Sandbox:ssw 2

Recommendation for Revascularization for CLI:

Class I

"1.In patients with CLI, revascularization should be performed when possible to minimize tissue loss.(Level of Evidence: B-NR)"

"2.An evaluation for revascularization options should be performed by an interdisciplinary care team before amputation in the patient with CLI.(Level of Evidence: C-EO)"

Recommendations for Endovascular Revascularization for CLI:

Class I

"1.Endovascular procedures are recommended to establish in-line blood flow to the foot in patients with nonhealing wounds or gangrene.(Level of Evidence: B-R)"

Pre-endoscopic medical therapy

Conditional recommendation (Class IIa)

1. Intravenous infusion of erythromycin (250 mg ~ 30 min before endoscopy) should be considered to improve diagnostic yield and decrease the need for repeat endoscopy. However, erythromycin has not consistently been shown to improve clinical outcomes

2. Pre-endoscopic intravenous PPI (e.g., 80 mg bolus followed by 8 mg / h infusion) may be considered to decrease the proportion of patients who have higher risk stigmata of hemorrhage at endoscopy and who receive endoscopic therapy. However, PPIs do not improve clinical outcomes such as further bleeding, surgery, or death

3. If endoscopy will be delayed or cannot be performed, intravenous PPI is recommended to reduce further bleeding.

Gastric lavage

Conditional recommendation (Class IIa)

1. Nasogastric or orogastric lavage is not required in patients with UGIB for diagnosis, prognosis, visualization, or therapeutic effect

Timing of endoscopy

Conditional recommendation (Class IIa)

Timing of endoscopy 1. Patients with UGIB should generally undergo endoscopy within 24 h of admission, following resuscitative efforts to optimize hemodynamic parameters and other medical problems.

2. In patients who are hemodynamically stable and without serious comorbidities endoscopy should be performed as soon as possible in a non-emergent setting to identify the substantial proportion of patients with low-risk endoscopic fi ndings who can be safely discharged.

3. In patients with higher risk clinical features (e.g., tachycardia, hypotension, bloody emesis or nasogastric aspirate in hospital) endoscopy within 12 h may be considered to potentially improve clinical outcomes.

Endoscopic diagnosis

Strong recommendation (Class I)

1. Stigmata of recent hemorrhage should be recorded as they predict risk of further bleeding and guide management decisions. The stigmata, in descending risk of further bleeding, are active spurting, non-bleeding visible vessel, active oozing, adherent clot, fl at pigmented spot, and clean base .

Endoscopic therapy

Strong recommendation Class I

1. Endoscopic therapy should be provided to patients with active spurting or oozing bleeding or a non-bleeding visible vessel.

2. Endoscopic therapy should not be provided to patients who have an ulcer with a clean base or a fl at pigmented spot .

3. Epinephrine therapy should not be used alone. If used, it should be combined with a second modality.

4. Thermal therapy with bipolar electrocoagulation or heater probe and injection of sclerosant (e.g., absolute alcohol) are recommended because they reduce further bleeding, need for surgery, and mortality.

Timing of endoscopy

Conditional recommendation (Class IIa)

Timing of endoscopy 1. Patients with UGIB should generally undergo endoscopy within 24 h of admission, following resuscitative efforts to optimize hemodynamic parameters and other medical problems.

2. In patients who are hemodynamically stable and without serious comorbidities endoscopy should be performed as soon as possible in a non-emergent setting to identify the substantial proportion of patients with low-risk endoscopic fi ndings who can be safely discharged.

3. In patients with higher risk clinical features (e.g., tachycardia, hypotension, bloody emesis or nasogastric aspirate in hospital) endoscopy within 12 h may be considered to potentially improve clinical outcomes.

Class I

"1. An interdisciplinary care team should evaluate and provide comprehensive care for patients with CLI and tissue loss to achieve complete wound healing and a functional foot(Level of Evidence: B-NR)"

"2. In patients with CLI, wound care after revascularization should be performed with the goal of complete wound healing(Level of Evidence: C-LD)"

Class IIb

"1. In patients with CLI, intermittent pneumatic compression (arterial pump) devices may be considered to augment wound healing and/or ameliorate severe ischemic rest pain. (Level of Evidence: B-NR)"

"2. patients with CLI, the effectiveness of hyperbaric oxygen therapy for wound healing is unknown. (Level of Evidence: C-LD)"