airway. Administer supplemental oxygen as ordered. Administer colloids as ordered to restore intravascular volume. Type and crossmatch for anticipated blood products.
What is the importance of proper nursing management when handling clients with upper gastrointestinal bleeding?Nurses should be aware that GI bleeds can often disguise another, less obvious problem. Therefore, nursing assessment of patients is of primary importance. It is essential to gain as much information as possible about a patient's health problems, use of medication, and alcohol intake.
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