Recovery, De-escalation, and Transition of Care After Variceal Hemorrhage

1. Weaning and De-escalation of Intensive Therapies

After bleeding is controlled and hemodynamics stabilize, a structured taper of vasoactive infusions minimizes rebound portal hypertension and supports end-organ perfusion.

A. Hemodynamic Stability Criteria

The following criteria must be met for at least two consecutive assessments before initiating a wean:

• Systolic blood pressure (SBP) ≥90 mm Hg without upward vasopressor adjustments
• Heart rate (HR) 55–60 bpm at rest
• Urine output >0.5 mL/kg/h
• Serum lactate trending down
• No new or worsening end-organ dysfunction (renal, hepatic, neurologic)

B. Protocol for Vasoactive Taper (Octreotide, Terlipressin)

Once stability is achieved, follow a systematic weaning process:

1. Continue the full therapeutic infusion for 2–5 days after the index bleed is controlled.
2. If stability is maintained, reduce the infusion rate by 25% every 4–6 hours.
3. If any stability criteria are violated (e.g., SBP falls below 90 mm Hg), immediately return to the last tolerated rate and hold the wean. Reassess stability in 2 hours before attempting to resume the taper.
4. Discontinue the infusion once the rate is less than 25% of the initial therapeutic dose and the patient remains stable.

2. Transition from IV to Enteral Medications

Early initiation of oral nonselective β-blockers (NSBBs) is critical for secondary prophylaxis, supporting long-term portal pressure control and facilitating rehabilitation.

A. Assessing Gastrointestinal Readiness

Before starting oral medications, confirm:

• Presence of bowel sounds and absence of clinical ileus.
• Tolerance of small-volume enteral nutrition.
• Patency of any enteral access tubes (nasogastric, nasojejunal, or gastrostomy) if the oral route is not yet feasible.

B. Nonselective β-Blocker (NSBB) Selection and Dosing

C. Conversion Steps

1. Begin the selected NSBB approximately 24 hours before the planned discontinuation of the vasoactive infusion to ensure overlap.
2. Titrate the NSBB dose every 48 hours (e.g., by 10–20 mg of propranolol) based on heart rate and blood pressure response.
3. Hold the NSBB dose and notify the provider if SBP drops below 90 mm Hg or resting HR is below 50 bpm.

3. Prevention and Mitigation of Post-ICU Syndrome (PICS)

Survivors of critical illness, particularly variceal hemorrhage, are at high risk for PICS—a constellation of new or worsened cognitive, psychological, and physical impairments. Proactive, bundled strategies can reduce long-term morbidity.

A. Risk Factors for PICS

• Mechanical ventilation >48 hours
• Deep or prolonged sedation
• ICU-acquired delirium
• High illness severity (e.g., multiorgan failure, acute-on-chronic liver failure)

B. The ABCDEF Bundle

This multicomponent, evidence-based bundle is the standard of care for preventing PICS:

• A: Assess, prevent, and manage pain
• B: Both Spontaneous Awakening Trials (SATs) and Spontaneous Breathing Trials (SBTs)
• C: Choice of analgesia and sedation to minimize delirium
• D: Delirium: assess, prevent, and manage
• E: Early mobility and exercise
• F: Family engagement and empowerment

C. Early Mobilization Protocol

Once vasoactive infusions are discontinued and the patient is hemodynamically stable:

1. Begin with passive range-of-motion exercises in bed.
2. Progress to active range-of-motion and sitting at the edge of the bed.
3. Collaborate with Physical and Occupational Therapy (PT/OT) to advance to standing, transferring to a chair, and ambulation as tolerated.

4. Comprehensive Medication Reconciliation

A pharmacist-led medication reconciliation at all care transitions (e.g., ICU to floor, hospital to home) is essential to avert medication errors, harmful duplications, and adverse drug interactions in this vulnerable population.

5. Discharge Counseling and Handoff

Standardized patient education and clear communication with outpatient providers are proven strategies to reduce hospital readmissions and ensure continuity of care.

A. Patient and Caregiver Education

• Medication Plan: Provide a clear NSBB titration schedule with explicit hold parameters (e.g., “Do not take your dose and call us if your top blood pressure number is less than 90 or your heart rate is less than 50”).
• Nutritional Guidance: Recommend small, frequent, high-protein meals to combat sarcopenia. Provide guidance on sodium restriction if ascites or edema is present.
• Warning Signs: Educate on signs of rebleeding (black or bloody stool, vomiting blood) or hypotension (dizziness, fainting) that warrant urgent medical evaluation.

B. Interdisciplinary Handoff

A structured handoff to the outpatient team is crucial. This should include:

• Transmission of the fully reconciled medication list to the primary care provider, hepatologist, and outpatient pharmacist.
• Clear documentation of vital sign targets (HR, SBP) and alert thresholds for NSBB therapy.
• A summary of the hospital course, including endoscopic findings and interventions performed.

6. Long-Term Follow-Up Strategies

Ongoing surveillance and multidisciplinary support are necessary to prevent variceal recurrence, manage the progression of cirrhosis, and address late complications.

A. Surveillance Endoscopy

• Initial Eradication: Repeat endoscopy with band ligation is typically performed every 2–4 weeks until all large varices are eradicated.
• Long-Term Surveillance: After eradication, surveillance endoscopy is recommended every 6–12 months to monitor for recurrence. The interval may be individualized based on the initial variceal grade and other risk factors for decompensation.

B. Adherence and Side-Effect Monitoring

At every follow-up visit, the clinical team should:

• Review NSBB adherence and address any barriers.
• Actively screen for common side effects like dizziness, fatigue, and symptomatic hypotension.
• Adjust the NSBB dose or hold therapy based on symptoms and measured vital signs.

C. Multidisciplinary Referrals

Ongoing care should involve a team approach:

• Hepatology: For primary management of cirrhosis and variceal surveillance.
• Nutrition/Dietetics: For ongoing dietary optimization to manage ascites and prevent malnutrition.
• Physical/Occupational Therapy: To maintain muscle strength, improve function, and combat frailty.