Bleeding

KEYPOINTS

  • Bleeding can sometimes occur in cancer especially as the disease progresses
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  • Patients and families can be very distressed by even small amounts of visible bleeding

ASSESSMENT

(see Foreword)

  • It is important to make an assessment of the cause, the severity and the prognosis of the patient when assessing bleeding
  • When appropriate carry out relevant tests including a coagulation screen

MANAGEMENT

  • Treatment of bleeding in palliative patients depends on the patient’s prognosis and whether the treatment is likely to be effective
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Consider if patient is well enough to benefit

General Measures

  • Reassure and explain the situation to patient and family
  • General supportive measures including fluid replacement if the bleeding is severe
  • Stop medications such as NSAIDs or anticoagulants that may be causing or exacerbating the bleeding
  • Consider correcting any abnormal clotting, i.e. with Vit K or fresh frozen plasma if available

Transfusion when Appropriate

  • Packed red cells
  • Platelets

(see Transfusion of Blood Products in Palliative Care)

Other

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  • Consider haemostatic radiation or embolisation

Bleeding from a Wound/Ulcer

  • Apply steady pressure
  • Adrenaline/epinephrine (1:1000) impregnated dressings

Bleeding from GI Tract

  • Stop NSAIDS and reduce and discontinue steroids if possible
  • Start omeprazole, ranitidine or similar medication
  • Endoscopy if possible and if warranted

Bleeding from Bladder

  • May benefit from continuous bladder irrigation and instillation of haemostatic agents
  • If well enough consider cystoscopy/diathermy
  • Tranexamic acid should be used with caution in genitourinary bleeding as clot formation may be problematic

Bleeding from Mouth/Gums

  • Cautious cleaning of the mouth
  • Tranexamic acid IV liquid (diluted 50:50 with water) as mouthwash may be useful

Bleeding from Nose

  • Can be stopped by continuous pressure
  • Use silver nitrate sticks
  • Packing for 15 minutes with gauze soaked in 1:1000 adrenaline/epinephrine

Massive Haemorrhage in Terminal Phase

  • Stay with patient
  • Reassure family
  • If appropriate sedate patient with midazolam 5 mg-10 mg SC/IV stat
  • Use dark green or blue towels to disguise blood

PITFALLS/CONCERNS

  • If a massive haemorrhage is likely at some stage the family and patient should be prepared for this as far as is possible
  • Do not use tranexamic acid when disseminated intravascular coagulation (DIC) is suspected

PALLIATIVE TIPS

  • Patients with advanced liver disease or renal failure may develop impaired clotting complicating this problem
  • In addition, they may have been started previously on anti-coagulants for another problem

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