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Abstract

Acute gastrointestinal hemorrhage is a critical condition requiring immediate and effective fluid resuscitation to stabilize hemodynamics and prevent complications. This evidence summary aims to synthesize the best available evidence to develop an evidence-based fluid resuscitation protocol for these patients, in order to guide clinical practice and improve patient outcomes. According to the “6S” evidence resource model, evidence retrieval was conducted to identify relevant literature in acute gastrointestinal hemorrhage. Two researchers evaluated the quality of studies using the JBI Evidence-Based Healthcare Center’s literature quality assessment criteria and evidence recommendation system, selecting and extracting evidence from eligible publications. Eleven articles were included, comprising 6 clinical guidelines, 2 systematic reviews, 2 expert consensuses, and one clinical decision tool. A total of 22 pieces of best evidence were synthesized and categorized into 6 key domains: (1) general principles of fluid resuscitation, (2) comprehensive patient assessment, (3) venous access establishment and fluid replacement protocols, (4) transfusion thresholds and strategies, (5) adjunctive pharmacotherapy, and (6) multi-parametric monitoring and outcome evaluation indicators. This study synthesizes the existing literature on fluid resuscitation in patients experiencing gastrointestinal hemorrhage, providing structured and concrete guidance for clinicians to facilitate evidence-based decision-making. The ultimate objectives are to stabilize patients, improve survival rates, and enhance both recovery and long-term quality of life.

Keywords

gastrointestinal hemorrhage fluid resuscitation evidence-based practice nursing management

Introduction

Acute gastrointestinal hemorrhage is a prevalent and potentially life-threatening emergency worldwide, with an annual incidence of 100 to 180 cases per 100 000 adults and a mortality rate ranging from 2% to 15%.^1
-4 This condition is characterized by rapid hemodynamic deterioration, necessitating prompt and evidence-based interventions to prevent hypovolemic complications and improve patient outcomes. The cornerstone of initial management is timely fluid resuscitation, especially in cases of massive hemorrhage, where achieving hemodynamic stability is essential before proceeding with definitive diagnostic and therapeutic measures.⁵

Optimal resuscitation in cases of acute gastrointestinal hemorrhage includes intravenous fluid administration, transfusion of blood products, targeted vasoactive medications when indicated, and continuous hemodynamic monitoring. Recent evidence underscores that standardized, protocol-driven fluid resuscitation substantially enhances clinical outcomes by reducing complications and mortality rates in this patient cohort.^2,6 In instances of massive hemorrhage, structured resuscitation strategies—such as the placement of large-bore venous access, prompt administration of blood products, and activation of massive transfusion protocols—are essential. Nurses play a crucial role in executing these strategies through ongoing patient assessment, accurate fluid administration, and real-time monitoring of outcomes, thereby, making their expertise fundamental to the successful implementation of fluid resuscitation.

Despite the emphasis on fluid resuscitation in contemporary clinical guidelines and expert consensus statements, recommendations often remain embedded within broader management algorithms and lack specific, actionable protocols tailored explicitly to gastrointestinal hemorrhage (GIH).^2,4
-6 Recent paradigm shifts toward precision medicine have highlighted the necessity for individualized fluid strategies; however, this has not yet been reflected in standardized, evidence-based guidelines for adult patients experiencing acute gastrointestinal hemorrhage. This gap often leads clinicians to rely on empirical approaches rather than structured protocols. This study seeks to address this deficiency by systematically synthesizing the best available evidence on fluid resuscitation, thereby providing a comprehensive, operational framework to guide clinical practice and improve patient outcomes.

Therefore, this study aims to systematically retrieve and critically appraise relevant literature, synthesize the best available evidence for fluid resuscitation in adults with acute gastrointestinal hemorrhage, and establish an evidence-based framework to guide healthcare professionals in optimizing fluid management for this patient population.

Methods

Study Design and Problem Formulation

This study was designed as an evidence summary, involved the systematic retrieval, appraisal, and synthesis of existing evidence. We formulated evidence-based questions using the problem development tool from the Evidence-Based Nursing Center of Fudan University.⁷ The framework included: P (Population): Adults with acute gastrointestinal hemorrhage; I (Intervention): Evidence-based fluid resuscitation strategies, including timing and protocols; P (Professionals Involved): Clinical healthcare workers; O (Outcomes): Vital signs, laboratory parameters, and bleeding control indicators; S (Settings): Medical institutions at all levels; T (Types of Evidence): Best practices, evidence summaries, guidelines, systematic reviews, and expert consensus.

Evidence Retrieval

A systematic search was conducted according to the “6S” evidence-based resource model,⁸ from the highest to the lowest level. Databases searched included BMJ Best Practice, the National Guideline Clearinghouse, Registered Nurses’ Association of Ontario Guidelines, Scottish Intercollegiate Guidelines Network, National Institute for Health and Care Excellence (NICE) Guidelines, International Society for Evidence-Based Healthcare Guidelines, UpToDate, Joanna Briggs Institute (JBI) Evidence-Based Healthcare Database, and Cochrane Library. Supplementary searches were performed in comprehensive bibliographic databases, including PubMed, Embase, CINAHL, Wanfang Data, CNKI, as well as professional society websites. The search terms were created based on the combination of Medical Subject Headings and free terms. Search terms for clinical decision tools, evidence summaries, clinical practice guidelines, and professional society resources included “gastrointestinal hemorrhage/gastrointestinal bleeding” combined with “fluid management/fluid resuscitation/fluid balance/capacity management/volume management/fluid therapy.” The PubMed search strategy serves as an example:

(“Gastrointestinal Hemorrhage”[Mesh] OR “gastrointestinal haemorrhage”[tiab] OR “gastrointestinal hemorrhage”[tiab] OR “gastrointestinal bleeding”[tiab] OR “GI bleed*”[tiab]) AND (“Fluid Therapy”[Mesh] OR “Resuscitation”[Mesh] OR “fluid management”[tiab] OR “fluid resuscitation”[tiab] OR “volume expansion”[tiab] OR “volume therapy”[tiab] OR “volume management”[tiab] OR “fluid balance”[tiab] OR “water electrolyte balance”[tiab] OR “capacity management” [tiab] OR hemodynamic*[tiab] OR “shock management” [tiab]) AND (“Systematic Review”[Publication Type] OR “Meta-Analysis”[Publication Type] OR “Practice Guideline” [Publication Type] OR “Consensus Development Conference” [Publication Type] OR guideline*[ti] OR consensus*[ti] OR “systematic review”[ti] OR “meta-analysis”[ti])

The search timeframe spanned from database inception to October 11, 2025.

Inclusion and Exclusion Criteria of Evidence

Inclusion Criteria: Studies were included if they: (1) addressed fluid resuscitation in patients with GIH, encompassing resuscitation assessment, intravenous fluid replacement strategies, transfusion protocols, monitoring parameters, outcome evaluation, and general principles of fluid resuscitation; (2) were published as clinical guidelines (within the past 10 years), best practice recommendations, policy documents, evidence summaries, or systematic reviews; and (3) were published in Chinese or English. Exclusion Criteria: Studies were excluded if they: (1) were duplicate publications or translations of previously published work; (2) were abstracts or contained incomplete data; or (3) failed to meet methodological quality assessment criteria.

Literature Screening

Initially, the retrieved literature was imported into EndNote to remove duplicates. Two evidence-based nursing researchers independently assessed the methodological quality of included literature. Discrepancies were resolved through consensus discussion among the research team until agreement was reached. Literature types included clinical guidelines, systematic reviews, randomized controlled trials (RCTs), and expert consensus statements. Guideline quality was evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool (updated 2017),⁹ which comprises 6 domains with 23 items, each scored on a 7-point Likert scale (1 = “strongly disagree” to 7 = “strongly agree”). Domain scores were standardized using the formula: [(actual score − minimum possible score)/(maximum possible score − minimum possible score)] × 100%. Systematic reviews, RCTs, and expert consensus were appraised using Joanna Briggs Institute (JBI) critical appraisal tools (2016).¹⁰

Literature Quality Evaluation

Two researchers independently extracted data, including the source, level of evidence, and content. Any discrepancies were resolved through discussion or, if necessary, by consulting a third researcher. The synthesis of evidence followed these principles: (1) Identical or complementary findings were logically consolidated; (2) Conflicting recommendations were addressed by prioritizing evidence of higher quality and more recent origin, with expert opinion incorporated as needed; (3) Independent entries were maintained in their original form; (4) Entries deemed irrelevant or clinically inconsistent were excluded. All synthesized evidence items explicitly reference their source literature, publication year, document type, and original evidence grade.

Evidence Extraction and Summary

The evidence-based nursing research team comprised graduate-level researchers and clinical nursing experts. Graduate researchers conducted literature searches, quality assessments, evidence extraction, and synthesis, while clinical experts evaluated the clinical relevance and applicability of extracted evidence. All team members received formal training in evidence-based nursing methodologies and demonstrated extensive expertise in systematic evidence summarization.

Results

Search Results and General Information

Following systematic screening, a total of 11 articles were included in the final analysis, consisting of 6 clinical guidelines, 2 expert consensus statements, 2 systematic reviews, and 1 clinical decision-making tool. The study selection process is presented in Figure 1, and the general information of the included literature is shown in Table 1.

Figure 1.

Flow diagram of literature search.

Table 1.

Basic Characteristics of the Included Literature.

Included literature	Literature theme	Publication time (year)	Literature resource	Type of evidence
NICE¹¹	Management of acute upper gastrointestinal hemorrhage in adults	2016	NICE	Guideline
Barkun et al¹²	Management of nonvariceal upper gastrointestinal hemorrhage	2019	PubMed	Guideline
Sengupta et al¹³	Management of acute lower gastrointestinal hemorrhage	2023	PubMed	Guideline
Joannes-Boyau et al¹⁴	Intravenous fluid selection in critically ill patients	2021	PubMed	Guideline
Chinese Journal of Internal Medicine¹⁵	Diagnosis and management of acute nonvaricose upper gastrointestinal hemorrhage	2018	Wanfang	Guideline
Colorectal Surgery Group of Chinese Medical Association Endoscopy Branch⁵	Diagnosis and management of lower gastrointestinal hemorrhage	2020	CNKI	Guideline
Xu et al²	Emergency management protocol for acute upper gastrointestinal hemorrhage	2021	CNKI	Expert consensus
Rodrigues⁶	Interventional management of gastrointestinal hemorrhage	2020	PubMed	Expert consensus
Saltzman¹⁶	Acute upper gastrointestinal hemorrhage in adults	2016	UpToDate	Clinical decision
Jairath et al¹⁷	Red blood cell transfusion for upper gastrointestinal hemorrhage	2010	Cochrane Library	Systematic review
Odutayo et al¹⁸	Blood transfusion strategies in gastrointestinal hemorrhage	2017	PubMed	Systematic review

Quality Evaluation Results of Literature

Quality Evaluation Results of Guidelines

Six included guidelines was independently appraised by 2 trained evaluators. Standardized domain scores (percentage) for each guideline are presented in Table 2.

Table 2.

Methodological Evaluation Results of Guidelines.

Guidelines	Scope and purpose	Stakeholder involvement	Rigor of development	Clarity of presentation	Applicability	Editorial independence
NICE¹¹	83.33	80.56	79.17	77.78	79.17	91.67
Barkun et al¹²	86.11	80.56	77.08	72.22	79.17	79.17
Sengupta et al¹³	91.67	77.78	87.50	88.89	75.00	87.50
Joannes-Boyau et al¹⁴	52.78	50.00	73.96	66.67	75.00	87.50
Bo¹⁵	52.78	41.67	47.92	72.22	62.50	95.83
Li⁵	72.22	69.44	55.21	80.56	50.00	87.50

Quality Evaluation Results of Systematic Reviews

The methodological quality of 2 included systematic reviews was assessed: Jairath et al from the Cochrane Library and Odutayo et al from PubMed.^17,18 Both studies demonstrated rigorous methodological design and high overall quality, with all criteria on the JBI critical appraisal tool rated “Yes,” confirming their eligibility for inclusion in this synthesis.

Quality Evaluation Results of Expert Consensus Statements

Two expert consensus statements were included. Methodological quality assessment using the JBI critical appraisal tool for expert consensus statements revealed all criteria rated “Yes.” One clinical decision tool from UpToDate also demonstrated complete methodological rigor with all assessment items rated “Yes.” All included documents exhibited robust study design and high methodological quality, confirming their eligibility for evidence synthesis.

Description and Summary of Evidence

A total of 112 distinct evidence points were initially extracted from the 11 included studies. Through a process of thematic consolidation and grading according to the JBI Evidence Recommendation System, these were synthesized into 22 best-practice recommendations. The final synthesized evidence was categorized into 6 core domains: (1) general principles of fluid resuscitation, (2) comprehensive patient assessment, (3) venous access establishment and fluid administration protocols, (4) transfusion thresholds and strategies, (5) adjunctive pharmacological interventions, and (6) multi-parametric monitoring and resuscitation outcome indicators. Detailed evidence items are presented in Table 3.

Table 3.

Summary of the Best Evidence on Fluid Management for Patients With Gastrointestinal Hemorrhage.

Category	Evidence content	Level of evidence	Level of recommendation
General Principles of Fluid Resuscitation	1. Fluid management strategy: For uncontrolled hemorrhage, implement restrictive fluid resuscitation with permissive hypotension, maintaining systolic blood pressure at 80-90 mm Hg. For controlled bleeding, initiate goal-directed resuscitation based on baseline hemodynamic parameters.^2,6	Level 1	A
	2. Core components of management include volume resuscitation, blood product transfusion, and targeted vasoactive medications when indicated.²	Level 5	B
	3. Endoscopic evaluation should be performed within 24 h of hospitalization following hemodynamic stabilization. High-risk patients with clinical indicators of severe bleeding require urgent endoscopy within 12 h.^6,13,15	Level 2	A
Patient Assessment and Risk Stratification	4. Comprehensive initial assessment: gastrointestinal hemorrhage patients require immediate evaluation of hemodynamic status, with prioritized ICU admission for high-risk cases. Severity assessment includes consciousness, airway, respiratory, and circulatory evaluation, utilizing the Glasgow-Blatchford Score (GBS) for clinical risk stratification.^2,6,15	Level 5	A
Patient Assessment and Risk Stratification	5. Volume status assessment: Evaluate hypovolemia using hemoglobin levels, hemodynamic parameters (pulse, blood pressure), shock index, mental status changes, urine output, urinary sodium levels, and weight trends to guide resuscitation adequacy.^6,16	Level 5	A
Venous Access and Fluid Administration	6. Immediate establishment of adequate venous access: Acute upper gastrointestinal hemorrhage requires at least two large-bore peripheral intravenous catheters (minimum 18-gauge).^2,6	Level 5	A
	7. Central venous access indication: Indicated for hemodynamically unstable patients, those with difficult peripheral access, or requiring massive transfusion protocols.^2,15	Level 5	A
	8. Fluid type selection: Crystalloids (lactated Ringer’s solution or normal saline) are preferred for initial resuscitation; colloids are not recommended. Resuscitation principles include: prioritize crystalloids over colloids, isotonic solutions over hypotonic solutions, rapid initial infusion followed by titrated administration, and potassium replacement guided by urine output.^14 -16	Level 1	A
	9. Special population monitoring: Patients with variceal rupture or comorbid cardiopulmonary/renal disease require close monitoring for fluid overload complications (heart failure, pulmonary edema).²	Level 5	A
	10. Resuscitation rate titration: Guided by hemodynamic response. Failure to improve blood pressure after initial resuscitation warrants increased infusion rate and consideration of vasopressors or emergency interventions. Patients at risk for fluid overload require strict total volume monitoring.¹⁶	Level 1	A
Transfusion Strategies	11. Transfusion triggers: Indicated for hemoglobin < 70 g/L, hematocrit < 25%, systolic blood pressure < 90 mm Hg, heart rate > 110 bpm, or clinical evidence of hemorrhagic shock.^2,5,15	Level 1	A
	12. Restrictive transfusion threshold: Target hemoglobin concentration of ≥7 g/dL (70 g/L) for most gastrointestinal hemorrhage patients.^11,12,15 -18	Level 1	A
	13. Liberal transfusion considerations: Relaxed thresholds (hemoglobin < 90 g/L) may be indicated for elderly patients, those with underlying cardiovascular/cerebrovascular disease, hemodynamically unstable patients, or with persistent massive bleeding.^{5,12,13,15 -18}	Level 1	A
	14. Goal-directed transfusion in active bleeding: Guided by hemodynamic parameters, bleeding rate, estimated blood loss, and hemostatic status rather than isolated hemoglobin measurements.¹⁶	Level 1	A
	15. Platelet transfusion: Active bleeding with a platelet count <50 × 10⁹/L. Pre-procedural prophylaxis to achieve a platelet count ≥50 × 10⁹/L before endoscopic intervention. Empiric transfusion after 5-6 units of packed red blood cells in the context of ongoing hemorrhage or a planned invasive procedure.^2,11	Level 5	B
	16. Fresh frozen plasma for variceal bleeding: Administer for fibrinogen <1 g/L in cirrhotic patients with active variceal hemorrhage.²	Level 5	B
Pharmacological Interventions	17. Vasoactive agents: Under the premise of active fluid replacement, vasoactive drugs (eg, dopamine or norepinephrine) may be considered to maintain organ perfusion in patients with hemorrhagic shock who exhibit severe and persistent hypotension refractory to initial fluid resuscitation.^2,15	Level 5	B
Pharmacological Interventions	18. Proton pump inhibitors for high-risk ulcers: Intravenous bolus followed by continuous infusion recommended for patients with high-risk ulcer bleeding post-endoscopic therapy to reduce rebleeding and mortality.¹²	Level 1	A
Monitoring and Outcome Evaluation	19. Comprehensive monitoring parameters: Continuous assessment of consciousness, vital signs, extremity perfusion, urine output, central venous pressure (CVP), complete blood count, coagulation profile, blood urea nitrogen, lactate, arterial blood gases, and electrolytes to evaluate tissue perfusion and resuscitation efficacy.^2,15	Level 5	B
	20. Invasive monitoring for massive hemorrhage: Consider invasive hemodynamic monitoring when available, with resuscitation guided by clinical, laboratory, and ultrasound findings. Monitor for complications including hypothermia, acidosis, coagulopathy, and exacerbation of comorbidities.²	Level 5	A
	21. Signs of active hemorrhage: (i) Increased frequency of hematemesis/melena with bright red vomitus or bloody stools and hyperactive bowel sounds; (ii) Fresh blood in gastric aspirate; (iii) Persistent or recurrent hypotension despite resuscitation; (iv) Progressive decrease in hemoglobin/hematocrit with reticulocytosis; (v) Elevated or rising blood urea nitrogen despite adequate fluid resuscitation.^2,15	Level 5	A
	22. Resuscitation endpoints: Achievement of baseline blood pressure, heart rate <100 bpm, urine output >0.5 mL/(kg·h), euvolemic status, and normalized lactate levels indicate adequate resuscitation.^2,6	Level 5	B

Discussion

In this study, we conducted a comprehensive literature review to ascertain evidence related to fluid resuscitation in patients with GIH. The review uncovered both a robust consensus and notable gaps in the evidence. These findings offer a structured, evidence-based framework to inform nursing practice, highlighting the importance of risk-stratified, restrictive resuscitation strategies.

Implementing Restrictive Fluid Resuscitation in GIH: Targets and Procedures

Several recommendations are supported by strong, consistent evidence from high-quality randomized controlled trials and systematic reviews. Evidence 1 to 3 indicates the fundamental principles of fluid resuscitation in GIH, highlighting its prognostic importance and delineating essential resuscitation components. Effective fluid resuscitation is pivotal in the management of GIH, as it directly influences patient outcomes and poses substantial clinical challenges. Current research emphasizes the prioritization of fluid resuscitation for hemodynamically unstable patients with non-variceal upper gastrointestinal hemorrhage, with the primary objectives being the restoration of end-organ perfusion and tissue oxygenation, alongside achieving hemostasis.¹² Restrictive fluid resuscitation, also known as permissive hypotension, involves maintaining controlled blood pressure levels during active hemorrhagic shock until definitive hemostasis is attained.¹⁹ Global evidence consistently endorses restrictive fluid resuscitation as the preferred approach, with clinical practice guidelines advocating for the maintenance of systolic blood pressure between 80 and 90 mmHg during active bleeding.²⁰ Expert consensus guidelines, which are mainly based on expert consensus as the current guidelines suggest, emphasize 3 main components: volume resuscitation, blood transfusion, and vasoactive drug administration.² Endoscopic intervention plays a vital role in managing active bleeding in GIH patients, particularly for patients with lower gastrointestinal hemorrhage, who should undergo colonoscopy following successful resuscitation to identify the bleeding source.⁶ The imperative to perform endoscopy within 24 h, and within 12 h for high-risk patients, is a strong, consistent recommendation (Grade A) across nearly all included guidelines, bolstered by robust observational data.^21,22

Implementing Risk Stratification in GIH

Other important aspects of care are guided by lower-level evidence (Level 3-5), primarily stemming from expert consensus, observational studies, and pathophysiological extrapolation. Evidence 4 to 5 delineates the assessment criteria for patients with GIH, facilitating an accurate evaluation of the efficacy of fluid resuscitation. Considering the diverse etiologies of GIH, it is imperative to implement patient-specific management strategies tailored to the clinical presentation. An international consensus of multidisciplinary experts advocates for the risk stratification of GIH patients into high-risk and low-risk categories. The early use of low-cost, validated scoring systems like the Glasgow-Blatchford Score (GBS) is especially critical in resource-limited settings, as it enables rapid risk stratification and prioritization of scarce resources (eg, ICU beds, blood products, urgent endoscopy) without the need for advanced technology. This stratification is intended to inform clinical decision-making concerning the timing of endoscopy, discharge criteria, and the intensity of care required.⁶ The primary assessment parameters include hemodynamic stability, hemoglobin levels, and the overall clinical condition of the patient.²³

Optimizing Vascular Access and Fluid Resuscitation in GIH

Evidence 6-11 synthesizes recommendations for the establishment of venous access and fluid resuscitation, providing practical guidance for clinical application. Current literature reveals a strong consensus on the requirements for venous access: patients experiencing acute upper gastrointestinal hemorrhage should have at least 2 peripheral intravenous access sites, with a minimum gauge of 18.^2,6 However, specific guidelines regarding the choice of fluid type (crystalloid vs colloid), resuscitation rate, and strategy (liberal vs restrictive) remain inadequately defined.¹² Existing evidence indicates that for patients with active GIH, this recommendation mainly stems from observational data. Intravenous fluid resuscitation may follow protocols established for hemorrhagic shock patients, preferably with normal saline or lactated Ringer’s solution. The resuscitation rate should be adjusted based on the patient’s hemodynamic response, necessitating careful monitoring in individuals with variceal bleeding or comorbid cardiopulmonary or renal conditions to minimize the risk of fluid overload.^14,16 Further high-quality prospective studies are needed to examine the impact of different fluid types and resuscitation rates on clinical outcomes. However, it is important to note that a lower level of evidence does not invariably preclude a strong grade of recommendation. In this review, several recommendations (eg, establishing large-bore intravenous access) are based primarily on expert consensus (Level 5) yet are assigned a strong recommendation (Grade A). This reflects their critical role in patient safety and the universal acceptance of their clinical necessity, despite the ethical and practical constraints of conducting randomized controlled trials in these scenarios.

Transfusion Strategies for Restrictive Fluid Resuscitation in GIH

A clear illustration of the difference between strong evidence and strong consensus can be found in transfusion strategies (Evidence 12-16). Guidelines consistently advocate for maintaining hemoglobin levels below 70 g/L as a critical criterion for transfusion.^2,5,6,24 Current evidence reveals partial heterogeneity in specific transfusion strategies, which include: (1) the absence of standardized upper transfusion thresholds; and (2) ambiguous transfusion thresholds for specific patient subgroups. Notably, the 2019 International Consensus Group guidelines recommend adhering to restrictive transfusion thresholds (Hb 7-8 g/dL) in patients with acutely hemodynamically stable GIH.¹² The British Society of Gastroenterology guidelines propose a hemoglobin target range of 70-90 g/L, with an 80 g/L trigger threshold and a 100 g/L target for patients without a cardiovascular history.²⁴ Furthermore, multidisciplinary expert consensus advocates for maintaining hemoglobin levels between 7-9 g/dL.⁶ The consensus suggests maintaining a hemoglobin (Hb) target range of 70-90 g/L, with more lenient criteria for elderly patients, individuals with underlying cardiovascular or cerebrovascular conditions, those who are hemodynamically unstable, or patients experiencing persistent massive bleeding, permitting transfusion when Hb levels drop below 90 g/L.² Strong evidence from randomized trials supports that the goal of blood transfusion for patients with GIH is to maintain the hemoglobin concentration at a level of ≥7 g/dL (70 g/L) rather than a higher level. For patients with comorbidities, the target hemoglobin level can be adjusted based on the clinician’s judgment.²⁵ Guidelines concerning lower gastrointestinal hemorrhage stress the importance of maintaining Hb levels above 90 g/L in severe cases that involve critical complications or when endoscopic intervention is not feasible.¹⁵ In addition to red blood cell management, research indicates that the supplementation of platelets and fibrinogen should be prioritized in patients with GIH. Evidence 17-18 summarize pharmacological treatment regimens for GIH patients. The regimen of intravenous loading followed by continuous infusion for 72 h in high-risk ulcer patients is a Grade A recommendation based on high-quality meta-analyses of RCTs.

The Essential Role of Nursing in Monitoring and Evaluating Fluid Resuscitation

Evidence 19 to 22 summarize monitoring and resuscitation efficacy evaluation indicators during fluid resuscitation. The nursing staff play an essential role in managing fluid therapy for patients with GIH.^26,27 Continuous monitoring of vital signs, consciousness levels, extremity temperature, urine output, central venous pressure, complete blood count, arterial blood gases, and electrolyte levels is crucial to ensuring adequate or improved end-organ perfusion following resuscitation, which is vital for patient prognosis.^2,16 Additionally, GIH patients should be monitored for signs of active bleeding. When advanced monitoring equipment is unavailable, clinicians must rely on fundamental, consensus-based parameters such as vital signs, mental status, and urine output, as outlined in this evidence. Currently, there is insufficient evidence to establish evaluation criteria for the effectiveness of fluid resuscitation. These practices are predominantly informed by expert consensus (Level 5 evidence), underscoring a substantial area for future research.

Implications for Nursing Practice and Health Policy

To facilitate the translation of evidence into clinical practice, we have developed an “Evidence-to-Practice Mapping Table” (Table 4). This table delineates specific nursing interventions derived from recommendations, tailored for application across various clinical environments.

Table 4.

Evidence-to-Practice Mapping: Nursing Implications of Fluid Resuscitation Guidelines in Acute Gastrointestinal Hemorrhage.

Evidence domain	Key evidence statement	Nursing actions/practice implications
General principles	Restrictive fluid resuscitation with controlled hypotension for uncontrolled bleeding; Aggressive resuscitation post-hemostasis.	• Monitor BP continuously; avoid over-resuscitation in active bleeders. • Educate team on risks of early normotensive goals.
General principles	Early endoscopy (<24 h, <12 h if high-risk) after hemodynamic stabilization.	• Assess readiness for endoscopy (vital signs, Hb, consent). • Prepare patient and equipment. Advocate for urgent scheduling in high-risk cases (eg, GBS > 12).
Patient assessment	Rapid assessment of airway, breathing, circulation, consciousness; use Glasgow-Blatchford Score (GBS) for risk stratification.	• Perform immediate ABC assessment. • Initiate GBS calculation using admission labs/vitals. • Escalate care promptly for high GBS; prepare for ICU transfer.
Patient assessment	Evaluate volume deficit via HR, BP, shock index, mental status, urine output, and lab trends.	• Track serial vitals and calculate shock index (HR/SBP). • Monitor hourly urine output. • Report subtle changes (eg, rising lactate, falling Hct) early.
IV Access & Fluid Administration	Establish ≥2 large-bore IV lines (≥18G); consider central access in unstable patients.	• Insert dual peripheral IVs rapidly. • Anticipate need for CVC placement in shock; assist with procedure setup and monitoring.
	Use crystalloids first (eg, lactated Ringer’s); avoid colloids. Follow “salts before sugars, fast before slow” principle.	• Administer isotonic fluids as first-line. Avoid dextrose-containing solutions unless indicated. • Adjust infusion rates based on response, not protocol alone.
	Monitor for fluid overload in variceal bleeders or cardiac/renal comorbidities.	• Auscultate lungs frequently; watch for dyspnea, crackles. • Limit fluid input in cirrhotic patients unless hypovolemic shock present.
Blood transfusion	Restrictive strategy: target Hb ≥ 7 g/dL; relax threshold to <9 g/dL in elderly or cardiopulmonary disease.	• Transfuse only when Hb < 7 g/dL (or <9 g/dL in select patients). • Monitor for transfusion reactions.
	Guide transfusion by hemodynamics and clinical picture, not Hb alone in active bleeders.	• Prioritize pulse, BP, mentation, and bleeding signs over lab values during resuscitation. • Communicate clinical deterioration even if Hb is stable.
	Transfuse platelets if count <50 × 10⁹/L; give FFP if fibrinogen < 1 g/L in variceal bleeders.	• Check coagulation panel and platelet count routinely. • Prepare and administer blood products per protocol. • Monitor for TRALI/TACO.
Pharmacological support	Use vasoactive drugs (eg, norepinephrine) only after adequate fluid resuscitation.	• Monitor vasopressor infusions. • Titrate per protocol; assess perfusion (lactate, skin temp, UOP).
Pharmacological support	Administer IV PPI post-endoscopic therapy in high-risk ulcers.	• Start PPI infusion immediately after successful endoscopic hemostasis. Ensure uninterrupted infusion for 72 h.
Monitoring & outcomes	Continuously monitor vitals, CVP, lactate, BUN, CBC, ABG, electrolytes.	• Document trends in perfusion markers. Alert provider to persistent ↑BUN (suggests ongoing bleed) or ↑lactate (tissue hypoperfusion).
Monitoring & outcomes	Signs of ongoing bleeding: ↑melena/hematemesis, gastric aspirate with blood, falling Hb, ↑reticulocytes, poor response to fluids.	• Monitor stool characteristics. Report any sign of rebleeding immediately.

From a nursing perspective, essential recommendations for clinical practice encompass the following: (1) the systematic application of validated scoring systems, such as the GBS, for efficient triage and risk stratification; (2) the adoption of restrictive transfusion strategies, such as maintaining a hemoglobin threshold below 70 g/L, to optimize resource utilization under nursing oversight; and (3) the diligent monitoring of vital signs and urine output to inform fluid management, particularly in resource-constrained environments.

To implement these recommendations on a global scale, particularly in resource-limited settings, nursing policy and training should concentrate on the aforementioned high-impact and feasible actions. This strategy is consistent with the principles of equitable, evidence-based care .²⁸ Future implementation research should emphasize the creation of nurse-led protocols, competency-based training, and streamlined decision-support tools to enable nurses worldwide to effectively apply this evidence.

Limitations and Future Research Directions

Although this summary integrates critical evidence, several limitations must be acknowledged. The recommendations primarily stem from observational studies and expert consensus, with a notable paucity of high-quality randomized controlled trials comparing liberal versus restrictive strategies within specific GIH subgroups. This limitation may weaken the robustness of the conclusions, especially concerning patients with concurrent cardiac or renal conditions. Furthermore, the evidence base is predominantly derived from high-resource settings, which may limit its applicability in regions with constrained monitoring capabilities or delayed access to endoscopic procedures. Future research should prioritize pragmatic trials that assess patient-centered outcomes, such as the time to achieve hemodynamic stability, the incidence of complications, and long-term functional recovery. Additionally, there is a pressing need to develop and validate risk-stratified fluid administration protocols, particularly for older adults or individuals with complex comorbidities. Finally, integrating novel non-invasive monitoring technologies into fluid resuscitation algorithms may represent a promising direction for enhancing precision in clinical practice.

Conclusion

This study synthesizes the best available evidence regarding fluid resuscitation in GIH patients. It provides nurses with clear, actionable interventions—from risk stratification and restrictive fluid administration to vigilant monitoring and complication management—directly supporting clinical decision-making at the bedside. We recommend that institutions adapt these recommendations to their local context to ensure feasibility. This approach will facilitate the development of customized fluid resuscitation protocols tailored to local medical institutions, thereby enhancing clinical nursing quality. Future research must address the critical evidence gaps, particularly through trials in specific patient subgroups and implementation studies in diverse resource environments.

Supplemental Material

sj-docx-1-inq-10.1177_00469580261435485 – Supplemental material for Evidence-Based Fluid Resuscitation Protocol for Patients With Acute Gastrointestinal Hemorrhage: An Evidence Summary

Supplemental material, sj-docx-1-inq-10.1177_00469580261435485 for Evidence-Based Fluid Resuscitation Protocol for Patients With Acute Gastrointestinal Hemorrhage: An Evidence Summary by Yushuang Chen, Ling Dai, Qiaozhen Guo and Siyu Yang in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Footnotes

Acknowledgements

The authors sincerely acknowledge all individuals who contributed to the conduct of this study.

ORCID iDs

Yushuang Chen

Ling Dai

Ethical Considerations

As this study constitutes a systematic synthesis and critical appraisal of previously published literature (an evidence summary), it did not involve direct human subject interaction or collection of original personal data. Consequently, ethical approval was not required in accordance with local institutional guidelines. The evidence retrieval and synthesis process adhered to established principles of academic integrity.

Author Contributions

YSC conceptualized and designed the study. SYY and LD performed data analysis. YSC drafted the initial manuscript. SYY and QZG critically revised the manuscript for intellectual content. All authors read and approved the final manuscript.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Tongji Hospital Research Fund Project, Tongji Medical College, Huazhong University of Science and Technology, the project was a study on self-management intervention strategies for patients with acute pancreatitis complicated by metabolic syndrome based on latent class analysis (2025D39).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request.*

Supplemental Material

Supplemental material for this article is available online.

References

Orpen-Palmer

Stanley

AJ.

Update on the management of upper gastrointestinal bleeding. BMJ Med. 2022;1(1):e000202. doi:10.1136/bmjmed-2022-000202

Dai

Yin

Acute upper gastrointestinal bleeding: expert consensus on emergency diagnosis and treatment procedures. Chin J Crit Care Med. 2021;41(1):1-10.

Thiebaud

Wassermann

de Caluwe

, et al. Assessment of prognostic scores for emergency department patients with upper gastrointestinal bleeding. Ann Emerg Med. 2025;85(1): 31-42. doi:10.1016/j.annemergmed.2024.06.024

Gralnek

Stanley

Morris

, et al. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021. Endoscopy. 2021;53(3):300-332. doi:10.1055/a-1369-5274

Colorectal Surgery Group of Chinese Medical Association Endoscopy Branch, Colorectal Surgery Group of China Medical Doctor Association Gastroenterology Branch, National Clinical Medical Research Center for Digestive System Diseases. Guidelines for the diagnosis and treatment of lower gastrointestinal bleeding (2020). Chin J Dig Endosc. 2020;37(10):685-695.

Rodrigues

Carrilho

Almeida

, et al. Interventional algorithm in gastrointestinal bleeding—an expert consensus multimodal approach based on a multidisciplinary team. Clin Appl Thromb Hemost. 2020;26:1076029620931943. doi:10.1177/1076029620931943

Zhu

Xing

, et al. Structure of different types of evidence-based questions. J Nurs Educ. 2017;32(21):1991-1994.

Dicenso

Bayley

Haynes

RB.

Accessing pre-appraised evidence: fine-tuning the 5S model into a 6S model. Evid Based Nurs. 2009;12(4):99-101. doi:10.1136/ebn.12.4.99-b

AGREE Next Steps Consortium. AGREE II: advancing guideline development, reporting and evaluation in healthcare. 2017. Accessed June 15, 2024. https://www.agreetrust.org

10.

Joanna Briggs Institute. The Joanna Briggs Institute critical appraisal tools for use in systematic reviews: checklist for randomized controlled trials. 2016. Accessed June 7, 2024. https://jbi.global/critical-appraisal-tools

11.

National Institute for Health and Care Excellence (NICE). Acute upper gastrointestinal bleeding in over 16s: management. 2019. Accessed June 15, 2024. https://www.nice.org.uk/guidance/cg141

12.

Barkun

Almadi

Kuipers

, et al. Management of nonvariceal upper gastrointestinal bleeding: guideline recommendations from the International Consensus Group. Ann Intern Med. 2019;171(11):805-822. doi:10.7326/M19-1795

13.

Sengupta

Feuerstein

Jairath

, et al. Management of patients with acute lower gastrointestinal bleeding: an updated ACG guideline. Am J Gastroenterol. 2023;118(2):208-231. doi:10.14309/ajg.0000000000002130

14.

Joannes-Boyau

Le Conte

Bonnet

, et al. Guidelines for the choice of intravenous fluids for vascular filling in critically ill patients, 2021. Anaesth Crit Care Pain Med. 2022;41(3): 101058. doi:10.1016/j.accpm.2022.101058

15.

Chinese Journal of Internal Medicine, Chinese Medical Journal, Chinese Journal of Digestive Medicine, et al. Guidelines for the diagnosis and treatment of acute non-varicose upper gastrointestinal bleeding (Hangzhou, 2018). Chin J Intern Med. 2019;58(3):173-180. doi:10.3760/cma.j.issn.0578-1426.2019.03.005

16.

Saltzman

JR.

Acute upper gastrointestinal bleeding in adults. UpToDate. 2024. Accessed June 2024. https://www.uptodate.com/contents/acute-upper-gastrointestinal-bleeding-in-adults

17.

Jairath

Hearnshaw

Brunskill

, et al. Red cell transfusion for the management of upper gastrointestinal haemorrhage. Cochrane Database Syst Rev. 2010;(9):CD006613. doi:10.1002/14651858.CD006613.pub3

18.

Odutayo

Desborough

Trivella

, et al. Restrictive versus liberal blood transfusion for gastrointestinal bleeding: a systematic review and meta-analysis of randomised controlled trials. Lancet Gastroenterol Hepatol. 2017;2(5):354-360. doi:10.1016/S2468-1253(17)30054-7

19.

Zhou

Song

, et al. Application of restrictive fluid resuscitation in emergency traumatic hemorrhagic shock and impact on blood gas indicators. Ann Vasc Surg. 2026;122:352-357. doi:10.1016/j.avsg.2025.06.009

20.

Gazmuri

Whitehouse

Whittinghill

Baetiong

Shah

Radhakrishnan

Early and sustained vasopressin infusion augments the hemodynamic efficacy of restrictive fluid resuscitation and improves survival in a liver laceration model of hemorrhagic shock. J Trauma Acute Care Surg. 2017;82(2): 317-327. doi:10.1097/TA.0000000000001318

21.

Garcia-Tsao

Abraldes

Berzigotti

Bosch

Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the Study of Liver Diseases. Hepatology. 2017; 65(1):310-335. doi:10.1002/hep.28906

22.

Chen

Hou

, et al. Delayed endoscopy increases re-bleeding and mortality in patients with hematemesis and active esophageal variceal bleeding: a cohort study. J Hepatol. 2012;57(6):1207-1213. doi:10.1016/j.jhep.2012.07.038

23.

Laine

Jensen

DM.

Management of patients with ulcer bleeding. Am J Gastroenterol. 2012;107(3):345-360. doi:10.1038/ajg.2011.480

24.

Oakland

Chadwick

East

, et al. Diagnosis and management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology. Gut. 2019;68(5):776-789. doi:10.1136/gutjnl-2018-317807

25.

Villanueva

Colomo

Bosch

, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013;368(1):11-21. doi:10.1056/NEJMoa1211801

26.

Kabil

Hatcher

Alexandrou

McNally

Emergency nurses’ experiences of the implementation of early goal directed fluid resuscitation therapy in the management of sepsis: a qualitative study. Australas Emerg Care. 2021;24(1):67-72. doi:10.1016/j.auec.2020.07.002

27.

Ladzinski

Thind

Siuba

MT.

Rational fluid resuscitation in sepsis for the hospitalist: a narrative review. Mayo Clin Proc. 2021;96(9):2464-2473. doi:10.1016/j.mayocp.2021.05.020

28.

Dinesen

Benson

Managing acute upper gastrointestinal bleeding in the acute assessment unit. Clin Med. 2012;12(6): 589-593. doi:10.7861/clinmedicine.12-6-589