Intubation in Upper Gastrointestinal Haemorrhage

OVERVIEW

Intubation of patients with upper gastrointestinal haemorrhage 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 wear 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 administration 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, midazolam, 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)
    • Trendelenburg 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

LITFL

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. 21783351.

FOAM and web resources

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.