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Department of Emergency Medicine and Anesthesiology, The Harry Max Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI
Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NMDepartment of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM
Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NMDepartment of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM
Upper gastrointestinal bleeding is a relatively common and life-threatening condition encountered by critical care transport crews. It is of paramount importance that transport crews understand the underlying pathophysiology of variceal and nonvariceal gastrointestinal bleeding as well as the nuanced management of this patient population. This article reviews the current clinical evidence on initial resuscitation, medical management, and advanced invasive therapies (such as balloon tamponade devices) that transport crews should be familiar with to manage these patients. In addition, we present a novel method of continuous balloon pressure monitoring of balloon tamponade devices that is applicable to the transport environment.
Upper gastrointestinal bleeding (UGIB) is a potentially life-threatening emergency defined as acute bleeding originating from a source within the gastrointestinal tract proximal to the ligament of Treitz (the suspensory ligament of the duodenum). Acute UGIB results in over 300,000 hospital admissions annually in the United States and likely a large number of interfacility transports. Mortality ranges from 3.5% to 10% and increases with age, comorbidities such as hypertension, diabetes, and the use of anticoagulants.
Multiple etiologies and risk factors contribute to UGIB. The most common cause being peptic ulcer disease, which accounts for approximately 50% of all reported cases and has an overall mortality reported to be 4%.
Risk factors for peptic ulcer disease include the use of nonspecific nonsteroidal anti-inflammatory drugs, alcohol use, and infection with Helicobacter pylori. Another common etiology for UGIB is erosive pathology, such as esophagitis. Variceal bleeding is the next most common cause and is associated with chronic alcohol use and cirrhosis.
Other, less common causes of UGIB include arteriovenous malformations, aortoenteric fistula (specifically in the setting of previous aortic endograft placement), tumors, gastritis, and esophageal (Mallory-Weiss) tears.
Interestingly, the confirmed source of bleeding in patients with known varices is often nonvariceal.
Esophageal and gastric varices are engorged veins that are adjacent to the upper gastrointestinal tract and develop because of portal hypertension. These varices can erode into the upper gastrointestinal tract causing life-threatening bleeding. The primary risk factors for the development of varices includes disease processes that lead to portal hypertension, with cirrhosis being the most common. Variceal bleeding, especially in cirrhotic patients, is often more severe because of decreased hepatic production of clotting factors. One observational study conducted in the United States showed a 21% mortality rate among cirrhotic patients admitted with UGIB because of variceal bleeding.
Patients with acute UGIB often require transport from resource-limited health care facilities to tertiary care centers, requiring treatment by critical care transport (CCT) crews. Previous studies have demonstrated the need for ongoing resuscitation throughout transport given frequent hemodynamic derangements encountered by CCT crews.
Therefore, it is of the utmost importance that CCT crewmembers be familiar with acute UGIB and its management. This article reviews the management of acute UGIB in the CCT environment with emphasis on the placement and monitoring of balloon tamponade devices (BTDs).
Initial Resuscitation and Medical Management
Airway Stabilization
When significant bleeding is encountered in patients suffering from acute UGIB, endotracheal intubation should be considered before transport. Clinicians should carefully evaluate the patient's hemodynamic status and resuscitate before induction when possible to avoid further hemodynamic deterioration. Clinicians should also be prepared to deploy the Suction Assisted Laryngoscopy and Airway Decontamination technique in the event of massive regurgitation, especially when using video laryngoscopy, which can become soiled (Fig. 1A and B).
For this reason, direct laryngoscopy should also be available when intubating these patients. If mental status and airway protection are normal, gastric tube placement before intubation may be helpful to decompress the stomach and is generally considered safe even in the setting of varices.
Figure 1(A and B) The Suction Assisted Laryngoscopy and Airway Decontamination technique for endotracheal intubation demonstrating placement of a rigid suction catheter in the hypopharynx to the left of the laryngoscope facilitating ongoing suction during endotracheal tube placement.
Figure 1(A and B) The Suction Assisted Laryngoscopy and Airway Decontamination technique for endotracheal intubation demonstrating placement of a rigid suction catheter in the hypopharynx to the left of the laryngoscope facilitating ongoing suction during endotracheal tube placement.
Vascular access is critical. Two large-bore (≥18-G) peripheral intravenous (IV) lines are the recommended vascular access for all patient's suffering from acute UGIB. For patients with difficult peripheral vascular access, ultrasound-guided IV placement or central venous access may be warranted. Invasive arterial pressure monitoring should be considered, specifically when the patient is hemodynamically fragile. As with any procedural intervention within the CCT environment, the ability to perform invasive vascular access depends on the level of licensure, training, and provider guidelines. The benefits of these procedures should be weighed against the time needed to complete them and the risk associated with the procedure.
The best initial fluid for the resuscitation of acute UGIB remains unclear,
but it is absolutely reasonable, if not prudent, to start with blood product administration if available. Generally speaking, the transfusion strategy for these patients falls into 1 of 2 categories based on their hemodynamic status. For patients with UGIB who are awake, alert, and oriented with stable hemodynamics and no evidence of ongoing brisk hemorrhage, a metered transfusion strategy targeting a hemoglobin of 7 g/dL is reasonable in most patients.
Restrictive versus liberal blood transfusion for acute upper gastrointestinal bleeding (TIGGER): a pragmatic, open-label, cluster randomized feasibility trial.
The second transfusion strategy is for patients with UGIB who have hemodynamic instability, specifically hypotension in the setting of active hemorrhage. Under these circumstances, blood products should be empirically administered to target a mean arterial blood pressure (MAP) goal and restore organ perfusion, as opposed to the hemoglobin laboratory value target used with stable patients. In the setting of suspected variceal bleeding, permissive hypotension is preferred to a normal blood pressure, targeting an MAP of 65 mm Hg or the lowest MAP that maintains mental status and urine output.
In other patients with UGIB, a normal MAP may be a reasonable target.
Patients with uncontrolled acute UGIB may require multiple units of blood products. Before departure, CCT crews should consider the patient's condition and transport time and request additional blood products from the sending facility when feasible. Calcium should also be available during transport because hypocalcemia is a known complication of blood product administration. When calcium levels cannot be confirmed with point-of-care testing, it is reasonable to administer 1 g intravenously for each 2 to 4 units of blood products. It is worth noting that plasma transfusion contributes even more to hypocalcemia than packed red blood cells.
There are no clear guidelines regarding the use of vasopressors in hemorrhagic shock from acute UGIB. Limited evidence has demonstrated that low-dose vasopressin can decrease the need for blood product during the resuscitation of trauma patients suffering hemorrhagic shock.
Effect of low-dose supplementation of arginine vasopressin on need for blood product transfusions in patients with trauma and hemorrhagic shock: a randomized clinical trial.
Although the application of these studies to patients with UGIB is unclear, high-dose vasopressin has been shown to reduce mortality among patients with acute variceal hemorrhage secondary to a reduction in portal venous pressure.
Although there may be some role for vasopressors to support hemodynamics, it is important to emphasize that the primary goal of resuscitation in hemorrhagic shock should be focused on volume resuscitation with blood products.
Adjunctive Medications
Anticoagulant Reversal Agents
Anticoagulation medications are common in patients who present with acute UGIB. Patients with UGIB requiring endoscopic intervention for hemostasis were found to take an anticoagulant medication 44% of the time.
Although a comprehensive review of anticoagulation reversal agents is outside the scope of this article, attention should be paid to identifying this subgroup of patients with acute UGIB and following local or institutional guidelines for anticoagulation reversal with therapies such as plasma, vitamin K, or prothrombin complex concetrates.
Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines.
CCT crews should consider whether reversal agents have been given and consider administering the appropriate reversal agents in hemodynamically unstable patients whose anticoagulation has not been reversed.
Clinical Services and Standards Committee of the British Society of Gastroenterology. UK guidelines on the management of variceal haemorrhage in cirrhotic patients.
Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases.
Vasoactive medications such as terlipressin, somatostatin, or somatostatin analogs (eg, octreotide) are recommended by international guidelines for managing variceal bleeding.
Early administration of somatostatin and efficacy of sclerotherapy in acute oesophageal variceal bleeds: the European Acute Bleeding Oesophageal Variceal Episodes (ABOVE) randomized trial.
These medications cause splanchnic artery vasoconstriction, thus decreasing vascular pressure in the portal venous circulation. Of these medications, only terlipressin (not currently available in the United States) has shown a significant mortality benefit in the setting of variceal UGIB.
Other vasoactive medications in this group have yet to demonstrate a clear benefit in mortality; multiple studies have demonstrated a significant decrease in bleeding at the time of endoscopy.
Early administration of somatostatin and efficacy of sclerotherapy in acute oesophageal variceal bleeds: the European Acute Bleeding Oesophageal Variceal Episodes (ABOVE) randomized trial.
Because these medications are also quite safe and affordable, it is very reasonable to administer them during transport when variceal bleeding is suspected. Their role in patients with nonvariceal hemorrhage is much less clear.
Proton Pump Inhibitors
Intravenous proton pump inhibitors (PPIs) such as pantoprazole or esomeprazole are generally safe and are commonly administered in the setting of acute UGIB from suspected peptic ulcer disease. PPIs provide clinical benefit by decreasing the secretion of gastric acid, which facilitates the stabilization of blood clots.
Studies have demonstrated that PPIs decrease rebleeding, the length of stay in the hospital, and the need for blood transfusion without improving the overall mortality.
Randomized controlled trial of standard versus high-dose intravenous omeprazole after endoscopic therapy in high-risk patients with acute peptic ulcer bleeding.
CCT crews should consider administering PPIs when available and peptic ulcer disease is a consideration.
Antibiotics
The administration of antibiotics, specifically IV ceftriaxone, has demonstrated a significant reduction in mortality, rebleeding, and the risk of severe infections in the subgroup of patients with advanced cirrhosis and confirmed or presumed variceal acute UGIB.
Clinical Services and Standards Committee of the British Society of Gastroenterology. UK guidelines on the management of variceal haemorrhage in cirrhotic patients.
Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases.
can increase gastric motility and improve visualization of the bleeding source at endoscopy if administered within 20 to 30 minutes of the procedure. If they are administered too early or too late, their clinical utility is limited. CCT crews should also consider the use of ondansetron or other antiemetics for the symptomatic control of nausea and vomiting if no contraindications exist. However, anecdotally, such medicines are less effective in this setting than causes of vomiting that are centrally mediated.
Tranexamic Acid
Tranexamic acid (TXA), an antifibrinolytic medication, has no clear benefit in this population based on the HALT-IT (Haemorrhage Alleviation With Tranexamic Acid-Intestinal System) study.
HALT-IT Trial Collaborators Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomized, double-blind, placebo-controlled trial.
However, a recently published systematic review of randomized clinical trials did show that TXA use was associated with a reduction in mortality, need for urgent endoscopy, and rates of continued bleeding.
Until further evidence is available, TXA is not considered a standard of care in treating acute UGIB.
Initiation of BTDs
The Sengstaken-Blakemore tube (SBT) was invented in 1950 by Drs Robert Sengstaken and Arthur Blakemore to temporarily control bleeding esophageal and gastric varices.
The SBT contains 3 lumens (2 balloons and 1 gastric aspiration port) and can be used to apply pressure to esophageal and gastric bleeding varices. The Minnesota tube is a more modern variation with 4 lumens (esophageal and gastric balloons as well as esophageal and gastric aspirates).
Balloon tamponade is indicated for patients who continue to bleed and are hemodynamically unstable despite initial aggressive medical management, as outlined previously, when emergent endoscopy is not available or is unsuccessful.
BTDs have been found to be safe and effective for mechanical tamponade of acute UGIB, specifically in the subpopulation of acute UGIB secondary to esophageal varices.
Expanding consensus in portal hypertension: report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension.
The reported rates of hemorrhage control vary between 30% and 92%, likely secondary to individual patient factors and provider familiarity with the device.
Although case reports document BTDs inserted nasally, endotracheal intubation is recommended before insertion of the BTD.
CCT crews should be familiar with BTDs because many of these patients require significant transport times from outside hospitals where endoscopy is unavailable to tertiary centers for definitive care. Under these circumstances, BTD placement by the CCT crew or the sending physician may be needed to stabilize the patient for transfer.
○ We recommend that this equipment be preassembled in a package reserved specifically for the placement of the BTD.
2. If a cuff manometer is available, move on to step 3. If a cuff manometer is not available, the BTD must be modified.
○ A 3-way stopcock should be placed in series with each balloon port (the esophageal and gastric balloon port on a Minnesota tube).
○ One end of the 3-way stopcock should be inserted into the balloon port, and the other two ends should have intravenous caps placed on top of them.
○ This will allow the attachment of a manometer, in the absence of a cufflator, to measure pressures as air is injected through the stopcock into the balloon.
3. The individual balloons in the BTD should be tested for leaks.
○ The balloons should be tested within a water bath, if available, because this ensures no leaks.
○ Each balloon (esophageal and gastric) should be tested individually.
4. The BTD should be prepared for insertion.
○ Each balloon should be fully deflated, and the port clamped with a Kelly clamp.
○ The BTD should be copiously covered with a water-soluble lubricant. Ultrasound gel is an acceptable alternative.
5. Patient should be intubated, sedated, and paralyzed.
○ Consider the Suction Assisted Laryngoscopy and Airway Decontamination technique given the likelihood for significant hemorrhage (See Figure 1A and 1B).
6. Insertion of the BTD
○ The tube should be inserted like an oral gastric tube to 50 cm.
• A laryngoscope and McGill forceps may assist with placement.
○ 50 mL air should then be placed into the gastric balloon.
○ Obtain an X-ray to confirm the balloon is below the diaphragm in the region of the stomach.
7. Inflation of the gastric balloon
○ Once an X-ray confirms that the gastric balloon is in the appropriate position, inflate the gastric balloon fully to a total of 500 mL, and clamp the gastric balloon port.
○ Retract the tube gently until resistance is felt, typically around 40 cm.
○ Secure the balloon tamponade device at the point where resistance is first encountered with a Hollister endotracheal tube holder under 1 to 2 lb of tension.
• The same Hollister that is used for endotracheal tubes can be modified to accommodate a BTD.
• Other methods that can be used to secure the BTD include Kerlix rolled gauze bandage tied to two 1-L intravenous solution bags to provide traction.
8. Inflation of the esophageal balloon
○ The esophageal balloon should only be inflated if there is a high clinical suspicion of esophageal bleeding or if blood returns from the esophageal port upon aspiration.
○ Inflate esophageal balloon to 30 mm Hg using a cuff manometer or manometer and clamp.
○ Re-aspirate from the esophageal port, and if continued bleeding, further inflate the esophageal balloon to 45 mm Hg and clamp the balloon port.
○ The esophageal balloon should not be inflated beyond 45 mm Hg.
There are no absolute contraindications to the placement of a BTD because it is an emergent, temporizing measure to stop life-threatening hemorrhage that continues despite aggressive medical management. It should be noted that although the vast majority of these devices are placed in adults, BTDs (specifically the SBT) have been safely placed in children less than 1 year old and up to 16 years old.
Although the risk of the procedure is often outweighed by the benefit, complications are significant and can occur in up to 20% of patients. Complications are primarily secondary to balloon misplacement, migration, overinflation, or prolonged use.
Inserting the Sengstaken-Blakemore tube successfully in a difficult case of uncontrollable esophageal variceal bleeding, using sutures and an endoscope.
These complications include aspiration; airway or large vessel obstruction; esophageal rupture; pressure necrosis of the lips, nose, and tongue; and ulceration of esophageal or gastric mucosa.
Esophageal rupture is a complication specific to BTDs that deserves particular attention because it has been documented in 6% to 20% of cases and demonstrates substantial morbidity and mortality.
Tracheal rupture and jejunal rupture, although exceptionally rare, have been reported and thought to be caused by balloon misplacement and overinflation.
When transporting a patient suffering from acute UGIB with a BTD, the CCT crews must continue the aggressive medical management discussed previously while simultaneously managing the BTD. The first step during the initial assessment is to identify the type of BTD (Blakemore, Minnesota, or Linton). This can be accomplished by asking the sending provider, evaluating the packaging the device came in, and/or examining the device itself to establish the presence or absence of different balloon ports or suction ports. Next, given the significant risk of complication associated with balloon misplacement and overinflation, CCT crews should confirm the positioning of the balloon and inflation pressures. Finally, CCT crews should confirm that the device is secured appropriately with adequate tension and at what depth the device is secured.
Ideally, the BTD should be confirmed radiographically at the sending facility. CCT crews should be familiar with correct radiographic placement (Fig. 3). If there is uncertainty or CCT crewmembers are not familiar with the appearance of a correctly placed BTD, it is prudent to check with the sending provider or confirm with a radiology report.
Figure 3Standard arterial pressure monitoring transducer tubing with the pressure bag line removed and the transducer capped.
After correct placement is confirmed, the balloon pressures must be checked. The most important pressure to check and monitor is that of the esophageal balloon. Esophageal balloon pressures should be 30 mm Hg up to a maximum of 45 mm Hg. Pressures in excess of 45 mm Hg are concerning for esophageal ischemia and rupture.
A cuff manometer, similar to those used to measure endotracheal tube balloon pressures, can be used to check this value.
Transport is a dynamic environment with changes in patient positioning and altitude. Fundamental principles of physics dictate that at a constant temperature the volume of the gas in the esophageal balloon will expand. The degree to which this expansion has a clinical impact has not been investigated. Given the morbidity and mortality associated with BTD esophageal injury, it is reasonable to continually monitor esophageal balloon pressure. We present a novel method for continuous BTD pressure monitoring using a transport monitor with pressure transduction capabilities and commonly available equipment (Table 2).
Table 2A List of Items Needed for Continuous Pressure Monitoring of an Esophageal Balloon
The preferred arterial line transducer setup includes access on either side of the transducer. First, the pressure bag line is removed, and the transducer is capped (Fig. 3). Then, a catheter adapter is placed within the esophageal port that attaches via a Luer lock connecter to the arterial line transducer (Fig. 4). The transducer cable is connected to the preferred monitoring system, and the transducer is zeroed at the esophageal balloon level in standard fashion.
Figure 4A Luer lock on the transducer tubing is attached to the esophageal balloon line via the catheter adapter.
It is important that CCT teams recognize that if the transducer falls below the level of the esophageal balloon, it will result in higher pressure readings. If the device is raised above the level of the esophageal balloon, it will result in lower pressure readings. If the monitoring setup has any leaks, the esophageal balloon port should be clamped with Kelly clamps and released intermittently to obtain a pressure reading. Finally, crews may notice variability in the pressure balloon with respiration. Again, the maximum pressure should not exceed 45 mm Hg. If pressures are consistently above 45 mm Hg, it is acceptable to let some air out of the esophageal balloon so that the pressure returns to a safe range.
After the appropriate position is established and safe inflation pressures are confirmed, the BTD should be checked to confirm it is secured appropriately. Traditionally, BTDs were secured by placing an American football helmet or baseball catcher's mask on the patient to attach the proximal end of the BTD to, providing traction. This approach can be problematic when providers needed to access the patient's airway or oropharynx. Several contemporary approaches for securing a BTD have been suggested and anecdotally appear to be safe and effective. One such method is attaching the BTD directly to the same AnchorFast Guard (Hollister Inc, Libertyville, IL) oral endotracheal tube fastener used to secure the endotracheal tube (Fig. 5). An alternative method includes running the BTD through a bag valve face mask and anchoring it with a clamp.
Throughout transport, CCT crews should monitor for migration and malposition of the BTD. The device may migrate because of the loss of gastric balloon air from altitude changes, air leak, or loss of clamping. If migration warrants emergent removal of the device, a CCT crewmember can use scissors to cut the tube distal to the bifurcation of the ports, allowing the balloons to deflate and the device to be removed. Further care of the BTD throughout transport include necrosis and erosion prevention, lavage, and suction maintenance (Table 3).
UGIB is a common, life-threatening condition that is frequently encountered by CCT crews and is broadly categorized as variceal or nonvariceal bleeding. Initial resuscitation consists of airway management, restoration of circulating intravascular volume with blood products, reversal of coagulopathy, and the use of appropriate adjunctive medications. BTDs are also used to provide mechanical hemostasis of bleeding varices. These devices can be a safe and effective temporizing measure until patients can be delivered to higher levels of care for definitive intervention. CCT crews should be familiar with how to safely monitor and manage these devices during transport.
References
Targownik LE
Nabalamba A.
Trends in management and outcomes of acute nonvariceal upper gastrointestinal bleeding: 1993-2003.
Restrictive versus liberal blood transfusion for acute upper gastrointestinal bleeding (TIGGER): a pragmatic, open-label, cluster randomized feasibility trial.
Effect of low-dose supplementation of arginine vasopressin on need for blood product transfusions in patients with trauma and hemorrhagic shock: a randomized clinical trial.
Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines.
Clinical Services and Standards Committee of the British Society of Gastroenterology. UK guidelines on the management of variceal haemorrhage in cirrhotic patients.
Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases.
Early administration of somatostatin and efficacy of sclerotherapy in acute oesophageal variceal bleeds: the European Acute Bleeding Oesophageal Variceal Episodes (ABOVE) randomized trial.
Randomized controlled trial of standard versus high-dose intravenous omeprazole after endoscopic therapy in high-risk patients with acute peptic ulcer bleeding.
Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomized, double-blind, placebo-controlled trial.
Expanding consensus in portal hypertension: report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension.
Inserting the Sengstaken-Blakemore tube successfully in a difficult case of uncontrollable esophageal variceal bleeding, using sutures and an endoscope.
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