12.5 (8.7) Management Of Bleeding In PC Flashcards
Which vessels are the most common sites are bleeding in patients with advanced cancer (list 3)?
Carotid, inter-pulmonary, femoral
List 3 broad categories of causes of bleeding in PC and examples
Local cause:
- Cancer invasion and destruction
Treatment related causes:
- Chemo, rads, surgery
Systemic causes:
- Coagulopathies: DIC
- Bone marrow failure
- Platelet dysfunction: drugs (ASA, NSAID, warfarin)
- Deficiency in clotting factors: Liver disease, bili obstruction, malabsorption causing
List three nutritional deficiencies that can cause bleeding in PC
Vitamin B12
Folate
Vitamin K
Zinc
Name the general approach to bleeding in PC patients (6 steps)
- Manage size of bleeding - ABC + IV (fluids or blood), O2, vitals + bwk (CBC, type and cross, E7)
- Start local measures - pressure, packing, topicals, interventions
- Manage (universal) causes of bleeding - stopping blood thinners/give antidotes, TXA, vasopressin, treat coagulopathies
- Manage site specific causes of bleeding
- Determine place of care
- Document and communicate bleeding management plan
Other way of thinking:
- Manage complications - ABC, IV O2 monitor, bloodwork
- Manage symptoms - transfuse, vasopressin, TXA
- Manage source:
Local - pressure, packing
Systemic - tx coagulopathy, embolize, radiation, surgery
Iatrogenic - stop blood thinner/give antidote
List five risk factors for bleeding in PC?
Thrombocytopenia
Coagulopathy
Anticoagulants
Previous bleeds
Age >50
Diabetes
10-50% loss of body weight
List 3 characteristics of tumors that increase bleeding?
List 3 types of tumors at high risk of bleeding?
Tumor close to major vessels (location)
Large tumors (size)
Fungating tumor
Fistulating tumors
Head and neck tumors
Hematological malignancies
GI tumors
What are 3 interventional treatments available for bleeding?
- Vascular radiology (embolization by vascular IR)
- Surgery (removal of bleeding tissue or surgical ligation of bleed vessels; endoscopic procedures; bronchoscopic procedures)
- Radiotherapy (external or internal)
FS: IR, rad, surgery/procedure
Vascular embolization by IR:
- Embolization materials x 3
- Limitations x 2
- Pre-requisites x2
- SEs x2
- Particles (polyvinyl alcohol), mechanical device (coil), liquid (glue, alcohol)
- Site and extent of tumor infiltration may affect success of embolization; inability to selectively catheterize tumor vasculature
- Cross sectional imaging, pre-procedure labs (E7, clotting abnormalities), pt needs to be able to lie flat for 1-2 hours + 2-4 hours of recovery
- Puncture site related complications (bruising, bleeding), post embolization syndrome (pain, N/V, ischemia), unintended critical ischemia or end organ damage
- When are radiotherapy less effective for bleeding (name 3 circumstances)
- When should surgery/procedures be done
- Anatomical site (some areas are less amenable to rads SEs), radioresponsiveness of tumor, previous exposure to rads
- For pts in early stage of disease OR those who have exhausted other options (meds, rads, vascular IR)
When to transfuse plts?
<10
<20 + sepsis
<30 + minor bleeding
< 50 + severe bleeding
<100 with intracranial bleeding
When to not transfuse plts - list 2 conditions
Thrombotic thrombocytopenic purpura (risk of precipitating clots)
Auto-immune or drug associated immune thrombocytopenia (plt count may not increase due to immune mediated factors)
Fresh frozen plasma -
What does it contain?
When is it indicated? Name 2
Contains all soluble plasma protein + clotting factors
Indicated for:
- Correction of major bleeding*
- In preparation for invasive procedures when INR is >2
- Deficiency in multiple coagulation factors (e.g. liver failure, DIC)*
When is Vit K indicated?
What if you can’t wait for Vit K reversal (life threatening bleed, reversal needed <6 hours)?
Bleeding due to oral vit K antagonist, liver disease, DIC
Give prothrombin complex concentrate (Octaplex) - which contains vit K dependent coagulation factors (2, 7, 9, 10)
What can you give to reverse the following when life threatening hemorrhage occurs
- DOACs ?
- Heparin / LMWH?
Idarucizumab (praxbind)
Protamine
TXA:
- What does it do?
- What routes?
- Risk?
- Contraindication?
- How long to continue?
- When to increase dose?
- Antifibrinolytic drugs prevent clot breakdown
- PO, IV, topical
- Increase risk of thrombosis
- CI: DIC
- Continue 7 days after bleeding is stopped
- Increase dose if bleeding continues after 3 days
How to manage hematuria?
Bladder irrigation/instilation (saline, alum 1%, prostaglanding, formalin)
Radiotherapy
IR - arterial embolization (renal artery)
Surgery - TURP, cystectomy
Note - TXA generally avoided as can increase clots -> ureteric obstruction
How to manage UGIB?
PPI + ABx + BB + Octreotide (PABO)
TXA
Vasopressin
Thalidomide (reduce VEGF)
Endoscopic hemostasis (injsection of sclerosing agents, thermal, clips, band ligation)
How to manage LGIB due to radiation proctitis (can present months to years after pelvic rads)? Name 3 treatments
Rectal sucralfate
Rectal steroid enema
Flagyl
hyperbaric O2 tx
How to manage hemoptysis?
Place patient in lateral decubitus position with bleeding side down
TXA
Vasopressin
Radiotherapy
Therapeutic broncoscopy (balloon tamponade, iced saline lavage, laser therapy, electrocautery)
IR - arterial embolization if above fails
How to manage bleeding at nasopharynx versus oropharynx:
Nasopharynx:
- Silver nitrate, petroleum jelly
- Electrocautery (anterior bleeds)
- Nasal tampons, ribbon gause, balloons +/- TXA
Oropharynx:
- TXA mouthwash
- Sulcrate mouthwash
- Nebulized adrenaline
IR embolization
How to manage vaginal bleeding
PO TXA
Vaginal packing
Radiotherapy (bleeding stops 12-48hours of tx)
Surgical ligation of pelvic arteries
IR embolization of pelvic arteries
How to manage bleeding malignant wounds
Compression
Hemostatic dressing
Silver sticks
Gauze soaked with adrenaline (may cause ischemia/necrosis/rebound vasodilation)
Surgery
Embolization
Chemotherapy
List four systemic modalities that can be used to manage bleeding
Vitamin K or Octaplex *
Praxbind (DOAC antidote)
Protamine (LMWH antidote)
Antifibrinolytic agents (TXA)*
Vasopressin analogues*
Somatostatin analogues (octreotide)*
Blood/plasma products (plts, FFP, cryoprecipitate)
Recombinant coag factors (VIIa, VIII, IX)
Hyperbaric O2 therapy
Other - pentosanpolysulphate, melatonin, thalidomide
List 3 causes of vit k deficiency
Decreased intake
Decrease absorption due to Small bowel disease or resection
Decreased absorption due to decreased bile:
Liver disease
Biliary obstruction
