1. Introduction to Recovery and Transition

Safe recovery from acute upper GI bleeding (UGIB) hinges on protocol-driven de-escalation of intensive therapies, effective multidisciplinary handoffs, and proactive planning that spans the continuum of care from the intensive care unit (ICU) to outpatient follow-up. The primary aim is to ensure a smooth and safe transition while minimizing the risk of rebleeding and other complications.

A. Goals of Recovery and Transition

• Confirm sustained hemostasis and resolution of active bleeding.
• Stabilize hemodynamic parameters and correct coagulopathies.
• Optimize pharmacotherapy, including appropriate conversion from intravenous (IV) to enteral routes.
• Initiate early rehabilitation and nutritional support.
• Develop a comprehensive discharge plan with clear follow-up instructions.

B. Typical Timeline and Care Settings

1. Intensive Care Unit (ICU): Focus on acute stabilization, endoscopic intervention, intensive monitoring, and initiation of therapies to prevent rebleeding.
2. Step-Down Unit / High Dependency Unit: Continue monitoring, begin weaning from intensive support (e.g., vasopressors), and assess readiness for oral intake.
3. General Medical Ward: Focus on rehabilitation, conversion to oral medications, patient education, and final preparations for discharge.
4. Outpatient Setting: Long-term surveillance, follow-up with gastroenterology and primary care, management of underlying conditions (e.g., portal hypertension, H. pylori eradication), and cardiac follow-up if relevant.

2. Protocol for Weaning Intensive Therapies

A systematic approach to weaning intensive therapies is crucial to prevent rebound instability and ensure the patient is truly ready for de-escalation of care.

A. De-escalation Criteria

Weaning of intensive therapies should generally commence when vital signs and laboratory parameters are stable, and there has been no clinical evidence of ongoing or recurrent bleeding for at least 24 to 48 hours.

• Hemodynamics: Mean arterial pressure (MAP) consistently ≥65 mmHg without an increase in vasopressor dose, heart rate <100 beats per minute, and no significant orthostatic hypotension.
• Hemoglobin: Stable hemoglobin level, typically ≥7 g/dL, in line with a restrictive transfusion strategy.
• Coagulation: International Normalized Ratio (INR) ≤1.5 (or within patient-specific therapeutic targets if on anticoagulation for other indications), and platelet count ≥50,000/µL.
• Clinical Signs: No hematemesis, melena, or hematochezia. Stable blood urea nitrogen (BUN) to creatinine ratio, suggesting no new significant upper GI blood digestion.

B. Stepwise Tapering of Vasopressors and Sedatives

Gradual reduction of vasoactive medications and sedatives is essential to avoid hemodynamic instability or withdrawal syndromes like delirium.

• Vasopressors: Taper agents like norepinephrine slowly, typically in decrements of 0.01–0.02 µg/kg/min, while closely monitoring MAP, urine output, and lactate levels for any signs of recurrent hypoperfusion.
• Sedation: Implement daily sedation interruptions (“sedation vacations”) to assess neurological status and facilitate earlier extubation. Target light sedation levels (e.g., Richmond Agitation-Sedation Scale [RASS] 0 to –2). Prefer short-acting agents like propofol or dexmedetomidine over benzodiazepines, especially in older adults, to reduce delirium risk.
• Monitoring: Frequent vital signs (e.g., every 15–60 minutes during active weaning), regular assessment using validated sedation scales, and delirium screening (e.g., Confusion Assessment Method for the ICU [CAM-ICU]).

C. Transition Off Continuous Proton Pump Inhibitor (PPI) Infusions

For patients with high-risk endoscopic stigmata of bleeding (e.g., active bleeding, non-bleeding visible vessel) who received an initial 72-hour continuous IV PPI infusion post-endoscopy, conversion to intermittent IV or oral PPI therapy can be considered once stability is achieved.

• Criteria for Conversion: No evidence of rebleeding for at least 24-48 hours after the 72-hour infusion, stable vital signs, and improving laboratory parameters (e.g., stable hemoglobin).
• Conversion Options:
  • Intravenous: Pantoprazole 40 mg IV every 12 hours.
  • Oral: Pantoprazole 40 mg orally twice daily (or equivalent dose of another PPI). Ensure patient can tolerate oral intake.
• Monitoring: Continue to monitor hemoglobin levels and clinical signs of GI bleeding. While not routinely performed, if intragastric pH monitoring is available, a target pH >6 is often aimed for optimal acid suppression.

3. Pharmacotherapy Conversion from IV to Enteral

Once the patient is hemodynamically stable, tolerating oral intake or has functional enteral access, and there is no evidence of ongoing bleeding, medications should be converted from IV to enteral routes.

A. Assessment of Enteral Access and GI Function

Before switching medication routes, confirm the readiness and functionality of the gastrointestinal tract.

• Enteral Tube Placement (if applicable): Verify correct placement of nasogastric, nasojejunal, or gastrostomy tubes (e.g., via X-ray confirmation, pH testing of aspirate). Ensure tube patency.
• GI Function: Assess for signs of intolerance such as high gastric residual volumes (e.g., >250 mL if on tube feeds), nausea, vomiting, or significant abdominal distension. Presence of bowel sounds is a positive sign.
• Nutritional Support: Early initiation of enteral nutrition is generally recommended in critically ill patients to maintain gut mucosal integrity and may reduce the need for stress ulcer prophylaxis in some populations, though this is distinct from therapeutic PPI use for UGIB.

B. Conversion Protocols for Key Agents

Standardized protocols for converting key medications from IV to enteral administration can help ensure dose equivalence and appropriate administration techniques.

C. Monitoring and Adjustments Post-Conversion

After converting to enteral medications, continue to monitor for efficacy and potential issues related to absorption or side effects.

• PPIs: Observe for any signs of recurrent GI bleeding. With prolonged use (months to years), monitor serum magnesium levels, particularly if the patient is also on diuretics.
• Nonselective Beta-Blockers: Titrate to target heart rate (55–60 bpm) while ensuring blood pressure remains adequate. Monitor for adverse effects like symptomatic bradycardia, hypotension, fatigue, or bronchospasm.
• Antibiotics: Adjust dosing based on renal function as needed. Monitor for resolution of infection (if treating SBP) and for antibiotic-associated diarrhea.

D. Pearls and Pitfalls in Enteral Conversion

4. Mitigating Post-ICU Syndrome (PICS)

Patients recovering from severe UGIB requiring ICU admission are at risk for Post-ICU Syndrome (PICS), which encompasses new or worsened impairments in physical, cognitive, or mental health domains that persist after hospital discharge.

A. Identifying High-Risk Patients

Early identification of patients at higher risk for PICS allows for targeted preventive and rehabilitative strategies.

• Risk Factors: Prolonged ICU stay (>7 days), mechanical ventilation (>48 hours), episodes of delirium, high cumulative doses of sedatives (especially benzodiazepines), pre-existing frailty or cognitive impairment, sepsis, and multiple organ dysfunction.
• Screening: Utilize tools like the CAM-ICU for delirium screening. Perform early assessments of mobility and functional status.

B. Implementing the ABCDEF Bundle

The ABCDEF bundle is an evidence-based, integrated set of practices designed to improve ICU patient outcomes, reduce PICS, and shorten the duration of mechanical ventilation and ICU stay.

• A – Assess, Prevent, and Manage Pain: Regularly assess pain using validated scales. Employ multimodal analgesia strategies to minimize opioid use.
• B – Both Spontaneous Awakening Trials (SATs) and Spontaneous Breathing Trials (SBTs): Perform daily SATs for sedated patients and SBTs for mechanically ventilated patients to evaluate readiness for liberation from sedation and ventilation.
• C – Choice of Analgesia and Sedation: Prefer non-benzodiazepine sedatives (e.g., propofol, dexmedetomidine) when sedation is needed. Target light levels of sedation.
• D – Delirium: Assess, Prevent, and Manage: Screen for delirium daily using validated tools (e.g., CAM-ICU). Implement non-pharmacological preventive measures (reorientation, early mobility, sleep promotion, correction of sensory deficits) and minimize deliriogenic medications.
• E – Early Mobility and Exercise: Initiate passive range of motion, progressing to active exercises and ambulation as tolerated, even in mechanically ventilated patients.
• F – Family Engagement and Empowerment: Involve family members and caregivers in the patient’s care, provide regular updates, and include them in care planning and decision-making.

C. Monitoring Rehabilitation Outcomes

Track progress in physical, cognitive, and psychological domains to guide ongoing rehabilitation efforts and identify needs for specialized follow-up.

• Physical Function: Use tools like the ICU Mobility Scale, Timed Up and Go test, or 6-minute walk test to quantify functional recovery. Refer to physical and occupational therapy.
• Cognitive Function: Screen for cognitive impairments using brief tools like the Montreal Cognitive Assessment (MoCA) or Mini-Cog. If deficits are identified, consider referral for formal neuropsychological testing and cognitive rehabilitation.
• Psychological Health: Screen for symptoms of anxiety, depression, and post-traumatic stress disorder (PTSD). Involve mental health services or social work for support and treatment as needed.

5. Medication Reconciliation and Discharge Counseling

A meticulous medication reconciliation process and comprehensive patient education are critical components of a safe transition from hospital to home, reducing the risk of adverse drug events and readmissions.

A. Medication Reconciliation Process

Perform medication reconciliation at every transition of care (admission, transfer between units, discharge) to ensure accuracy and prevent discrepancies.

• Steps:
  1. Obtain the best possible medication history (BPMH), including pre-admission medications (prescription, OTC, herbals).
  2. Compare this list with medications ordered during the inpatient stay and those planned for discharge.
  3. Identify and resolve any discrepancies (omissions, duplications, incorrect doses/frequencies, interactions) in consultation with the prescribing physician and pharmacist.
• Tools: Utilize electronic health record (EHR) medication reconciliation tools where available. Manual checklists and pharmacist involvement can enhance accuracy.

B. Patient and Caregiver Education

Provide clear, concise, and understandable instructions about discharge medications and follow-up plans. Empower patients and their caregivers to manage medications safely at home.

• Content to Cover:
  • Name of each medication (brand and generic).
  • Indication (why it’s being taken).
  • Dose, route, frequency, and duration of therapy.
  • Specific administration instructions (e.g., with or without food, technique for inhalers or injectables, how to administer via feeding tube if applicable).
  • Common and serious side effects to watch for and what to do if they occur.
  • Any planned changes to long-term medications (e.g., temporary discontinuation of anticoagulants).
• Methods:
  • Provide written information (e.g., medication list, information leaflets) in a clear, large font, and in the patient’s preferred language.
  • Use the “teach-back” method to confirm patient/caregiver understanding: ask them to explain in their own words how they will take their medications.
  • Address any questions or concerns.

C. Handoff Communication Protocols

Ensure effective communication of the patient’s status and care plan to the next providers (e.g., primary care physician, outpatient gastroenterologist).

• SBAR Format: Utilize a structured handoff format like SBAR (Situation, Background, Assessment, Recommendation) for verbal and written communication.
• Key Information to Include:
  • Reason for admission and summary of hospital course.
  • Final discharge medication list, including doses, frequencies, and any recent changes or planned tapers.
  • Key monitoring parameters (e.g., target hemoglobin, INR if on warfarin).
  • Pending test results.
  • Scheduled follow-up appointments and specific plans for outpatient management (e.g., repeat endoscopy, variceal surveillance, H. pylori eradication therapy).

D. Follow-up and Outpatient Planning

Proactive scheduling of follow-up appointments before discharge can improve adherence and reduce the likelihood of readmission.

• Gastroenterology (GI) Follow-up: Schedule as appropriate for potential repeat endoscopy, surveillance for varices or malignancy, confirmation of H. pylori eradication, or management of underlying liver disease.
• Primary Care Physician (PCP) Follow-up: Essential for overall care coordination, management of comorbidities, and ongoing medication management.
• Cardiology Follow-up: If UGIB was related to antithrombotic use, or if the patient has underlying cardiac conditions requiring management (e.g., recent acute coronary syndrome, atrial fibrillation).
• Ancillary Support: Arrange referrals for pharmacy follow-up (e.g., medication therapy management), nutritional counseling, physical/occupational therapy, or mental health services as indicated.