What to do next for a patient with high bleeding risk?

Management of a Patient with High Bleeding Risk (Score of 6 on Bleeding Assessment Tool)

For a patient who scored 6 on the bleeding assessment tool, immediate risk stratification and implementation of a bleeding management protocol is required, including discontinuation of any anticoagulants, assessment for critical site bleeding, and consideration of reversal agents if necessary.

Initial Assessment and Risk Stratification

A score of 6 on the bleeding assessment tool indicates high bleeding risk that requires prompt intervention. The first step is to determine the severity of bleeding using established criteria:

• Check for criteria of major bleeding 1:

  • Bleeding at a critical site (intracranial, intraspinal, intraocular, retroperitoneal, pericardial, intra-articular, or intramuscular with compartment syndrome)
  • Hemodynamic instability
  • Clinically overt bleeding with hemoglobin decrease ≥2 g/dL or requiring ≥2 units of RBC transfusion

• Assess vital signs, including:

  • Heart rate and blood pressure to detect hemodynamic instability
  • Skin color and capillary refill
  • Level of consciousness

Immediate Management Actions

1. If major bleeding is present:

   • Stop any oral anticoagulants (OACs) and antiplatelet agents immediately 1
   • Provide local therapy/manual compression if applicable
   • If the patient is on a vitamin K antagonist (VKA), administer 5-10 mg IV vitamin K
   • Provide supportive care and volume resuscitation
   • Consider surgical/procedural management of the bleeding site

2. If bleeding is at a critical site or life-threatening:

   • Administer appropriate reversal/hemostatic agents 1:
     • For dabigatran: idarucizumab
     • For apixaban or rivaroxaban: andexanet alfa
     • For VKAs: prothrombin complex concentrates and vitamin K

3. Laboratory investigations:

   • Obtain baseline blood tests including full blood count, prothrombin time (PT), activated partial thromboplastin time (aPTT), Clauss fibrinogen, and cross-match 1
   • If available, perform near-patient testing (thromboelastography or thromboelastometry)

Management of Upper Gastrointestinal Bleeding (if suspected)

If upper GI bleeding is suspected:

1. Pharmacological management:

   • Administer high-dose intravenous PPI therapy (80 mg IV bolus followed by 8 mg/hour continuous infusion) for 72 hours after successful endoscopic hemostasis 2
   • Follow with twice-daily oral PPI for 11 days, then once-daily PPI to complete 6-8 weeks of treatment 2

2. Endoscopic evaluation:

   • Perform endoscopy within 24 hours of presentation, with earlier endoscopy for high-risk patients 2
   • For peptic ulcers with high-risk stigmata, use combination endoscopic therapy (epinephrine injection plus thermal method) 2

Management of Anticoagulation

If the patient is on anticoagulants:

1. For patients on warfarin:

   • Discontinue warfarin immediately
   • For severe hemorrhage, reverse with vitamin K and prothrombin complex concentrate 1
   • Consider restarting warfarin 7 days after bleeding has stopped 1

2. For patients with high thrombotic risk:

   • Consider low molecular weight heparin therapy 48 hours after hemorrhage is controlled 1

3. For patients on antiplatelet therapy:

   • If aspirin is for primary prophylaxis, permanently discontinue 1
   • If aspirin is for secondary prevention, restart as soon as hemostasis is achieved 1
   • P2Y12 receptor antagonist therapy should be reinstated within 5 days 1

Ongoing Care and Monitoring

• Actively warm the patient and all transfused fluids 1
• Monitor coagulation parameters, hemoglobin, and blood gases
• Assess for signs of rebleeding
• Once bleeding is controlled, normalize blood pressure, acid-base status, and temperature
• Avoid vasopressors if possible 1
• Consider admission to a critical care area for monitoring

Special Considerations

• For patients with peptic ulcer disease, test for H. pylori and provide eradication therapy if positive 2
• For patients requiring NSAIDs with history of bleeding, use combination of PPI and COX-2 inhibitor if NSAIDs must be continued 2
• Initiate standard venous thromboprophylaxis as soon as bleeding is controlled 1

Decision on Restarting Anticoagulation

Once bleeding is controlled and the patient is stable, assess whether there is a clinical indication for continued anticoagulation:

• If any of the following apply, delay restarting anticoagulation 1:

  • Bleeding occurred at a critical site
  • Patient is at high risk of rebleeding
  • Source of bleed has not been identified
  • Surgical or invasive procedures are planned

• If none of the above apply and anticoagulation is indicated, restart anticoagulation at an appropriate time 1

By following this structured approach, you can effectively manage a patient with a high bleeding risk score while minimizing morbidity and mortality.