Bleeding in Cancer

• Causes of bleeding include vascular tumours, tumour invasion into vascular structures, or systemic processes like disseminated intravascular coagulopathy or thrombocytopenia. The approach includes general and pharmacological measures relating to the site of bleed.
• Massive bleeding can cause significant distress to anyone who witnesses it; and it can be a terminal event.
  

Assessment has to be prompt in order to decide on the next most appropriate management:

• Identify and optimize risk factors
• Identify aetiology and reversibility of bleed
• Consider patient’s prognosis and goals of care
• Weigh benefit and burden of interventions
  

• Provide a calm and reassuring presence
  
  • Invite family to step out until the situation is under control
  • Reassure family what will be done to keep patient comfortable
    

• If appropriate, consider:

  • Resuscitative support
  • Interventions (e.g. embolization) to stop the bleed
• All medications that can worsen bleeding should be discontinued.
• Use curtains to ensure privacy is maintained and dark colour towels to camouflage bleeding. 
• If bleeding is catastrophic (e.g. carotid blow out) and terminal, consider referral to specialist palliative care team and discussion about palliative sedation.
• After the incident, look out for and provide practical and psychological support to family, relatives and all staff involved. Offer social worker services to support family.

 

Topical:
Topical agents may be used if the site of bleeding is exposed. The following are common drugs used for surface bleeding.

• Tranexamic Acid: Crush 500mg tablet to fine powder and sprinkle it on wound; or soak gauze with Tranexamic acid ampoule (500mg/5mL) to pack wound.
• Adrenaline 1:1000: Soak gauze with adrenaline 1:1000 to pack wound . Avoid long term use in view of risks of ischemic necrosis and rebound vasodilatation
• Other materials for wound packing include calcium alginate dressing (for skin/mouth/rectum/vagina)
  

Systemic:

• Discontinue offending agents e.g. anticoagulation
• IV Vitamin K 10mg for 3 days, if appropriate
• Other systemic treatments that may help to reduce triggers for bleeding includes cough suppressants for patients with hemoptysis, or proton-pump inhibitors for patients with hematemesis
• Consider radiotherapy, arterial embolization or endoscopy (including bronchoscopy, cystoscopy) for direct haemostasis, if appropriate

Drugs	How to prepare	Notes
Tranexamic Acid	PO/IV 500mg-1000mg t.d.s. (max. dose 1500mg t.d.s.) Oral bioavailability≈ 45% Onset of action= 1-3 hrs Time to peak plasma concentration (PO)≈2.5 hrs Plasma half-life: 2 hrs (IV), 11 hours (PO) Duration of action: 24 hr	Do not use for hematuria as it will increase risks of clot formation leading to urinary retention Do not use for hemoptysis caused by pulmonary embolism Caution: Renal impairment, history of thromboembolism

• Hulme B, Wilcox S; Yorkshire Palliative Medicine Clinical Guidelines Group. Guidelines on the management of bleeding for palliative care patients with cancer. 2013.
• Twycross R, Wilcock A, Howard P, eds. Palliative Care Formulary. 5TH ed. Nottingham, UK: palliativedrugs.com Ltd; 2014.