PhysicianOrder Set PATIENT LABEL UPPER …

1 Physician Order Set UPPER GASTROINTESTINAL bleed HOSPITAL ORDERS PATIENT LABEL General Location Consider ICU Admission if one or more of the following conditions exists: Admit to ICU Admit to Medical/Surgical Unit with Telemetry Responsible Service/Physicians: Diagnosis: Vital Signs VS - q1h VS - q4h Allergies: Activity Bed rest Nursing Orders Assessments Cardiac monitor Measure Orthostatic VS Measure I&O and record q shift Measure weight - daily Pulse oximetry monitoring Interventions If Suspicious for Variceal bleed - okay to place temporary NGT - this will not worsen ongoing variceal bleeding or cause a varix to rupture For BOTH Suspicious and NOT Suspicious Variceal bleed - Avoid foley catheter Elevate HOB at least 30 degrees Insert 2 large bore IVs NG/OG tube insertion - place to low intermittent suction Suction at bedside Contingency Dr.

2 Rapid per Protocol Respiratory Oxygen Therapy per protocol PATIENT /Caregiver Education Consider smoking cessation counseling for current smokers Education, smoking cessation Diet NPO except ice chips Positive Tilt TestOngoing active blood lossAge greater than 65 Unstable or high potential to become unstableHistory of CADS evere COPDC oagulopathyESRDG ross bright red blood or coffee ground material in nasogastric aspirateSuspicious for variceal bleedgfedcgfedcgfedcgfedcgfedcbgfedcbgfe dcgfedcgfedcgfedcgfedcgfedcgfedcgfedcgfe dcbgfedcgfedcgfedcb Physician Name (Type): rev kcc 04/16/13 db 03/26/12 Page 1 of 3 Pager Number: Print All Physician Order Set UPPER GASTROINTESTINAL bleed HOSPITAL ORDERS PATIENT LABEL IV Fluids NaCl mL bolus NaCl at mL/hr Medications Suspicious for Variceal bleed Pantoprazole (PROTONIX) 40 mg IV daily until tolerating PO Evidence Octreotide (SANDOSTATIN) 50 mcg IV once - bolus Evidence Octreotide (SANDOSTATIN)50 mcg/hr IV If using Prophylactic Antibiotics, select either Ceftriaxone OR Ciprofloxacin cefTRIAXone (ROCEPHIN) 1 g IVPB q24h for 5 days for Prophylaxis Evidence ciprofloxacin (CIPRO) 400 mg IVPB q12h until tolerating PO, then 500 mg PO daily for 5 days for Prophylaxis Evidence ciprofloxacin (CIPRO)

3 400 mg IVPB q24h until tolerating PO, then 500 mg PO daily for 5 days - if CrCl is less than 30 mL/min phytonadione (Vitamin K) mg PO x one dose - if not tolerating PO, give same dose SubQ phytonadione (Vitamin K) mg SubQ x one dose NOT Suspicious for Variceal bleed Pantoprazole (PROTONIX) 80 mg IV x one dose - bolus Evidence Pantoprazole (PROTONIX) 8 mg/hr IV until tolerating PO, then change to 40mg PO daily Comfort Medications Milk of Magnesia 30 mL PO q12h PRN constipation, OR Dulcolax 5 mg PO once daily PRN constipation (for patients with renal insufficiency) Mylanta/Maalox 30 mL PO q6h PRN indigestion OR Calcium carbonate 15 mL PO q4h PRN indigestion (for patients with renal insufficiency) Acetaminophen 650 mg PO q6h PRN mild or headache pain (Unless PATIENT is taking other acetaminophen-containing meds) Chloraseptic / Cepastat 1 lozenge q2h PRN dry mouth or sore / irritated throat Adult PATIENT Controlled Analgesia (PCA) Hospital Orders Deep Venous Thrombosis Prophylaxis Laboratory CBC with differential, INR, CMP - STAT (If not done in ER)

4 Blood Bank Type and crossmatch, AHG Units Type and screen Blood Transfusion If INR greater than and on coumadin suspect variceal / portal hypertensive bleed - FFP rarely indicated without ongoing blood loss Correct any coagulopathies to a goal of INR less than and Correct Thrombocytopenia to platelets of greater than 50,000 and actively bleeding (if present consider portal hypertensive/variceal source). If Suspicious for Variceal bleed - Plan to transfuse blood to a goal hemoglobin of 8-10. Volume Resuscitation goal of SBP greater than 100 In hemodynamically stable patients without increased risk of ischemia, consider lowering Hgb transfusion breakpoint to less than 7 g/dL with caveats for acute blood loss resulting in: 1.

5 Estimated or anticipated blood loss greater than or equal to 15% of total blood volume (ex: 750mL in 70kg male) 2. DBP less than or equal to 60mmHg 3. Decrease in SBP by more than 30mmHg gfedcgfedcgfedcgfedcgfedcgfedcgfedcgfedc gfedcgfedcgfedcgfedcgfedcgfedcgfedcgfedc gfedcgfedcgfedc Physician Name (Type): rev kcc 04/16/13 db 03/26/12 Page 2 of 3 Pager Number: Physician Order Set UPPER GASTROINTESTINAL bleed HOSPITAL ORDERS PATIENT LABEL 4. Oliguria/anuria or symptomatic anemia resulting in: a) Tachycardia b) Mental status changes c) ECG signs of cardiac ischemia d) Angina e) Shortness of breath, lightheadedness or dyspnea with mild exertion Blood Transfusion Orders Hematology CBC with differential - in AM INR - in AM H&H q6h H&H after Units of blood transfused Panels BMP - in AM CMP - in AM LFTs Diagnostic Tests Radiology American College of Radiology Appropriateness Criteria for treatment of acute nonvariceal GI tract bleeding Evidence American College of Radiology Appropriateness Criteria for UPPER GI bleeding Evidence CT, abdomen, with contrast Evidence - reason.

6 CT, abdomen, without contrast - reason: Ultrasound, abdomen - reason: Cardiology 12-lead ECG - reason: Consults Consult Gastroenterology if Suspicious for Variceal bleed or if NOT Suspicious for Variceal bleed and PATIENT is admitted to ICU, actively bleeding, or endoscopy is warranted Consult to gastroenterology Evidence Reason: Consult to general surgery EvidenceReason: Consult to dietitian, adult Reason: Consult to social services Reason: Medication Reconciliation Link Additional Orders 1. 2. 3. 4. 5. 6. gfedcgfedcgfedcgfedcgfedcgfedcgfedcgfedc gfedcgfedcgfedcgfedcgfedcgfedcgfedc Physician Name (Type): rev kcc 04/02/13 db 03/26/12 Page 3 of 3 Pager Number: Print All