What are the discharge instructions for a patient with bleeding varicose veins, considering potential underlying conditions such as bleeding disorders or anticoagulant medication use?

Discharge Instructions for Bleeding Varicose Veins

Immediate Home Care Instructions

Apply direct pressure with a clean cloth or gauze for 10-15 minutes if bleeding recurs, elevate the leg above heart level, and call 911 if bleeding does not stop within 15 minutes. 1

Bleeding Control Technique

• Keep clean gauze or towels readily accessible at home in case of recurrent bleeding 1
• If bleeding starts, immediately lie down and elevate the affected leg above the level of your heart 1
• Apply firm, direct pressure to the bleeding site with a clean cloth for at least 10-15 minutes without peeking 1
• Do not remove the initial cloth if it becomes soaked—add additional layers on top 1
• Call emergency services (911) if bleeding does not stop after 15 minutes of continuous pressure 1

Leg Elevation and Activity

• Elevate your legs above heart level for 15-20 minutes every 2-3 hours while awake to reduce venous pressure 2, 1
• Avoid prolonged standing or sitting with legs dependent 2
• When sitting, prop your legs up on pillows or an ottoman 2
• Sleep with legs elevated on 2-3 pillows at night 1

Compression Therapy

• Wear prescribed compression stockings (20-30 mmHg) daily from morning until bedtime unless otherwise instructed 3, 1
• Remove compression stockings at night while sleeping with legs elevated 3
• Replace compression stockings every 3-6 months as they lose elasticity 1

Medication Management

If You Are on Blood Thinners (Anticoagulants)

• Do NOT stop your anticoagulant without explicit instruction from your prescribing physician 4
• Contact your anticoagulation clinic or prescribing physician within 24 hours to discuss your bleeding episode 4
• If you were instructed to temporarily hold anticoagulation, resume only when specifically told to do so by your physician 4
• Expect to restart anticoagulation once there has been no bleeding for at least 24 hours 4

Prophylactic Antibiotics

• Complete the full course of prophylactic antibiotics as prescribed (typically 3-7 days) 5, 6
• Take antibiotics even if you feel well, as they prevent infection in the damaged vein 5

Beta-Blockers (If Prescribed)

• If you were started on a non-selective beta-blocker (propranolol or nadolol) for variceal bleeding prevention, continue taking it daily as prescribed 5, 6
• Do not stop this medication without consulting your physician 6

Wound Care

Bleeding Site Management

• Keep the area clean and dry 3, 1
• Gently wash with mild soap and water once daily 3
• Pat dry—do not rub the area 3
• Apply a clean, dry dressing if there is any oozing 3
• Do NOT apply any creams, ointments, or lotions to the bleeding site unless specifically prescribed 3

Signs of Infection to Watch For

• Increasing redness spreading beyond 1 inch from the wound 1
• Warmth or heat at the site 1
• Pus or cloudy drainage 1
• Fever above 100.4°F (38°C) 1
• Red streaks extending up the leg 1

Activity Restrictions

What to Avoid

• Avoid any trauma to the affected leg, including bumping, scratching, or rubbing the varicose veins 1, 7
• Do not wear tight clothing that constricts the legs 2
• Avoid hot baths, hot tubs, or saunas for 2 weeks 1
• No heavy lifting (>20 pounds) for 1 week 1
• Avoid vigorous exercise for 1 week, then gradually resume as tolerated 1

Safe Activities

• Walking is encouraged—aim for short walks (5-10 minutes) every 2-3 hours while awake 1
• Light household activities are acceptable 1
• Driving is permitted if you are not taking narcotic pain medications 1

Follow-Up Care

Scheduled Appointments

• You must attend your scheduled vascular surgery or vein specialist appointment within 2-8 weeks for definitive treatment (endovenous ablation or sclerotherapy) 1
• Missing this appointment significantly increases your risk of life-threatening rebleeding 1
• If you have underlying liver disease or portal hypertension, you also need hepatology follow-up within 1-2 weeks 5, 6

Surveillance Endoscopy (If Applicable)

• If your bleeding was from rectal or anorectal varices related to portal hypertension, you will need repeat endoscopy every 7-14 days until varices are obliterated 4
• After variceal obliteration, surveillance endoscopy every 3-6 months is required 4

When to Seek Emergency Care

Call 911 Immediately If:

• Bleeding that does not stop after 15 minutes of direct pressure and elevation 1
• Large volume of blood loss (soaking through multiple towels) 1
• Feeling dizzy, lightheaded, or faint 1
• Rapid heartbeat or chest pain 1
• Confusion or difficulty staying awake 1
• Pale, cold, or clammy skin 1

Go to Emergency Department If:

• Recurrent bleeding episodes even if they stop with pressure 1
• Signs of infection as listed above 1
• New or worsening leg swelling 2
• Severe pain not controlled with over-the-counter pain medication 1

Special Considerations

If You Have Heart Failure

• You are at higher risk for recurrent bleeding 2
• Strict adherence to your heart failure medications and fluid restrictions is essential 2
• Daily weights—report weight gain of >2 pounds in 24 hours or >5 pounds in 1 week to your cardiologist 2

If You Have Liver Disease or Portal Hypertension

• Continue all liver disease medications as prescribed 5, 6
• Avoid alcohol completely 6
• Monitor for signs of hepatic encephalopathy (confusion, drowsiness, personality changes) 5
• Maintain adequate nutrition—consult with a dietitian if needed 6

Long-Term Prevention

Definitive Treatment Required

• Sclerotherapy or endovenous ablation is necessary to prevent recurrent life-threatening bleeding 2, 1
• Without definitive treatment, 85-93% of patients remain free from rebleeding, but 7-15% will have potentially fatal recurrence 2, 1
• The two-step protocol of immediate sclerotherapy followed by endovenous ablation within 8 weeks provides the most durable freedom from hemorrhage 1

Lifestyle Modifications

• Maintain healthy weight to reduce venous pressure 2
• Regular exercise (walking) to improve calf muscle pump function 2
• Avoid prolonged standing or sitting 2
• Wear compression stockings daily for life 1