Yorkshire Palliative Medicine Clinical Guidelines Group

Guidelines on the management of bleeding for

palliative care patients with cancer - summary

January 2009

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 Patient
bleeding

Apply External Is patient dying

haemostatic bleeding from a massive
dressing evident? haemorrhage?

Record pulse, lying and

standing BP. See management of
Obtain IV access and request sudden catastrophic
FBC, clotting screen, G+S haemorrhage
blood and U+Es

Review drugs chart -

See Appendix 3

Treat any underlying

coagulopathy -
See Appendices 1 & 2

Consider infection as contributory

cause and send cultures for
sensitivities.
Consider empirical antibiotics in
mean time

Bleeding confined to a particular Generalised bleeding from

anatomical site? - multiple sites?
See site specific guidance Consider underlying
coagulopathy

Decide on appropriateness of escalation of

treatment and preferred place of care in event
of deterioration

Document plan in notes,

communicate with other
professionals and review plan
regularly

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 Summary of recommendations

1. Head and Neck

Treatment in most care settings

1. For general bleeding from a number of anatomical sites, or where the

bleeding site is not easily accessible to local therapy, consider use of
oral tranexamic acid (1g TDS)
2. For bleeding from the nasopharynx
• Use silver nitrate sticks for localised bleeding in accessible sites
• Use haemostatic packing kept in site until bleeding controlled
(usually a few days). If no commercial preparations kept locally use
gauze soaked in 1% alum.
• Cautious use of gauze soaked in 1:1000 adrenaline (beware of
rebound bleeding once removed)
3. For bleeding in the oropharynx
• Use tranexamic acid mouthwash (5g in 50ml warm water BD), or
• Use sucralfate suspension mouthwash (2g/10ml suspension BD)
• Consider topical 1 in 1000 adrenaline soaked on gauze for bleeding
in localised and accessible sites
• Consider nebulised adrenaline (5ml 1% adrenaline with 5ml 0.9%
saline QDS) for bleeding in less accessible bleeding sites

Treatment in hospital

4. Seek advice from oncologist for possibility of further palliative chemo-

or radiotherapy.
5. If service available, consider use of interventional radiology for
(potential) bleeds from major blood vessels

2. Haemoptysis

Treatment in most care settings

Try to rule out a pulmonary embolism (PE) before embarking on the following:
1. Oral tranexamic acid (1g TDS) and/or ethamsylate (500mg QDS)
2. Consider oral steroids (2-4mg dexamethasone OD)
3. Consider nebulised adrenaline (1ml of 1 in 1000 adrenaline with 4ml 0.9%
saline QDS)
4. Consider nebulised orlipressin / vasopressin (5IU in 2ml 0.9% saline prn)

Hospital Setting

1. Refer for radiotherapy or brachytherapy

2. Consider embolisation or bronchoscopy
[Link] use of recombinant factor VIIa (need to liaise with a
haematologist)

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 3. Upper GIT

Treatment in most care settings

1. proton pump inhibitor (oral or IV)

2. oral tranexamic acid (1g QDS po initially)
3. oral sucralfate (2g BD po)
4. consider iv/im octreotide/somatostatin
5. consider oral thalidomide (?100-300mg daily)

Hospital Measures

1. consider definitive treatment of tumour (if not already exhausted)

2. refer for radiotherapy provided the patient is well enough to tolerate it
3. consider referral for arterial embolisation or cryotherapy
4. consider iv pressins (need central line if used long-term)

4. Rectal

Treatment in most care settings:

• Oral tranexamic acid (1g TDS)

• Rectal sucralfate (2g suspension or 2g tablets mixed with aqueous jelly
BD)
• Rectal tranexamic acid (5g injectable vials mixed with 50ml warm water
as emema BD)
• Consider oral thalidomide (?50-100mg daily initial dose)

Additional treatment in specialised centres:

• Consider radiotherapy to tumour sites where an immediate effect is not

required, and patient has not had maximum radiotherapy to this site
previously
• Consider referral for endoscopy (for laser treatment, cryotherapy,
argon plasma coagulation, or application of formalin, alum packs or
fibrin glue), where the patient is fit enough to tolerate procedure
• There may be a role for interventional radiology in selected cases of
bleeding resistant to other measures. Consultation with an vascular
interventional radiologist is recommended
• For radiation proctitis hyperbaric oxygen therapy may be useful, but is
time consuming and limited by local availability

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5. Renal tract

In hospital settings:

1. Kidney Embolisation of Renal artery

Nephrectomy
2. Bladder Radiotherapy
Embolisation Internal iliac artery or branches of
Oral Tranexamic acid (use with caution due to risk of clot
retention. Intravesical tranexamic acid via 3-way catheter is
preferable)
Oestrogens
(Sodium pentosanpolysulphate if available)
Intravesical Tranexamic acid
Aluminium salts (beware of systemic
toxicity)
Prostaglandins (for cyclophosphamide
induced haemorrhage)
Sodium hyaluronate
Formalin (GA or sedation required)
Silver nitrate (beware of precipitating salts)

Also consider:
Systemic Hyperbaric oxygen therapy for radiation
induced cystitis

Surgery Radical cystectomy

3. Prostate Oral Fibrinolytic Inhibitors

5 α-reductase inhibitors
Radiotherapy
TURP

In hospice / home settings:

Always consider transfer to a hospital for above measures if possible

1. Bladder Oral tranexamic acid (risk of clot retention)

Oral oestrogens
?Intravesical instillations
2. Prostate Oral tranexamic acid
5 α-reductase inhibitors

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6. Gynaecological

For most treatment settings

1. vaginal packing/tampon
2. trial of oral tranexamic acid (1g TDS)
3. consider topical application of tranexamic acid (500mg tablet crushed
with aqueous jelly or 5ml vial soaked on gauze) or sucralfate (2g in
10ml suspension)

For Hospital Setting

5. consider definitive treatment of tumour (if not already exhausted)

6. refer for radiotherapy provided the patient is well enough to tolerate it
7. arterial embolisation if available and with careful selection of suitable
patients
8. for life-threatening haemorrhage, consider topical acetone or
formaldehyde

7. Summary of management of bleeding wounds

Consider antibiotics if signs or symptoms of infection as infected wounds

are more likely to bleed. For all patients consider the appropriateness of
radiotherapy, chemotherapy, cauterisation or embolisation.

• Minimize trauma during dressing changes by cleaning gently with

irrigation and using non-adherent dressings (Level 4).
• Some brands of alginate (Kaltostat, Sorbsan) claim to have haemostatic
properties that can be used to control minor bleeding (Level 4). Alginate
dressings are manufactured from the calcium salt of an alginic acid
polymer derived from brown seaweed. It is claimed that calcium ions that
are released into the wound from the dressing activate platelets, which
results in haemostasis. These dressings are not licensed as haemostatic
dressings.
• To control profuse bleeding, use Adrenaline soaked gauze, 1 in 1000
(1mg in 1ml) applied with pressure for 10 minutes. This causes local
vasoconstriction, but may also cause ‘rebound’ bleeding once these
effects wear off. Care should be taken to avoid ischaemic necrosis
(Level 4). An alternative is Tranexamic acid 500mg in 5ml soaked into
gauze and applied with pressure for 10 minutes (Level 4).
• Sucralfate can be applied topically to help slow capillary ooze. To apply
it, a paste is made of Sucralfate 1-2g, which is then crushed with water-
soluble gel. The resulting mixture is adherent and can be applied to the
bleeding site once or twice daily. (Level 4).
• Consider oral Tranexamic acid or Etamsylate to stop the bleeding and
prevent further future bleeding (Level 4). This can be discontinued 1
week to 10 days after bleeding stops. Restart if bleeding recurs.

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 MANAGEMENT OF A MAJOR CATASTROPHIC BLEED IN ADVANCED
CANCER PATIENTS

Risk Assessment

Patients potentially at risk include:

• Site of cancer eg. head and neck, haematological
• Presentation with bleeding eg. haemoptysis in lung cancer
• Co-existing disease eg. gastrointestinal bleeding, oesophageal varices
• Smaller warning bleeds
• Local infection at the tumour site
• Clotting abnormalities
• Drugs eg. heparin, enoxaparin

Is the patient at risk of a major life-threatening bleed?

Yes No Reassess as appropriate

Advance Care Plan If an inpatient: offer a side

room where possible
• Stop anticoagulants and antiplatelet drugs where
possible.

Consider: If at home: provide

• Who needs to be aware of risk? – patient, family, telephone numbers for
carers, other healthcare professionals? emergency
• Preferred care setting – available level of care
• Equipment: dark sheets/towels, gloves, aprons,
plastic sheet or inco pad, clinical waste bags.
• Plan for who will clean up after an event and how to
contact them

• Prescription and preparation of crisis medication (not

always appropriate/available) * see overleaf

IN THE EVENT OF AN ACUTE BLEED:

• Stay calm and if possible summon assistance

• Ensure that someone is with the patient at all times
• If possible nurse in recovery position to keep airway clear
• Stem/disguise bleeding with dark towels/sheets
• Apply pressure to the area if bleeding from external wound with adrenaline soaks if
available
• Administer crisis medication if available (see overleaf) which can be repeated after
10minutes if needed.

* REMEMBER patient support & non-drug interventions may be more important than crisis
medication *

After the Event

• Offer de-briefing to the whole team

• Ongoing support as necessary for relatives/staff members
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• Disposal of clinical waste appropriately
 Crisis Medication

If nursing staff are available quickly (within minutes) 24h/day:

Drug Route * Dose Rate of onset

Midazolam IV 10mg 2-3minutes

(pre-drawn up if
possible) IM (preferably 10mg 5-15minutes
deltoid)

* The subcutaneous route is inappropriate due to peripheral shut down and

unpredictable absorption.

Note: If the patient is already on large background doses of midazolam or

other benzodiazepines, but still not adequately sedated during catastrophic
bleeding they may need larger doses of midazolam in proportion with the
background dose.

If domiciliary setting or nursing staff not available quickly:

Drug Route Dose Rate of onset

Diazepam PR 10mg 5-15mins

Midazolam Buccal 10mg(1ml) – note 15min

unlicensed, special
order.

Lorazepam Sublingual 4mg (1ml) 5mins

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