A new device for managing refractory epistaxis in ICU
patients with COVID19
Key words: epistaxis treatment, COVID-19, recurrent epistaxis
Five Key points
COVID 19 treatment generate nose bleeding
Covid 19 treatment necessitate prone position
Nasal packing is useful but sometimes insufficient
CAVI-T is a new treatment of epistaxis
CAVI-T is especially adapted to COVID patient in prone position due to its specific form
Introduction :
Epistaxis is a common and a well-known symptom. Nasal packing is an effective treatment in most cases. (1)
The COVID-19 disease treatment includes conventional or high flow nasal oxygen therapy and systemic anticoagulation (2). Patients in intensive care unit may require therapeutic anticoagulation for venous thromboembolism, hyperinflammatory status, extracorporeal membrane oxygenation (ECMO) and multiple other pathologies. The use of therapeutic anticoagulation increases risk of nose bleeding and its management may be challenging.
CAVI-T (Picture 1 & 2) is a new asymmetrical low-pressure balloon that have shown promising results to control epistaxis in emergency.
We report herein the management of severe epistaxis in two COVID 19 patients admitted to ICU for severe respiratory failure.
Patient 1
A 51-year-old COVID-19 positive male patient admitted to ICU for respiratory failure. He was intubated, sedated and ventilated in prone position. Therapeutic anticoagulation with enoxaparin was indicated due to hyperinflammatory status (fibrinogen = 8.7g/l).
Because of enteral feeding intolerance, a nasogastric tube (SALEM) was inserted and placed on suction for 12 hours. The patient then developed epistaxis with hemoglobin drop from 10.4 g/dL to 9.2g/dL within 24 hours. Further tests revealed no hemostasis abnormalities (platelets 231 g/l, TCA 1.43, TP 100%). Hence, therapeutic anticoagulation was deemed to be the cause of patient’s epistaxis. Despite anterior packing with Algosteril@ bleeding continued and hemoglobin level dropped to 8.0g/l.
Therefore, a CAVI-T balloon was placed in each nostril and inflated with 15 cc of air. Bleeding decreased within few hours and stopped thereafter. Hemoglobin stabilized and red blood cell transfusion was not necessary despite maintaining therapeutic anticoagulation. Balloons were deflated and removed 48 hours after insertion without relapse of epistaxis.
Patient 2
A 31-year-old male patient was admitted in ICU for respiratory failure due to SARS Cov 2 infection. Patient did not improve despite high flow oxygen delivery, and he needed to be intubated and sedated.
Because of severe adult respiratory distress syndrome with a PaO2/FiO2 ratio of 50 despite prone positioning a venovenous ECMO was implemented. In addition, acute renal failure developed and the patient was placed on continuous hemodialysis. After initiation of anticoagulation, patient developed diffuse hemorrhagic status with epistaxis, hematuria and bleeding at puncture sites. Bilateral nasal packing with Algosteril@ was ineffective. Hemoglobin dropped and patient was transfused.
CAVI-T balloons were inserted in each nasal cavity and were inflated with 10 cc air. Epistaxis resolved within 24 hours. Hemoglobin stabilized and patient did not need further blood transfusion. Balloons were deflated after 48 hours and removed without epistaxis recurrence.