What to do if a bladder tamponade (catheter) fails to control bleeding?

Management of Failed Bladder Tamponade Catheter

If a bladder tamponade catheter fails to control bleeding, proceed immediately to TIPS (Transjugular Intrahepatic Portosystemic Shunt) placement as a rescue treatment, which achieves control of bleeding in 90-100% of cases. 1

Initial Assessment After Catheter Failure

When a bladder tamponade catheter fails to control bleeding, rapid assessment and escalation of care is essential:

1. Confirm true failure of tamponade:

   • Ensure catheter is properly positioned and not kinked
   • Verify adequate size (at least 20 French for flushing catheter) 2
   • Check if manual evacuation of clots was attempted

2. Immediate interventions while preparing for definitive treatment:

   • Continue bladder irrigation with normal saline
   • Consider placement of a larger catheter (≥20 French)
   • Maintain hemodynamic stability with fluid resuscitation
   • Monitor hemoglobin levels (target 7-9 g/dL) 1

Rescue Treatment Options

First-line Rescue Treatment:

• TIPS placement - Most effective rescue treatment with immediate bleeding control rates of 90-100% 1
  • Should be performed urgently when pharmacological and endoscopic therapy fail
  • One-year survival rates of approximately 51.7% have been reported

Bridge Therapies (while arranging TIPS):

• Self-expandable metal esophageal stent - Preferred over balloon tamponade

  • Higher bleeding control rates (85% vs 47%) 1
  • Lower serious adverse events (15% vs 47%) 1
  • Can remain in place for up to 2 weeks

• Balloon tamponade - Traditional bridge therapy

  • Provides hemostasis in 80-90% of patients 1
  • High rebleeding rate (approximately 50%) after deflation
  • Should not exceed 24 hours due to risk of complications (esophageal ulceration, rupture, aspiration pneumonia) 1

For Catheter-Related Issues:

• Thrombolytic therapy for catheter occlusion
  • Tissue plasminogen activator (tPA) is the recommended agent 1
  • Urokinase or recombinant urokinase can also be used 1
  • Success rates of 72% with first dose, increasing to 83% with second dose 1

Alternative Approaches for Persistent Bleeding

If TIPS is not immediately available or contraindicated:

1. Endoscopic interventions:

   • Hemostatic powder application via endoscopy (within 2 hours of admission) 1
   • Followed by early elective endoscopy for definitive treatment

2. Transurethral coagulation for bladder-specific bleeding 3

3. Intravesical treatments for radiation-induced hemorrhagic cystitis:

   • Intravesical instillation of aluminum hydroxide gel and magnesium hydroxide (50-100 ml for an hour daily) 4

When to Consider TIPS Futile

TIPS may be futile in patients with:

• Multiple organ failure
• Child-Pugh score ≥14
• MELD score ≥30 and/or lactatemia ≥12 mmol/L after initial resuscitation 1

Special Considerations

• Antibiotic prophylaxis should be instituted in patients with acute bleeding 1
• Vasoactive agents should be initiated as soon as possible if portal hypertension-related bleeding is suspected 1
• Restrictive blood transfusion strategy with target hemoglobin of 7-9 g/dL is recommended 1

Monitoring After Rescue Treatment

• Close monitoring of vital signs
• Serial hemoglobin measurements
• Monitoring for signs of rebleeding
• Assessment of liver function and encephalopathy in cirrhotic patients

Remember that failure to control acute bleeding is defined as death or need to change therapy within 5 days, characterized by fresh hematemesis, hypovolemic shock, or significant drop in hemoglobin 1.