A forty-two (42) year old man has been well, apart from a history of alcohol induced liver dysfunction and portal hypertension. He has abstained from alcohol for the past 8 months after being told that it would kill him. After a large haematemesis he presents drowsy, clinically shocked, with a blood pressure of 80 systolic, heart rate of 124 beats/minute, cold and clammy peripheries. He is also clinically jaundiced.
(b) Variceal bleeding is diagnosed and it initially responds to therapy.
48 hours post admission he remains on invasive respiratory support, with weak withdrawal response to pain despite minimal sedation, a persistent coagulopathy, and is inotrope dependent. Serum bilirubin concentration is elevated (100 micromol/L [N 3-20]).
He develops a further acute variceal bleed associated with hypotension.
Outline your management of this episode.