Intubation in Upper Gastrointestinal Haemorrhage

Revised and reviewed 13 April 2015

OVERVIEW

Intubation of patients with upper gastrointestinal haemorrhage is may be complicated by:
- obscured laryngeal exposure due to blood or vomitus
- aspiration risk
- potential haemodynamic instability
- comorbidities
- blood/ body fluid exposure of staff

INDICATIONS FOR INTUBATION

Patients with upper gastrointestinal haemorrhage may require intubation for:

airway protection
- decreased level of consciousness (e.g. hypotension, hepatic encephalopathy)
- aspiration
- high risk of further deterioration
- will require intubation for further interventions (e.g. Minnesota tube, endoscopy)
coexistent conditions

MODIFICATIONS TO RAPID SEQUENCE INTUBATION

Emergency intubation for patients with upper gastrointestinal haemorrhage requires a modified rapid sequence intubation approach:

all bedside staff should ear PPE (googles, gloves, gown, mask)
anticipate and prevent haemodynamic instability
- institute therapy pre-intubation
- early blood transfusion
- start vasopressors peripherally for haemodynamic compromise (e.g. noradrenaline via large bore peripheral line in the short-term; phenylephrine or metaraminol boluses are less satisfactory alternatives)
- if difficult venous access consider using ultrasound to site a 20G IV cannula then convert this to a RIC line; IO access is an alternative
head up positioning
- for pre-oxygenation and aspiration prevention
- perform intubation at 45 degrees head up (improves view, decreases aspiration risk)
consider emptying the stomach
- prokinetics
  - e.g. metoclopramide 20mg IV and/or erythromycin 250mg IV
  - metoclopramide also increases lower esophageal sphincter tone
  - onset may be too slow and adminstration should not delay intubation in an emergency
- large bore nasogastric tube insertion
  - allows aspiration of gastric contents
  - not contra-indicated in varices
  - can remove prior to intubation or leave in situ
  - BUT may trigger vomiting and may not be effective at completely emptying the stomach
“double suction setup”
- 2 assistants employ two assistants with yankauer suction either side
- assistants watch video laryngoscope screen to facilitate suctioning
induction drugs and dose
- e.g. ketamine (1-2 mg/kg IV) or low dose sedatives (e.g. fentanyl, midazalam, or propofol)
- correct drug dosing is more important than drug selection
- use rocuronium 1.2 mg/kg IV or suxamethonium 1.5mg/kg IV for neuromuscular blockade
avoid positive pressure ventilation
- i.e. avoid CPAP/ NIV / PPV via a BVM for preoxygenation and apnoeic oxygenation if possible due to risk of gastric insufflation
- if BVM is required, use a slow, gentle technique at 6-10 breathes per min, ideally with <15 cmH20
use video laryngoscopy
- this allows assistants share the view
- have a direct laryngoscope on standby in case video gets obscured by vomitus/ blood
- a video device such as the C-MAC allows both video and direct laryngoscopy to be performed with one piece of equipment
if the patient vomits or regurgitates
- release cricoid pressure (if used)
- Trendelenberg position (do not sit patient up, vomitus is more likely to enter the airway in this situation)
- consider using a meconium aspirator attached to endotracheal tube to suction as the ETT is advanced (ETT may be soiled, can be replaced later)
- consider using the SALAD approach (Suction Assisted Laryngoscopy Airway Decontamination)
aspiration management
- results in a chemical pneumonitis (no evidence for antibiotics), requiring supportive management
- expect SIRS response to aspiration, may lead to hypotension (treat with vasopressors if required, e.g. noradrenaline)
antibiotics
- required if aspiration pneumonitis progresses to aspiration pneumonia
- required for variceal bleeding (ceftriaxone)

References and links

Lifeinthefastlane.com

CCC — Gastrointestinal haemorrhage
CCC — Rapid sequence intubation
CCC — Suction Assisted Laryngoscopy Airway Decontamination (SALAD))

Journal articles

Weingart SD, Bhagwan SD. A novel set-up to allow suctioning during direct endotracheal and fiberoptic intubation. J Clin Anesth. 2011 Sep;23(6):518-9. doi: 10.1016/j.jclinane.2010.08.021. Epub 2011 Jul 23. PubMed PMID: 21783351.

FOAM and web resources