Critical Care Time 55. Cirrhosis & Variceal Bleeds
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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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Intubate High‑Risk Upper GI Bleeds Early
- Intubate patients with high suspicion for variceal hemorrhage who are somnolent or actively vomiting blood to prevent aspiration.
- Perform a controlled ICU intubation before endoscopy when possible to protect airway and facilitate endoscopy.
Use Ketamine And Rocuronium For Induction
- Prefer ketamine with rocuronium for induction to preserve hemodynamics in mixed hemorrhagic/distributive shock.
- Have blood, push‑dose vasopressors, and plan for preload loss during induction.
Lead With Suction And Maximize Head Elevation
- Lead with aggressive suction and position the head high to keep blood pooled away from the airway during intubation.
- Use two suction catheters and large‑bore suction devices to maintain a clear view for first‑pass success.