Wound care can take a different approach towards the end of life as healing may be an unrealistic aim. We use nursing skills and knowledge to keep the area and the patient as comfortable and contained as possible. Malignant wounds can be caused by direct tumour invasion into the skin due to primary or metastatic growth. The majority of malignant wounds are associated with at least one significant symptom which could include pain, infection, odour, oozing and bleeding. They are a significant source of distress to patients as they can have a major impact on body image. One of the challenging aspects of management is the propensity for capillary oozing and bleeding. Bleeding can be at least inconvenient and at worst potentially terminal. The following information is intended for guidance with the management of capillary bleeding and not intended for use in preparation for potential major bleeds.
As with any symptom, the first step is considering whether the situation has any reversible aspects:
- Consider antibiotics if there are signs or symptoms of infection, as infected wounds are more likely to bleed
- Consider the appropriateness of radiotherapy, chemotherapy, cauterisation to minimise the bleeding
- In order to minimize trauma during dressing changes, clean gently with irrigation and use non-adherent dressings.
Drug treatments that may be helpful
1. Adrenaline 1 in 1000
Adrenaline causes vasoconstriction and can be used topically to control capillary bleeding. It can be applied by sprinkling the contents of one or more ampoules either directly onto the wound or onto gauze or the dressing (there are reports of up to 10ml being used). Applying pressure helps further. Bleeding is likely to recur once the adrenaline effects have worn off. Long-term use of topical adrenaline is not recommended as repeated vasoconstriction incurs a risk of tissue necrosis but the use may be justified towards the end of life and preferable to bleeding for a palliative care patient. For wounds requiring larger volumes than 1 or 2ml, a topical solution of adrenaline 1 in 1000 can be supplied in 30ml bottles. This is manufactured as an unlicensed ‘special’ in the pharmacy production unit at Huddersfield Royal Infirmary so there may be a few days delay in receiving this product. It has a shelf life of months rather than years and is more expensive than the ampoules but it saves nursing time.
Adrenaline injection 1 in 1000 – supplied in boxes of 10 ampoules
Adrenaline 1 in 1000 topical solution – 30ml bottles (written order required)
2. Tranexamic Acid injection 500mg in 5ml
Tranexamic acid is a potent antifibrinolytic. Fibrin is essential to the natural clotting process but once a clot has been formed for protective reasons, it needs to be broken down again once healing is established. Tranexamic acid slows down the natural breakdown of fibrin so the blood clots for longer than usual.
For bleeding wounds, oral tranexamic acid can be tried at the usual doses of 500mg to 1g up to qds. If the oral route is not available or is not helping, there have been reports of topical use of the injection. Sprinkle the injection solution directly onto the wound or soak it onto a gauze dressing and apply with pressure for 10 minutes. If the wound is heavily exudating, additional dressings may be needed on top of this. The dressing can be changed daily or on alternate days according to need but the solution can be applied more frequently if required as it is unlikely to be absorbed systemically to any noticeable extent.
Sucralfate creates a gel to form a protective layer on a mucous membrane (normally in the stomach, hence its licensed use in peptic ulceration) but it will adhere to any moist damaged tissue. It has been used directly on wounds or applied to a non-adherent dressing, which is then applied to the wound. The effects are apparently longer lasting than that of adrenaline. Unfortunately the suspension is no longer commercially made but 1 or 2 x 500mg tablets crushed and dissolved in 5–10ml water or lubricating jelly can be applied to a bleeding surface if practicable.
4. Oxycel or Surgicel dressings
These oxidised cellulose dressings are highly absorbent and also staunch bleeding but must be left in place for some time after application and can only be used once. They were developed for use in surgery to mop up bleeds and are not on the Drug Tariff – i.e. not available on FP10. They are a useful dressing to have at hand for potentially serious bleeds and to provide for patients at home for the same reasons. They are probably too costly for use daily on capillary bleeds where some of the above methods may be preferable.
Some brands of alginate (Kaltostat, Sorbsan) claim to have haemostatic properties, due to their calcium content, that can be used to control minor bleeding although this is not a licensed use of these dressings.
Oxycel dressing 5cm x 8cm (very expensive)
Surgicel dressing 1.25cm x 5cm (moderately expensive)
Kaltostat is regarded as useful for prophylactic dressings in between bleeds.
(1)Recka et al. ‘Management of bleeding associated with bleeding malignant wounds.’ Journal of Palliative Medicine Volume 15, Number 8, 2012
Other information from the BNF, Palliative Care Formulary and direct communications with wound care nurses at the Royal Marsden Hospital