Management of upper gastrointestinal bleeding in neonates admitted at Neonatal Intensive Care Unit of Assiut University Children's Hospital: A clinical audit

Abstract

BackgroundUpper gastrointestinal bleeding (UGIB) is an uncommon but potentially serious, life-threatening condition in neonates. Rapid assessment, stabilization, and resuscitation should precede all diagnostic modalities in unstable neonates. The diagnostic approach includes history, examination, laboratory evaluation, endoscopic procedures, and imaging studies. The clinician needs to determine carefully whether any blood or possible blood reported represents true UGIB because most neonates with true UGIB require admission to a neonatal intensive care unit (NICU).ObjectiveThe aim of this clinical audit study is to assess how much the adapted protocols of diagnosis and management of UGIB were applied in NICU in Assiut University Children Hospital.Patients and methodsThe present study was conducted in Assiut University Children's Hospital and included 100 neonates with UGIB who were admitted to NICU of Assiut University Children's Hospital over a 1-year period from the 1st of January 2017 to 31st of December 2017.ResultsComplete history was fulfilled in 100% of cases including the type of delivery, way of nutrition, history of maternal drug use, family history of bleeding, and vitamin K prophylaxis. Data of examination was fulfilled in 100% of cases including vital sign, hepatosplenomegaly, jaundice, bowel sound, and passing of stool. Data of investigations was fulfilled in 100% of cases except for Alkali denaturation test (Apt–Downey test) and upper endoscopy for ulcer evaluation was recorded in 0% of cases. Data about management was fulfilled in 100% of cases regarding secure airway, prophylaxis vitamin K, antibiotic therapy, and gastric lavage with normal saline; obtain two intravenous line was done in 18% of cases; replace blood loss with saline was done in 96% of cases; Foley catheter placement in shocked patient was done in 12% of cases; epinephrine lavage was done in 37% of cases; administration of H2 blockers was done in 13% of cases; administration of PPIs was done in 46% of cases; blood transfusion was done in 72% of cases; and plasma transfusion was done in 79%.ConclusionThe international guidelines for the management of UGIB had been followed by personnel working at NICU of Assiut University Children's Hospital regarding treatment lines and that some of the default is due to poor resources and lack of medication.RecommendationsInfection control measures must be appropriately done, this can be achieved by training nurses and resident doctors on infection control program continuously and also by staff members' supervision.Prolonged use of total parenteral nutrition increases the incidence of neonatal sepsis, this can be prevented by start of oral feeding as early as possible and proper infection control. Early weaning from ventilation as much as possible as prolonged use of mechanical ventilation to newborn predisposes them to develop sepsis and stress ulcer; this can be prevented by early weaning from ventilation. Evaluation and stabilization with airway management, intravenous fluids, or blood transfusion is essential before and during diagnostic evaluation. Gastric lavage with normal saline and epinephrine lavage should be done for all cases with UGIB. Complete laboratory investigations such as complete blood count, type and cross-match blood and coagulation profile should be done for all cases. Mother should be examined for cracked nipples as a source of swallowed blood, blood is usually apparent on examination.