Abstract
BackgroundPalliative care patients, those suffering from at least one chronic lifelong medical condition and hospice care patients, those with a life expectancy less than 6 months, are regularly hospitalised in general internal medicine wards. By means of a clinical case, this review aims to equip the internist with an approach to bleeding in this population. Firstly, practical advice on platelet transfusions will be provided. Secondly, the management of bleeding in site-specific situations will be addressed (from the ENT/pulmonary sphere, gastrointestinal - urogenital tract and cutaneous ulcers). Finally, an algorithm pertaining to the management of catastrophic bleeding is proposed.MethodsElectronic databases, including EMBASE, Pubmed, Google Scholar and the Cochrane Library were studied as primary resources, in association with local guidelines, to identify papers exploring platelet transfusions and alternative management of site-specific bleeding in palliative care patients.ResultsHaemorrhagic complications are frequent in palliative care patients in the internal medicine ward. Current guidelines propose a therapeutic-only platelet transfusion policy. Nonetheless, prophylactic and/or therapeutic transfusion remains a physician-dependent decision. Site-specific therapeutic options are based on expert opinion and case reports. While invasive measures may be pertinent in certain situations, their application must be compatible with patient goals. Catastrophic bleeding requires caregivers' comforting presence; pharmacological management is secondary.ConclusionLiterature is lacking regarding management of bleeding in the palliative care population hospitalised in an acute medical setting. Recommendations are of limited quality, the majority based on case reports or expert opinion. Further studies, exploring for example the impact on patient quality of life, are desirable to improve the management of this frequently encountered complication.
Highlights
Clinical case: A 49-year old male is admitted to the internal medicine ward complaining of a decline in general health
An algorithm pertaining to the management of catastrophic bleeding is proposed
Electronic databases, including EMBASE, Pubmed, Google Scholar and the Cochrane Library were used as primary resources, in association with local guidelines, in order to identify papers exploring platelet transfusions and alternative management of site-specific bleeding
Summary
Clinical case: A 49-year old male is admitted to the internal medicine ward complaining of a decline in general health. The laboratory work-up reveals bicytopenia with haemoglobin at 90 g/l (norms 140–180 g/l), platelets 25 G/l (norms 150400 × 109/L), an inflammatory syndrome CRP 235 mg/dL (norms < 10 mg/dL), white blood cell count at 15.5 G/l (norms 4.0–10.0 G/l) and renal failure AKIN 1 (Creatinine 130 μmol/l, norms 50–110 μmol/L) This is the second hospitalisation since his initial diagnosis. The patient complains of orthostatic symptoms (dizziness and blurry vision upon sitting up), but no nausea or abdominal pain Palliative care patients, those suffering from at least one chronic lifelong medical condition and hospice care patients, those with a life expectancy less than 6 months, are regularly hospitalised in general internal medicine wards. Further studies, exploring for example the impact on patient quality of life, are desirable to improve the management of this frequently encountered complication
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