Bleeding

KEYPOINTS

• Bleeding can sometimes occur in cancer especially as the disease progresses

• 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

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

• Tranexamic acid: adult 1 g tid PO or IV

• Tranexamic acid
  • 10-20 mg/kg bid to tid IV
  • 25 mg/kg/dose tid to qid PO

• 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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