What is involved in nasal packing for a patient with a nosebleed, impaired renal function, and taking anticoagulants like rivaroxaban (Xarelto)?

Nasal Packing for Nosebleed: Procedure and Special Considerations

Nasal packing should only be performed after firm sustained compression to the lower third of the nose for at least 5 minutes has failed to control bleeding, and in patients on anticoagulants like rivaroxaban with renal impairment, resorbable packing materials must be used exclusively. 1, 2

When to Proceed with Nasal Packing

• Apply firm sustained compression to the soft lower third of the nose for a minimum of 5 minutes before considering packing 1, 2
• If bleeding persists despite adequate compression, attempt to identify the bleeding source using anterior rhinoscopy after removing blood clots 1, 2
• Proceed with packing only when ongoing active bleeding continues despite compression or when bleeding prevents identification of the source 2

Critical Packing Material Selection for Your Patient

For patients on rivaroxaban (Xarelto) with renal impairment, you must use resorbable packing materials exclusively - this is non-negotiable. 2 Options include:

• Nasopore
• Surgicel
• Floseal
• Gelatin sponge
• Fibrin glue 2

The rationale is that resorbable materials reduce rebleeding risk upon removal and improve patient comfort compared to nonresorbable materials. 2 This is particularly important because rivaroxaban clearance is impaired in renal dysfunction, increasing bleeding risk. 3, 4

The Packing Procedure

• Before packing, apply topical vasoconstrictors to the nasal mucosa 1
• Insert the packing material into the affected nostril, ensuring adequate coverage of the bleeding site 5
• In 52% of cases requiring packing, nasal cautery is performed concurrently; 41% receive anterior packing alone; 7% require both anterior and posterior packing 5
• Posterior packing is reserved for cases where anterior bleeding cannot be controlled or the source is clearly posterior 6

Duration and Removal

• Resorbable packing does not require removal - it dissolves over time with nasal saline spray use 2
• If nonresorbable packing were used (which it should NOT be in your patient), it must be removed within 5 days maximum 2
• Follow-up is still recommended even with resorbable packing to monitor proper mucosal healing 2

Mandatory Patient Education

You must educate the patient about the following before discharge: 5, 2

Expected symptoms (normal and not concerning):

• Nasal obstruction
• Decreased sense of smell
• Facial pressure and headaches
• Nasal drainage
• Eye tearing
• Symptoms mimicking a cold 2

Activity restrictions:

• Avoid straining, lifting over 10 pounds, bending over, and exercising 2
• Sleep with head elevated 2
• Do NOT blow the nose while packing is in place 5
• If sneezing occurs, sneeze with mouth open 5

Medication precautions:

• Avoid over-the-counter pain medications that increase bleeding (aspirin, ibuprofen) 5
• Acetaminophen (Tylenol) is safe and does not increase bleeding 5

Post-Procedure Care Protocol

• Apply nasal saline spray frequently throughout the day to keep packing moist and reduce crusting 2
• Use petroleum jelly or saline gel to the nasal vestibule 1-3 times daily 2
• Consider using a bedside humidifier 2

Warning Signs Requiring Immediate Medical Attention

Instruct the patient to seek emergency care for: 5, 2

• Return of blood from nose or mouth
• Fever over 101°F
• Increasing pain
• Vision changes
• Shortness of breath or labored breathing
• Loss of color around the skin of the nose
• Swelling of the face
• Diffuse skin rash 5

Special Considerations for Rivaroxaban and Renal Impairment

Critical pitfall to avoid: Do NOT discontinue rivaroxaban before attempting first-line treatments (compression, packing, cautery) unless bleeding is life-threatening. 1, 2 The American Academy of Otolaryngology-Head and Neck Surgery recommends initiating these interventions before considering anticoagulation reversal or withdrawal. 1, 2

Renal impairment increases rivaroxaban exposure significantly: Patients with moderate renal impairment have substantially increased rivaroxaban levels compared to those with normal renal function, and this increases bleeding risk exponentially. 3, 4, 7 Your patient's impaired renal function means rivaroxaban clearance is reduced by approximately 56% compared to normal renal function. 3

Infection risk: Packing is a foreign material that can support bacterial growth, with low but real risk of sinusitis or toxic shock syndrome. 2 Consider prophylactic antibiotics in high-risk cases, though this requires discussion of antibiotic risks (allergic reactions, gastrointestinal problems). 2

Follow-Up Requirements

• Document the outcome of intervention within 30 days 2
• Schedule follow-up even with resorbable packing to monitor mucosal healing 2
• If bleeding recurs despite packing, perform or refer for nasal endoscopy 2

If Packing Fails

For persistent or recurrent bleeding not controlled by packing or cauterization, evaluate candidacy for: 1

• Surgical arterial ligation (endoscopic sphenopalatine artery ligation)
• Endovascular embolization 1