Should I stop Clexane (enoxaparin) in a patient with a tracheostomy who is experiencing bleeding?

Management of Bleeding in a Tracheostomy Patient on Clexane (Enoxaparin)

Yes, you should immediately stop Clexane (enoxaparin) in a patient with a tracheostomy who is experiencing active bleeding, as hemorrhage in tracheostomy patients carries a two- to four-fold increased mortality risk and requires urgent intervention. 1

Immediate Actions Required

Stop Anticoagulation

• Discontinue enoxaparin immediately when active bleeding is observed from the tracheostomy site, as bleeding complications are common and can be life-threatening in this population 1, 2
• The decision to stop anticoagulation should prioritize hemorrhage control over thrombotic risk in the acute bleeding phase, as mortality from tracheostomy hemorrhage ranges from 10-33% depending on patient population 1, 2, 3

Assess Bleeding Severity

• Suspect tracheoinnominate artery fistula (TIAF) if you observe moderate to severe bleeding from the stomal site, pulsation of the tracheostomy tube, or a "sentinel bleed" (which occurs in approximately 50% of TIAF cases before massive hemorrhage) 2
• Minor bleeding (self-limiting, localized stomal ooze) occurs in approximately 32% of cases and may be managed conservatively, while significant bleeding (requiring surgical control or associated with hemoglobin drop >20 g/L) occurs in 8% and requires aggressive intervention 4

Emergency Management Algorithm

For Suspected Major Bleeding or TIAF:

• Hyperinflate the existing tracheostomy tube cuff or insert a cuffed tracheal tube via the stoma with the tip placed distal to the fistula 2
• Apply digital pressure either directly through the stoma or externally to the innominate artery site (Utley Maneuver) 2
• Activate massive transfusion protocol and prepare for emergency operative intervention with personnel capable of performing sternotomy 2
• Division and ligation of both ends of the innominate artery is the definitive management for TIAF 2

For Minor Bleeding:

• Identify and address the underlying cause, including traumatic suctioning, granulation tissue, or local infection 2
• Review suctioning technique to ensure the suction catheter is measured to pre-determined depth (100-200 cmH₂O negative pressure) and passes easily beyond the tube tip 2
• Examine the stoma for signs of local infection and change dressing with physiological saline 2

Risk Factors and Coagulation Considerations

High-Risk Coagulation Parameters:

• Activated partial thromboplastin time (aPTT) >50 seconds increases chronic bleeding risk 3.7-fold (NNT 18.4) 5
• Platelet count <50 × 10⁹/L increases chronic bleeding risk 5-fold (NNT 12.3) 5
• Two or more abnormal coagulation variables increase chronic bleeding risk 9.5-fold (NNT 6.2) 5

Important Caveat:

• Interestingly, low-dose heparin treatment (prophylactic dosing) did not significantly increase the risk of chronic bleeding in one study 5, though this should not prevent stopping therapeutic anticoagulation in active bleeding

When to Resume Anticoagulation

Timing Considerations:

• For minor bleeding with adequate hemostasis: Consider resuming enoxaparin 24 hours after bleeding has stopped and hemostasis is confirmed 1, 6
• For significant bleeding or surgical intervention: Delay restart 48-72 hours after achieving hemostasis 6
• Assess the underlying indication for anticoagulation and weigh thrombotic risk against ongoing bleeding risk before restarting 1

Bridging Strategy:

• If the patient has high thrombotic risk (mechanical heart valve, recent VTE, atrial fibrillation with high CHADS₂-VASc score), consult cardiology or hematology for bridging strategy once bleeding is controlled 7
• Do not overlap enoxaparin with oral anticoagulants when transitioning, as this significantly increases bleeding risk without additional thrombotic protection 7

Critical Pitfalls to Avoid

• Never dismiss a "sentinel bleed" as minor—this precedes massive hemorrhage in 50% of TIAF cases and requires immediate surgical consultation 2, 3
• Do not attempt vigorous hand ventilation via the tracheostomy if tube patency cannot be confirmed with a suction catheter, as this can cause massive surgical emphysema 2
• Avoid instilling saline before suctioning, as this increases coughing and aerosolization with little benefit and may worsen bleeding 2
• Do not delay definitive surgical management for suspected TIAF—mortality approaches 10% with significant hemorrhage and can be reduced with appropriate recognition and intervention 2, 3