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
      • may not be effective at completely emptying the stomach
      • should not delay intubation
• “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

• EMCrit — A novel set up for suctioning during intubation (2011)
• EMCrit — Intubating the GI Bleeding Patient (2009)