Perioperative Epistaxis

Kyle J. Joseph DMD, MS and Cara J Riley DMD MS

Today’s PAAD focuses on perioperative epistaxis¹, a topic recently covered at the American Society of Dentist Anesthesiologists (ASDA) Annual Scientific Session held in April 2024. Epistaxis is a common complication of nasal instrumentation and intubation that ranges in severity from minor to life-threatening. While the saying “an ounce of prevention is worth a pound of cure” certainly applies, treatment of epistaxis must remain fresh in the minds of all anesthesia providers utilizing approaches at risk for nasal bleeding. The nasal cavity is highly vascular, and instrumentation, insertion of nasal tubes, and tube movement during an anesthetic can all lead to trauma, hemorrhage, and catastrophic airway loss. The literature referenced in today’s PAAD discusses the perioperative management of epistaxis including preventative measures and treatment options for epistaxis of various severities.

Original article

Shieh A, Cranford JA, Weyand AC, Bohm LA, Tomlinson SE. Risk Factors and Management Outcomes in Pediatric Epistaxis at an Emergency Department. J Emerg Med. 2024 Feb;66(2):97-108. doi: 10.1016/j.jemermed.2023.10.031. Epub 2023 Oct 30. PMID: 38307761.

This retrospective study assessed 858 emergency department (ED) visits for epistaxis in patients below 22 years of age. Severity of epistaxis (mild, moderate, and severe) was assessed along with various management modalities, risk factors, and outcomes. Mild epistaxis was noted in 750 (87%) of patients, but 41 (5%) patients had moderate and 67 (8%) had severe epistaxis. Most cases of pediatric epistaxis are mild and respond adequately to nasal compression or intranasal medications. However, more significant interventions, such as nasal packing, cautery, transfusions, or factor replacement, are likely for moderate and severe epistaxis. Furthermore, identified factors for an increased risk of epistaxis included older patients, bleeding lasting longer than 30 minutes, a prior ED visit within 72 hours, bleeding disorders, antiplatelet medication use, nasal procedures within 30 days, and anticoagulation use.

The findings of this study, which focused on the general management of pediatric patients who presented to the ED, loosely mirrored those in a 2021 article on the general management of an adult patient with epistaxis.² The authors state “management of epistaxis is straightforward in most cases but can be challenging in patients with cardiovascular disease, impaired coagulation, or platelet dysfunction.”

General epistaxis is appropriately controlled in a systematic and escalating fashion. Initially, patients in the medical setting are advised to apply digital compression to the lower third of the nose for 15 to 20 minutes, which is followed by anterior rhinoscopy. Anterior bleeding can usually be controlled with topical vasoconstrictors, tranexamic acid, cautery, or anterior nasal packing. Continued epistaxis despite these measures requires more aggressive treatment, with the involvement of specialists in otolaryngology and head and neck surgery and, generally, hospital admission.”

The management options detailed in both articles focus mainly on the general management of epistaxis. However, given the unique circumstances often surrounding sedation and general anesthesia, a detailed look at perioperative epistaxis management related to nasal intubation is likely warranted as discussed in a 2019 article published in Anesthesia Progress (AP).³ 

According to the algorithms presented in both the NEJM and AP documents, treatment of perioperative epistaxis occurs in a progressive fashion. It begins with digital compression (if possible based on the patient’s position and level of consciousness) and proceeds to application of topical vasoconstrictors such as oxymetazoline, consideration of cautery, consideration of tranexamic acid, packing of the anterior nasal cavity, tamponade of the posterior nasal cavity, and finally, consultation with specialists for more advanced modalities of hemorrhage control. Of note, the NEJM article mentions the use of oral and topical tranexamic acid; since patients under sedation or general anesthesia typically have IV access established, an IV infusion of tranexamic acid is another viable option, although unlikely in office-based settings. 

Epistaxis originating in the posterior nasal cavity is more profuse, more difficult to control, and more likely to lead to airway compromise and/or aspiration than anterior bleeding events. Identifying the true site of hemorrhage can be difficult, particularly as it relates to nasal intubation, as tissue injury can occur anywhere along the NETT’s path. Focusing on epistaxis in the setting of nasal intubation, the authors of the AP article state the following premise:³

“1. if bleeding occurs during [NETT] tube insertion, intubation should be completed as rapidly as possible, with the endotracheal tube itself acting to tamponade the bleeding; and

2. if tracheal intubation cannot be completed at that time and there is active bleeding during attempted intubation, the [nasal] endotracheal tube may be withdrawn and repositioned with the inflated cuff within the postnasal space, to prevent blood passing into the oropharynx and to act simultaneously as a nasopharyngeal airway.”

The latter maneuver can also be accomplished using a Foley balloon catheter, as is presented in the two case studies. Additionally, Kido et al., mention the use of a supraglottic airway device (i.e., an LMA) as an alternative means of isolating the airway from significant nasal bleeding during an emergency. Attention must be paid to maintaining airway patency and effective ventilation/oxygenation throughout the perioperative event while simultaneously attempting to control and stop the nasal bleeding. 

Anecdotally, for mild to moderate anterior epistaxis following NETT extubation, a simple treatment is to place an oxymetazoline-soaked cotton roll into the nasal cavity for compression and vasoconstriction, which can be removed prior to patient discharge. Oxymetazoline is also frequently used prior to nasal intubation as a preventative measure, but it must be applied correctly. The spray requires a fine mist to cover as much mucosa as possible. The commercial bottles only create a mist when sprayed upwards; when sprayed downward in a supine patient, the bottle produces a stream of oxymetazoline that likely just traverses the nasal cavity floor and downward into the posterior pharynx. A mucosal atomizer device attached to a syringe of oxymetazoline can be substituted to create the desired mist. Another consideration is the onset time of oxymetazoline, which approximates 5-10 minutes. Administering oxymetazoline immediately before intubation is unlikely to produce the maximal vasoconstriction and decongestion practitioners desire; it may, however, help to prevent epistaxis on extubation.

In my (CJR) career at Children’s Hospital Colorado, the two most dire code-blue situations during dental surgeries of which I am aware involved disastrous epistaxis. In one case, posterior epistaxis occurred covertly, following deep extubation (no bleeding was reported on intubation) and was not discovered until the attending anesthesiologist recognized the patient was in respiratory distress. Thankfully, reintubation was successful despite copious blood in the oropharynx; large blood clots were evacuated from the airway during and after intubation. The patient ended up being admitted to intensive care for a week. In the second case, epistaxis occurred upon intubation that was so severe it precluded visualization of the airway and effective ventilation via mask or LMA placement. An oral and maxillofacial surgeon present for the case expeditiously secured a surgical airway. Although both patients were ASA III, neither had any obvious reported risk factors for epistaxis. These cases highlight the importance of preventing and effectively managing perioperative epistaxis.

Send your thoughts and comments to Myron who will post in a Friday reader response

References

1.            Shieh A, Cranford JA, Weyand AC, Bohm LA, Tomlinson SE. Risk Factors and Management Outcomes in Pediatric Epistaxis at an Emergency Department. J Emerg Med 2024;66(2):97-108. (In eng). DOI: 10.1016/j.jemermed.2023.10.031.

2.            Seikaly H. Epistaxis. The New England journal of medicine 2021;384(10):944-951. (In eng). DOI: 10.1056/NEJMcp2019344.

3.            Kido K, Shindo Y, Miyashita H, Kusama M, Sugino S, Masaki E. Acute Management of Massive Epistaxis After Nasotracheal Extubation. Anesth Prog 2019;66(4):211-217. (In eng). DOI: 10.2344/anpr-66-02-09.