Critical Care Time 55. Cirrhosis & Variceal Bleeds
Aug 11, 2025
Dr. David Dulaney, a Gastroenterologist and program director at a GI fellowship in San Antonio, shares insights into managing cirrhosis and variceal bleeds. He discusses the challenges of coagulopathy in advanced liver disease and the importance of nuanced treatments like TXA in variceal bleeding. Through clinical case studies, he emphasizes the need for multidisciplinary care and tailored approaches in critical situations. With a dash of humor, Dulaney navigates complex anesthesia considerations and highlights best practices for intubation and vascular access.
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Variceal Bleeds Have High Short‑Term Mortality
- Variceal hemorrhage carries high short-term mortality, roughly 10–15% at six weeks.
- David Dulaney emphasizes these patients need multidisciplinary care and have worse outcomes without it.
Start Octreotide Early
- Start octreotide early when you suspect portal‑hypertensive bleeding to counter splenic vasodilation.
- Stop it if endoscopy shows a non‑variceal source or after the planned treatment window.
Target Perfusion Not A Single MAP
- Target organ perfusion rather than chasing an arbitrary MAP in cirrhotic shock.
- Use lactate trends, base excess, and clinical perfusion as resuscitation end points instead of MAP 65 alone.