BCCCP: Portal Hypertension Critical Care Questions

Question 1 of 10

1. Question

A 62-year-old man with alcohol-related cirrhosis was admitted 3 days ago for an acute variceal hemorrhage that was successfully controlled with endoscopic band ligation. He has been hemodynamically stable off vasopressors for 24 hours, is tolerating oral intake, and remains on a continuous octreotide infusion. His hemoglobin is stable at 8.5 g/dL. Which of the following is the most appropriate next step in his medication regimen?

Discontinue the octreotide infusion and initiate oral propranolol.
Continue the octreotide infusion for an additional 48 hours and then initiate oral propranolol.
Initiate oral propranolol immediately while continuing the octreotide infusion for 24 additional hours.
Discontinue the octreotide infusion and defer initiation of propranolol until hemoglobin increases to >10 g/dL.

Question 2 of 10

2. Question

A 62-year-old man with alcoholic cirrhosis is in the intensive care unit following massive hematemesis. He was intubated for airway protection and has a central venous catheter in place; he was extubated this morning and is now alert, following commands, and tolerating sips of water. He has received continuous octreotide infusion at 50 mcg/hour for 72 hours and completed a 5-day course of ceftriaxone prophylaxis this morning. Endoscopy 48 hours ago confirmed actively bleeding esophageal varices, which were successfully banded. His vital signs are stable (BP 110/70 mmHg, HR 78 bpm, SpO₂ 98% on room air). Labs show hemoglobin 9.2 g/dL and INR 1.8. Which of the following is the most appropriate next step in managing his therapy?

Transition from octreotide infusion to oral propranolol for secondary prophylaxis of variceal bleeding.
Continue octreotide infusion to a total of 5 days before changing therapy.
Initiate pantoprazole for stress ulcer prophylaxis.
Administer fresh frozen plasma to correct coagulopathy before adjusting vasoactive therapy.

Question 3 of 10

3. Question

A 62-year-old man with alcoholic cirrhosis was admitted 3 days ago for acute esophageal variceal hemorrhage. He underwent urgent endoscopic band ligation on admission, and continuous infusions of octreotide and pantoprazole were initiated. He has since been extubated and is hemodynamically stable (blood pressure 115/70 mmHg, heart rate 75 bpm) without vasopressor support. His hemoglobin is stable at 9.2 g/dL, INR is 1.6, platelets are 85,000/mcL, and he is alert, oriented, and tolerating an oral diet. Which of the following pharmacologic management plans is most appropriate at this time?

Discontinue octreotide infusion, initiate oral nonselective beta-blocker therapy, and discontinue pantoprazole.
Continue octreotide infusion until Day 5, then initiate oral nonselective beta-blocker therapy.
Initiate oral nonselective beta-blocker therapy, continue octreotide infusion, and continue pantoprazole.
Administer fresh frozen plasma for coagulopathy, then initiate oral nonselective beta-blocker therapy.

Question 4 of 10

4. Question

A 62-year-old man with alcohol-related cirrhosis was admitted to the ICU 4 days ago for acute variceal hemorrhage. He remains on a continuous octreotide infusion via a central venous catheter and continuous cardiac monitoring. He is hemodynamically stable (BP 105/65 mmHg, HR 72 bpm), alert, oriented, and tolerating an oral diet. Endoscopic variceal ligation (EVL) successfully controlled bleeding on admission day 1, with no further bleeding. The current plan is to continue octreotide for 7 days. Which adjustment to his management is most appropriate at this time?

Continue octreotide infusion through day 7 as planned, then initiate oral propranolol.
Discontinue octreotide today (day 4) but delay starting oral propranolol until after hospital discharge.
Discontinue octreotide on day 5 and initiate oral propranolol concurrently for secondary prophylaxis.
Continue octreotide infusion until completion of scheduled repeat EVL sessions (approximately 2–3 weeks), then start oral propranolol.

Question 5 of 10

5. Question

A 62-year-old man with cirrhosis due to alcohol use disorder was admitted to the critical care unit 72 hours ago for acute variceal hemorrhage. He required intubation for airway protection and a continuous norepinephrine infusion through a central line for hemodynamic support. He received emergent endoscopic variceal ligation (EVL), followed by a continuous octreotide infusion at 50 mcg/hour and intravenous ceftriaxone for antibacterial prophylaxis. Over the past 24 hours, his hemodynamics have stabilized, he has been successfully extubated, and his mentation has returned to baseline. There is no evidence of rebleeding. His blood pressure is currently 118/72 mmHg, and his heart rate is 88 bpm. Given the patient’s current clinical status and the duration of therapy, which of the following is the MOST appropriate next step in de-escalating his pharmacotherapy?

Discontinue octreotide and initiate oral carvedilol.
Continue octreotide infusion until day 5 and then discontinue.
Discontinue intravenous ceftriaxone and continue octreotide.
Initiate oral carvedilol while continuing octreotide infusion.

Question 6 of 10

6. Question

A 62-year-old man with alcohol-related cirrhosis underwent endoscopic variceal ligation for an acute esophageal variceal hemorrhage 72 hours ago. He has been stable since, with a hemoglobin of 8.2 g/dL and an INR of 1.6. He is on a continuous octreotide infusion. Which of the following pharmacotherapy adjustments is most appropriate at this time?

Initiate oral propranolol.
Continue octreotide infusion for an additional 48 hours.
Initiate pantoprazole 40 mg IV daily.
Administer 2 units of fresh frozen plasma.

Question 7 of 10

7. Question

A 60-year-old man with known cirrhosis was admitted for acute esophageal variceal hemorrhage. On hospital day 3 he is hemodynamically stable, has had no rebleeding for 24 hours, and is tolerating an oral diet. He has been receiving intravenous octreotide 50 mcg/hour and ceftriaxone 1 g daily. Which of the following is the most appropriate next step in his pharmacotherapy?

Discontinue intravenous octreotide and ceftriaxone now, and initiate oral propranolol for secondary prophylaxis.
Continue octreotide infusion until day 5 before starting oral propranolol, and continue ceftriaxone for a total of 7 days.
Stop octreotide now, wait 24 hours, then start oral propranolol, and continue ceftriaxone for a total of 7 days.
Discontinue octreotide and ceftriaxone now, and initiate oral carvedilol for secondary prophylaxis.

Question 8 of 10

8. Question

A 62-year-old man with cirrhosis is admitted to the ICU following an acute esophageal variceal hemorrhage. He was started on a pantoprazole infusion on admission and is receiving octreotide 50 mcg/hour via a central line and IV ceftriaxone. Twenty-four hours ago, endoscopic variceal ligation successfully controlled his bleeding. He is intubated on assist-control ventilation, NPO, and his vital signs are stable. His hemoglobin is 7.2 g/dL. Which of the following is the most appropriate pharmacotherapy plan for his ongoing management?

Continue the octreotide infusion for a total of 2–5 days, discontinue the pantoprazole infusion, and initiate oral propranolol once octreotide is stopped and the patient can tolerate oral intake.
Discontinue the octreotide infusion within the next 24 hours, initiate oral nadolol immediately despite NPO status, and administer intravenous vitamin K to correct the INR.
Continue the octreotide infusion for 7 days, maintain the pantoprazole infusion, and transfuse packed red blood cells to maintain hemoglobin above 9 g/dL.
Initiate intravenous carvedilol for portal pressure control, continue the octreotide infusion for 7 days, and transfuse platelets for a count below 100,000/mm³.

Question 9 of 10

9. Question

A 62-year-old male with alcohol-related cirrhosis is stable three days after endoscopic variceal ligation for an acute variceal hemorrhage. He remains on a continuous octreotide infusion (50 mcg/hour) and intravenous pantoprazole (40 mg daily). His vital signs are stable; hemoglobin is 7.8 g/dL, INR is 1.6, and platelets are 120,000/mm³. He is alert and tolerating oral sips. Considering his current status, what is the most appropriate next pharmacologic step?

Discontinue pantoprazole.
Continue the octreotide infusion for 2 more days to complete a 5-day course.
Administer fresh frozen plasma to correct the INR.
Transfuse packed red blood cells to raise hemoglobin to 9 g/dL.

Question 10 of 10

10. Question

A 62-year-old man with alcohol‐related cirrhosis was admitted to the ICU for acute esophageal variceal hemorrhage. He was intubated on arrival and started on an octreotide infusion (50 mcg/hour) plus a PPI infusion. Endoscopic variceal ligation achieved hemostasis. After 48 hours, he is hemodynamically stable (BP 110/70 mmHg, HR 88 bpm), has been extubated, and is tolerating a soft diet and oral medications. His hemoglobin is stable at 8.2 g/dL, and he is being transferred to the telemetry unit. Which of the following is the most appropriate medication management plan at this time?

Initiate an oral nonselective beta-blocker immediately, discontinue the octreotide infusion immediately, and discontinue the PPI infusion.
Continue the octreotide infusion for 3 more days, then initiate an oral nonselective beta-blocker and discontinue the PPI infusion.
Initiate an oral nonselective beta-blocker immediately, continue the octreotide infusion for an additional 24–48 hours, then discontinue the PPI infusion.
Discontinue the octreotide infusion immediately, initiate an oral nonselective beta-blocker 48 hours later, and discontinue the PPI infusion.

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