2025 PACUPrep BCCCP Preparatory Course Portal Hypertension & Variceal Hemorrhage Supportive Care & Complication Monitoring in Acute Variceal Hemorrhage
Supportive Care & Complication Monitoring in Acute Variceal Hemorrhage

Supportive Care & Complication Monitoring in Acute Variceal Hemorrhage

Objective Icon A clipboard with a list, symbolizing care objectives.

Objective

Critically ill cirrhotic patients with acute variceal hemorrhage require coordinated supportive care beyond hemostasis—including airway protection, tailored hemodynamics, complication prophylaxis, organ‐dysfunction monitoring, and structured goals‐of‐care discussions.

1. Hemorrhagic Shock Support & Monitoring

Early airway control, lung‐protective ventilation, hemodynamic stabilization with balanced fluids and vasoactive agents, and restrictive transfusion reduce mortality and rebleeding.

Airway Protection & Mechanical Ventilation

Intubation should be considered for patients with:

  • GCS ≤8 or refractory encephalopathy
  • Active hematemesis or high aspiration risk
  • Severe hypoxemia (SpO₂ <90% on a non-rebreather mask)

Once intubated, a lung-protective strategy is crucial:

  • Tidal Volume: 6 mL/kg of ideal body weight
  • PEEP: Start at 5–8 cmH₂O, titrating for a PaO₂/FiO₂ ratio >150
  • Plateau Pressure: Limit to <30 cmH₂O; keep FiO₂ ≤60% when possible
Pearl IconA shield with an exclamation mark, indicating a clinical pearl. Clinical Pearl: Airway Management

Early intubation avoids aspiration pneumonia, a common and deadly complication, and allows for controlled oxygenation and sedation during endoscopy and resuscitation.

Hemodynamic Resuscitation

The goal is to restore tissue perfusion without exacerbating portal hypertension. This involves a careful balance of fluids, vasoactive agents, and blood products.

Hemodynamic Resuscitation Flowchart A flowchart for hemodynamic resuscitation in variceal hemorrhage. It starts with immediate portal pressure reduction using Terlipressin or Octreotide. It then shows parallel pathways for fluid resuscitation with balanced crystalloids, vasopressor support with norepinephrine to target a MAP over 65, and a restrictive transfusion strategy for hemoglobin less than 7. Immediate Portal Pressure Reduction Terlipressin or Octreotide Infusion 1. Fluid Choice Balanced Crystalloids (Lactated Ringer’s) Avoid over-resuscitation 2. Vasoactive Support If MAP <65 mmHg: Norepinephrine Monitor lactate & UO 3. Transfusion Strategy If Hb <7 g/dL: Transfuse RBCs Target Hb: 7-9 g/dL
Figure 1: Hemodynamic Resuscitation Strategy. A multi-pronged approach targeting portal pressure, systemic perfusion, and oxygen-carrying capacity is essential. All interventions should be guided by continuous monitoring to avoid iatrogenic harm.
Pearl IconA shield with an exclamation mark, indicating a clinical pearl. Clinical Pearl: Transfusion Targets

A restrictive transfusion strategy (targeting Hb 7–9 g/dL) is superior to a liberal one. Over-transfusion increases portal pressure, which can worsen bleeding and increase mortality.

2. ICU-Related Complication Prevention

Patients with cirrhosis are highly susceptible to ICU-acquired complications. Prophylaxis must be tailored to balance the risks of bleeding, thrombosis, and infection.

VTE Prophylaxis

Despite coagulopathy, cirrhosis is a prothrombotic state. The decision to use prophylaxis requires careful assessment.

  • Pharmacologic: Enoxaparin 40 mg SC daily (or 30 mg if CrCl <30 mL/min) is preferred. Hold if platelets are <50,000/mm³ or there is active variceal bleeding.
  • Mechanical: Use intermittent pneumatic compression devices if pharmacologic prophylaxis is contraindicated due to high bleeding risk.

Stress-Related Mucosal Disease

Prophylaxis is indicated for patients on mechanical ventilation >48 hours or with significant coagulopathy.

  • Therapy: Pantoprazole 40 mg IV daily is the agent of choice. Famotidine is an alternative.
  • Risks: Prolonged PPI use is associated with an increased risk of C. difficile, spontaneous bacterial peritonitis (SBP), and hepatic encephalopathy. De-escalate therapy as soon as the bleeding risk subsides (typically after 5–7 days).

Infection Prevention

Bacterial infections are a major trigger and complication of variceal bleeding.

  • Antibiotic Prophylaxis: Initiate immediately upon suspicion of variceal hemorrhage. Ceftriaxone 1 g IV daily for 5–7 days is the standard of care.
  • Surveillance: Maintain a high index of suspicion for infection. Obtain blood and ascites cultures if the patient develops fever, leukocytosis, or hemodynamic instability.

3. Management of Iatrogenic Organ Dysfunction

Therapies essential for resuscitation can inadvertently cause organ injury. Vigilant monitoring is required to detect and manage these complications promptly.

Ischemic Colitis & Bowel Injury

  • Cause: High doses of vasopressors (especially vasopressin analogs) can cause splanchnic vasoconstriction, leading to bowel ischemia.
  • Recognition: Suspect ischemic colitis if a patient develops new abdominal pain, distension, or a rising lactate despite stable hemodynamics. Confirm with a CT scan of the abdomen.
  • Management: Use the lowest effective dose of norepinephrine. If ischemia is suspected, reduce the vasopressor dose and consult GI surgery.
Editor’s Note IconA notepad icon, indicating an editor’s note. Editor’s Note: Vasodilator Adjuncts

Insufficient source material exists to provide definitive protocols for vasodilator adjuncts like low-dose nitroprusside or PDE inhibitors. Their use in mitigating vasopressor-induced ischemia is theoretical and requires expert consultation and careful hemodynamic monitoring.

Renal Dysfunction & Hepatorenal Syndrome

  • Prevention: Avoid nephrotoxins like NSAIDs and intravenous contrast whenever possible. Ensure adequate volume resuscitation.
  • Monitoring: Track daily creatinine, BUN, and urine output.
  • Management: Indications for renal replacement therapy (RRT) include refractory volume overload, severe acidosis, or uremia. Continuous RRT (CRRT) is preferred in hemodynamically unstable patients.

Hepatic Encephalopathy Exacerbation

  • Triggers: GI bleeding, infections, broad-spectrum antibiotics, and prolonged PPI use can alter gut flora and precipitate or worsen encephalopathy.
  • Treatment: Lactulose is first-line therapy, titrated to 2–3 soft stools per day. Rifaximin can be added for secondary prevention.

4. Multidisciplinary Goals-of-Care & Ethical Decision-Making

Decisions regarding invasive therapies must align with the patient’s prognosis, values, and goals. This requires early and frequent multidisciplinary communication.

TIPS Placement Discussions

  • Candidate Selection: Transjugular intrahepatic portosystemic shunt (TIPS) is considered for patients with rebleeding or high-risk features (e.g., Child-Pugh class B with active bleeding, or select class C patients).
  • Contraindications: Uncontrolled infection, severe heart failure, and severe, refractory encephalopathy are relative contraindications.
  • Prognosis: Use prognostic models like MELD and CLIF-C ACLF to inform discussions about the risks and benefits.

Advance Care Planning & Palliative Integration

  • Shared Decision-Making: Use structured frameworks to discuss prognosis, the burdens of life-sustaining interventions, and the patient’s personal goals.
  • Documentation: Clearly document all goals-of-care discussions, including DNR/DNI status and the patient’s preferred setting of care.

5. Pharmacotherapy Summary

This table summarizes key medications used for supportive care and complication prevention in acute variceal hemorrhage.

Pharmacotherapy for Supportive Care & Complication Prevention
Agent Mechanism Indication Dosing Monitoring Clinical Pearl
Ceftriaxone β-lactam; cell‐wall synthesis inhibitor Infection prophylaxis in AVH 1 g IV q24h x5–7 days Renal function, C. difficile risk Start immediately on presentation.
Norepinephrine α₁-agonist Vasoplegic shock; MAP ≥65 mmHg 0.05–0.2 μg/kg/min infusion MAP, lactate, perfusion signs Avoid high doses; risk of mesenteric ischemia.
Enoxaparin LMWH; anti-Xa VTE prophylaxis in immobilized ICU pts 40 mg SC q24h (CrCl <30: 30 mg) Platelets; anti-Xa if renal dysfn. Hold if active bleeding or PLT <50,000.
Pantoprazole PPI; H⁺/K⁺ ATPase inhibitor Stress ulcer prophylaxis in high-risk ICU 40 mg IV q24h Mg²⁺, infection signs De-escalate after 5–7 days to reduce infection risk.

References

  1. Kaplan DE et al. AASLD Practice Guidance on portal hypertension and varices. Hepatology. 2024;79(4):1180–1211.
  2. Villanueva C et al. Transfusion strategies for acute upper GI bleeding. NEJM. 2013;368(1):11–21.
  3. Odutayo A et al. Restrictive vs liberal transfusion in GI bleeding. Lancet Gastroenterol Hepatol. 2017;2(5):354–360.
  4. Amitrano L et al. Acute variceal bleed treatments: prognosis and risk factors. Am J Gastroenterol. 2012;107(12):1872–1878.
  5. Wells M et al. Vasoactive medications for acute variceal bleeds: meta-analysis. Aliment Pharmacol Ther. 2012;35(11):1267–1278.
  6. O’Leary JG et al. Antibiotics and PPIs predict infections in cirrhosis. Clin Gastroenterol Hepatol. 2015;13(4):753–759.e2.
  7. Dam G et al. PPIs and infection risk in cirrhosis. Liver Int. 2019;39(3):514–521.
  8. García-Pagán JC et al. Early use of TIPS in variceal bleeding. NEJM. 2010;362(25):2370–2379.
  9. Copelan A et al. TIPS: indications, contraindications, patient work-up. Semin Intervent Radiol. 2014;31(3):235–242.
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