Paediatric guidelines (in development)
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Paediatric significant upper gastrointestinal bleeding guideline
Warning
Objectives
This guidance is appropriate for all children in whom significant acute gastrointestinal (GI) bleeding is the presenting concern. There are a broad range of presentations in the paediatric population ranging from altered blood (“coffee grounds”), frank upper GI bleeding (haematemesis), passage of altered blood (melaena) or fresh blood (haematochezia) per rectum.
The causes of acute GI bleeding are extremely varied. Examples include upper GI bleeding secondary to varices due to intrinsic liver disease or portal vein abnormalities, battery/foreign body ingestion and gastric/duodenal ulceration. An acute GI bleed may be the first presentation of a child with portal hypertension and varices; these presentations can often be dramatic and seemingly unprovoked.
This guidance is based on local expertise but does reflect the consensus management suggested by the three National Paediatric Hepatology Centres (Birmingham Children’s Hospital, Leeds Children’s Hospital and King’s College London) which is summarised in the BSPGHAN guidance1.
This guideline is only intended to be referred to in those cases in which the attending health care team, in whatever setting, feel that bleeding from the upper GI tract is significant (e.g. large volume haematemesis, cardiovascular compromise, known underlying condition predisposing to an upper GI bleed, need to activate the Major Haemorrhage Protocol*). This guidance is not suitable for clinically stable patients with a small amount of fresh blood in their vomit (e.g. small Mallory-Weiss tear on a background of persistent vomiting) or those with small volume altered blood (i.e. “coffee-grounds”) in their vomit or visible in their gastrostomy drainage bag. In cases where this is unclear, a senior clinician should be consulted to determine the best course of action.
*Only accessible via NHS Lothian Intranet
Scope
This guideline applies to all nursing and medical staff caring for children and young people with presumed upper gastrointestinal bleeding within NHS Lothian paediatric services.
Audience
NHS Lothian paediatric services
Roles and Responsibilities
It is the responsibility of all staff likely to be involved in the care of a paediatric patient with presumed upper GI bleeding to have read and understood this guidance. If any member of staff has any concerns, they should address these with a trained member of staff before proceeding.
Activate the RHCYP Major Haemorrhage Protocol* by calling 2222. If activated then as well as the automatic involvement of the PET Team and PCCU the Gastroenterology and Surgical Consultants should be informed as soon as possible.
*Only accessible via NHS Lothian Intranet
As in all cases of upper GI bleeding the surgical team should be involved at an early stage. This may be less important in patients with known portal hypertension. In patients with rapid upper GI bleeding of any cause this may present with fresh rectal bleeding and as such a joint discussion with Gastroenterology and Surgery is strongly advised on a case-by-case basis.
Always strongly consider contacting PCCU early in all cases of upper GI bleeding – however this should happen in all cases involving major haemorrhage, cardiovascular compromise, out-of-hours presentation and when it is determined that Octreotide is indicated.
AIRWAY, BREATHING AND CIRCULATION (ABC)
- Airway: Ensure airway is patent
- Breathing:
- Visually assess breathing efficacy and effort
- Obtain respiratory rate and oxygen saturation
- Administer oxygen via facemask
- Circulation:
- Obtain heart rate, manual pulse, capillary refill and blood pressure
- Start continuous monitoring of heart rate and oxygen saturation
- Cycled blood pressure every 5 minutes
FLUID RESUSCITATION and INITIAL MANAGEMENT
Fluids and sampling
1. Insert two wide bore peripheral IV cannulas
2. Obtain capillary or venous blood gas and near patient blood glucose- treat hypoglycaemia (BG <2.6mmol/L) with glucose 10% bolus 2mL/kg as indicated.
3. Ensure blood samples for FBC, coagulation and two cross match samples are obtained and sent urgently
4. Give a 10mL/kg intravenous (IV) fluid bolus (sodium chloride 0.9%) if indicated and commence IV fluids
Blood products
- If you need to use blood products, please activate the Major Haemorrhage Protocol as per RHCYP Guideline (phone 2222)
- If blood group matched blood is not available, use the O Negative blood
- Ideally after haematology advice, give platelets (usually if platelets <100x109/L), fresh frozen plasma (FFP; usually if INR >1.5) and cryoprecipitate (if fibrinogen <1.0) where indicated, especially if bleeding is not controlled.
- Appropriate transfusion strategy:
-
- In those with known portal hypertension and a likely variceal bleed (or when the cause of bleeding is unknown) do not over transfuse. Initially aim to transfuse to a haemoglobin level of 90g/L. If the patient is haemodynamically stable commence the transfusion slowly rather than as a bolus as this will reduce the risk of increased portal pressure and re-bleeding.
- In patients in whom portal hypertension and bleeding varices are definitely not the cause of bleeding (e.g. confirmed foreign body ingestion) or if the patient is haemodynamically unstable then a more rapid transfusion of blood may be appropriate.
- Placement of a nasogastric tube – strongly consider inserting an NG tube following discussion with on-call GI consultant. If inserted then place on free drainage (allows removal of blood from the stomach and monitoring of ongoing bleeding)
- Commence patient on two thirds maintenance intravenous fluids as per RHCYP Paediatric Intravenous Fluid Management Guidelines* once resuscitation complete.
- Keep child nil by mouth.
- Monitor blood glucose 2-4hourly (aim for blood glucose of 4-8mmol/L). Consider early change to glucose 10% containing IV fluids if the patient is hypoglycaemic.
- Correct any electrolyte abnormalities.
- Strict fluid balance – monitor input and output closely.
*Only accessible via NHS Lothian intranet
- Commence Octreotide in children where the cause of their GI bleed is suspected to be variceal or cause is unknown – all children receiving or planning to receive octreotide should be admitted to a Critical Care bed and discussed with the on-call Paediatric Gastroenterologist.
- If possible, use a dedicated IV cannula for infusion to reduce interruption of infusion for other medications (can however be run alongside maintenance fluids if difficult access)
- Continue the octreotide infusion until 24 hours after bleeding is controlled
- Wean infusion slowly over the following 24 hours to reduce the risk of rebound bleeding
- Octreotide has a very short half-life – if the cannula stops working/tissues, it needs to be re-sited immediately
Octreotide Dosing
- All patients should be administered an initial IV bolus dose, followed by a continuous IV infusion
- Step 1 – IV loading dose of 1 microgram/kg over 5 minutes (max 50 micrograms)
- Step 2 - Continuous IV infusion at 1-3 micrograms/kg/hr (max 50micrograms/hour)
Octreotide Preparation
- Within RHCYP octreotide 500micrograms/mL preparation is stocked in the Emergency Department (Red zone fridge and the emergency fridge in the ED store cupboard), PCCU and theatres (outside theatre 30 anaesthetic room). Other strengths of octreotide are available through pharmacy. At SJH octreotide is available from pharmacy or the emergency drug cupboard out of hours.
- Suggested dilution: 500microgram vial of octreotide diluted up to 10mL with sodium chloride 0.9%, to give 50microgram/mL (1mL/hr = 50microgram/hr)4.
- Initially prepare the above infusion for all patients. An alternative volume may be more appropriate for older patients to avoid multiple syringe changes per day. Consult ward/on-call pharmacist for further advice.
All patients should be administered intravenous proton pump inhibitor and vitamin K when upper GI bleeding is suspected. There should also be a very low threshold for the addition of broad-spectrum antibiotics.
Proton Pump Inhibitor
- IV Esomeprazole
- 0-1month: 0.5mg/kg OD
- 1-11months: 1mg/kg OD
- 1-11years and <20kg: 10mg OD
- 1-11years and >20kg: 10-20mg OD
- 12 years and above: 40mg OD
- IV Omeprazole5
- Child 1 month–11 years Initially 500 micrograms/kg once daily (max. per dose 20 mg) increased if necessary to 2 mg/kg once daily (max. per dose 40 mg)
- Child 12–17 years 40 mg once daily
Vitamin K (Phytomenadione)
- 300micrograms/kg (max 10mg) as a slow IV injection over 3 – 5 minutes.
Intravenous antibiotics
- IV Cefotaxime (50mg/kg) should be given and continued until further discussion with microbiology.
- If patient is jaundiced or has known intrinsic liver disease then piperacillin/tazobactam is indicated as first line. (See BNFc for dosing)
Tranexamic acid
There is currently no evidence regarding the use of tranexamic acid in children and young people with upper GI bleeding. The adult literature remains unclear, with some evidence suggesting a reduction in re-bleeding2 but a recent RCT showing no effect on mortality and an increase in venous thromboembolic events and seizures with a high-dose infusion3. We would therefore recommend that tranexamic acid should not be used routinely in the management of a child with upper GI bleeding. However it may be warranted in extreme cases if other treatments fail and following discussion within the wider MDT.
Variceal bleeding - Specialist (GI) Management
- Consider contacting an adult GI colleague for support
- Options for control of bleeding:
- Band ligation (Wilson Cook Six Shooter [MLB 6 or MLB 6-XS])
- Thrombin injection
- use Floseal Haemostatic Matrix kit – only use thrombin vial
- dissolve using sodium chloride 0.9% - no other components
- make a 10ml volume giving 2500 units/ml - Inject in 2-3ml aliquots
- Hemospray® – use as per manufacturer instructions
- Fibrovein® – use as per manufacturer instructions
Ulcer bleeding - Specialist GI Management
- Adrenaline: 1 in 10 000 with quadrantic injections (up to 30mls)
- Hemoclips® – use as per manufacturer instructions
- Hemospray® – use as per manufacturer instruction
Sengstaken-Blakemore Tube - Specialist Management
If bleeding continues despite above measures consider placing the Sengstaken-Blakemore Tube. This is, however, rarely needed. Consider deployment in children who continue to have rapid blood loss despite adequate medical / endoscopic management. Control of the airway and volume replacement are essential. Patients must be intubated and have intensive care support prior to the insertion.
- SENGSTAKEN TUBE (Cliny brand) – See RHCYP Sengstaken guide – Use only with specialist advice:
- This is located in the GI store cupboard opposite Theatre 35 in the GI trolley (bottom right drawer) along with laminated instruction sheet and all items for use. The same kit is also in a Sengstaken box in the CEPOD Theatre 31 prep room.
- 16Fr tube inflated with 50-150mL of air depending on age of child (see ‘RHCYP CLINY Sengstaken how to use guidance’ and ‘Sengstaken where to find’ documentation)
- Do not routinely inflate the oesophageal balloon unless discussed and under the instruction of the GI team.