title: Prospective evaluation of hemoclip application with injection of epinephrine in hypertonic saline solution for hemostasis in unstable patients with shock caused by upper GI bleeding.
abstract: BACKGROUND
  It is difficult to arrest severe upper GI bleeding with any of the available hemostatic modalities in unstable patients who are in shock, and the rates of persistent bleeding and mortality in this group remain high. This prospective study evaluated hemoclip application alone and in combination with injection of hypertonic saline solution with epinephrine in this subgroup of patients with GI bleeding.
  
  
  METHODS
  Twenty-two patients in shock because of upper GI bleeding were enrolled and divided into 2 groups based on the response of systolic blood pressure to rapid infusion of 1000 mL of lactated Ringer's solution: an unstable shock group, in which systolic blood pressure did not stabilize at greater than 90 mm Hg, and a stable shock group, in which systolic blood pressure stabilized at greater than 90 mm Hg. Emergency endoscopy was performed in both groups; those in the stable group were treated by hemoclip application alone and those in the unstable group were treated by hemoclip application combined with injection of hypertonic saline solution with epinephrine. The following parameters were compared: vital signs on admission and after infusion of lactated Ringer's solution, hemoglobin concentration, endoscopic classification of type and site of bleeding, number of hemoclips required to arrest bleeding, volume of hypertonic saline solution with epinephrine injected, initial hemostatic rate, rate of recurrent bleeding, the need for additional preventive therapy (hemoclip application), and mortality.
  
  
  RESULTS
  The rate of initial hemostasis was 92% in the stable shock group and 100% in the unstable shock group. Bleeding did not recur in either group. The volume of packed red cells transfused and the endotracheal intubation rate were significantly greater in the unstable shock group. Preventive application of hemoclips was performed at endoscopic follow-up 12 times in 10 patients in the stable shock group and 9 times in 7 patients in the unstable shock group. There were no deaths in either group.
  
  
  CONCLUSIONS
  Endoscopic injection of hypertonic saline solution with epinephrine combined with hemoclip application provides effective hemostasis in unstable patients in shock caused by severe upper GI bleeding. The hemostatic result is comparable with that achieved by hemoclip application alone in patients with bleeding but less severe shock.
authors.affiliation: Department of Traumatology and Critical Care Medicine, Kyorin University School of Medicine, Tokyo, Japan.
authors.forename: Hideaki
authors.initials: H
authors.lastname: Goto
authors.forename: Shoichi
authors.initials: S
authors.lastname: Ohta
authors.forename: Yoshihiro
authors.initials: Y
authors.lastname: Yamaguchi
authors.forename: Tetsuo
authors.initials: T
authors.lastname: Yukioka
authors.forename: Hiroharu
authors.initials: H
authors.lastname: Matsuda
authors.forename: Shuji
authors.initials: S
authors.lastname: Shimazaki
mesh_terms: D001794:Blood Pressure; D004837:Epinephrine / Q000008:administration & dosage*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000628:therapy*; D016558:Hemostasis, Endoscopic; D006489:Hemostatic Techniques / Q000295:instrumentation*; D006801:Humans; D006982:Hypertonic Solutions; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012771:Shock, Hemorrhagic / Q000209:etiology / Q000628:therapy*
chemical_list: D006982:Hypertonic Solutions; D004837:Epinephrine