GASTROENTEROLOGY ACUTE UPPER GASTROINTESTINAL HAEMORRHAGE ■«•the degree of blood loss•the source of the bleeding•early re-bleedingMany personnel were involved, and the patient needed extremely close monitoring.Characteristically, there was uncertainty over the indications and timing of surgery -in circumstances in which a clear management plan from the outset is afundamental requirement. An early, combined and well-documented consultationbetween the physicians, surgeons andtaff is invaluable in cases such as this, inwhich the risks of major complications can be anticipated from the moment thepatient is first seen. While difficult management decisions are being considered, it is also criticalthat the nurse is focused on the immediate condition of the patient:•Quarter-hourly observations may be necessary during the first few hours after a massive bleed to determine whether the bleeding has stopped. These can be reinstated at the first sign of re-bleeding (e.g. a fall in a previously stable CVP or a large fresh melaena stool).•Reassuring signs are a decrease in the pulse rate and reduction in any postural hypotension.•The respiratory rate is raised in shock, but will also increase if the patient develops pulmonary oedema due to over-transfusion - this is a particular risk in an elderly patient with pre-existing heart disease who has needed vigorous resuscitation with fluids and blood.Intensive monitoring and urgent investigative procedures are likely to lead todisorientation and distress in these elderly patients. Constant reassurance is needed,combined with careful explanations of the various interventions and staff that thepatient is suddenly encountering. It will be a great comfort to the patient to be ableto identify at least one familiar face among the frenetic activity of the first 12-24 h.Patients with significant blood loss are extremely weak and debilitated. If there isfrequent melaena, the effort of calling for, and using, a commode at short noticewill be exhausting (and often extremely embarrassing) for the patient. Nursing staffhave to be readily available to assist the patient and to deal with the distress ofmelaena or haematemesis with sensitivity and professionalism.Intravenous pantoprazole/omeprazole?High dose i.v. proton pump inhibitors pantoprazole/omeprazole 80 mg stat and 8mg per hour for 72 hours are only used in patients who have had a major bleed froma peptic ulcer. Treatment is started after the patient has returned from endoscopichaemostatic therapy.