Acta Otorrinolaringol Esp 2005; 56: 305-308
CLINICAL RESEARCH
Statistical study regarding anemia in patients
admitted with epistaxis. Importance of its control
and the associated risk factors
V. Pino Rivero, A. González Palomino, C. G. Pantoja Hernández, G. Trinidad Ruiz, G. Pardo Romero, C.
Montero García, E. Rejas Ugena, A. Blasco Huelva
Servicio de Otorrinolaringología. Complejo Hospitalario Infanta Cristina. Badajoz.
Abstract: Objective: To highlight the importance of
hemodynamic stability and the importance of risk
factors for patients hospitalized with epistaxis. Material
and methods: A retrospective study of 200 consecutive
patients who were admitted with epistaxis between the
years of 1997 and 2004. 46 of the patients (23%)
developed some degree of anemia. Amongst other
clinical variables we analyzed the risk factors present,
age, sex, the level of hematocrit and hemoglobin, the
origin of the nasal hemorrhage, the number of
transfusions that were required and the type of nasal
packing used. Results: We found a statistically
significant association (p<0.01) between anemizing
epistaxis and risk factors. About 39% of such cases
needed a blood transfusion; generally of red cell
concentrates. Conclusion: With every case of epistaxis
admitted it is necessary to first and foremost control the
patient’s hemodynamic state and to treat the associated
underlying pathology.
Key words: Epistaxis. Anemia. Transfusion.
INTRODUCTION
Anemia occurs when there is a decrease in the
number of erythrocytes, with hemoglobin (Hb)
circulating below the normal levels in relation to factors
such as age, sex, physiological state and environmental
conditions. In clinical practice and according to the
criteria of the WHO, anemia is diagnosed when Hb<13
Correspondence: Dr. Vicente Pino Rivero
Avda. Antonio Masa 3,5º G
6005 Badajoz
E-mail: [email protected]
Fecha de recepción: 14-3-2005
Fecha de aceptación: 9-5-2005
g/dl in adult males; Hb<13 g/dl in adult females or <11
in pregnant women and/or when there is a gradual or
sudden drop of 2g/dl or more in the usual Hb level of a
patient, even though that figure may remain within the
normal limits for the patient’s age and sex.
Anemia is a sign of illness and, at the same time, a
common manifestation of many different diseases
frequently seen in patients in the hospital Emergency
department. Epistaxis is one of the possible causes of
anemia and one that particularly requires that the
possible general risk factors and the hemodynamic state
be controlled, as well as that the appropriate local
treatment be administered. In our hospital complex it is
normal or common to find risk factors or triggers in
patients with recurrent epistaxis. From among the
numerous possible risk factors we must highlight high
blood pressure (HBP), the taking of anticoagulant or
anticlotting drugs, trauma, blood dyscrasia, upper
respiratory tract infections (URTI), kidney or liver
failure and associated cardiopulmonary pathology.
Here we contribute our casuistic of epistaxis cases
hospitalized over the last 8 years. We have analyzed in
detail the cases of patients who suffered anemia in
direct relation to blood loss from nosebleeds with the
aim of comparing the presence or absence of risk factors
found in them with the cases of epistaxis without
anemia admitted during that period and to establish
statistically significant differences between the two.
MATERIAL AND METHODS
A retrospective, descriptive study with a total
population of 200 adult patients admitted to our
hospital between 1997 and 2004 inclusively (an 8-year
period) and diagnosed with epistaxis. One hundred and
fifty-two were male and forty-eight were female, with
an average age of 60, of whom a total of 46 developed
anemia during their stay.
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V. PINO RIVERO ET AL.
The risk factors that were analyzed and the
variables that were collected in the medical history
following the anamnesis were the following: HBP,
treatment with anticoagulants-anticlotting drugs,
alcohol and tobacco habits, associated cardiopathy,
chronic obstructive pulmonary disease (COPD),
mellitus diabetes, blood dyscrasia, previous nasal
trauma, upper respiratory infection and epistaxis
without apparent cause (or idiopathic).
We measured the levels of hematocrits (Hct) and
hemoglobin (Hb) to confirm the degree of anemia
observed. Taking 40-52% to be the normal levels of Hct
in men with Hb between 13.5-17.7g/dl and 36-48% in
women with 12-16g/dl respectively, we differentiated 3
degrees of anemia (Table 1).
The general criteria for a blood transfusion were
established in relation to the drop in Hct<24% and/or
Hb<7.5 and in most cases the products transfused were
red cell concentrates.
Finally, we made a contingency table to study the
relationship between epistaxis with anemia and risk
factors. We used the Chi-squared test (Χ2) applying
Yates’ correction in order to study this association
between qualitative variables, establishing a null
hypothesis (Ho) or one of no association between the
cases of epistaxis with anemia and risk factors as well as
an alternative hypothesis (Ha) whose acceptance
supposedly confirms that an association between the
above variables exists. The α level that we chose was
0.01, that is to say 99% safe, accepting Ha with p<0.01 if
the Chi-squared value with Yates’ correction was
greater than the corresponding value for α = 0.01 and its
corresponding degree of the theoretical table for such an
effect.
We used Microsoft Access for the database,
Microsoft Excel 2000 to design the graphs and tables
and SPSS for the statistics.
RESULTS
Forty-six of the 200 patients (23%) admitted with
recurrent epistaxis developed acute anemia as a result of
the blood they lost during their hospital stay. 29 were
men and 17 women with an average age of 62 (23-84)
and 68 (39-89) respectively. The average age of the
patients with epistaxis with anemia was greater than
Table 1: Levels of hematocrit and hemoglobin with the degrees of
anemia differentiated in our study
Hemogram/Degree
Slight
Moderate
Severe
Hematocrit (%)
27 – 33
21 – 26
< 20
Hemoglobin (g/dl)
9 – 11
7–9
<7
306
Figure 1. Risk factors found in the cases of epistaxis with anemia (number
of cases). HBP: High blood pressure, ACG/AC: Treatment with
anticoagulants/anticlotting drugs, TOXHB: Toxic Habits; CARD:
associated cardiopathy; COPD:
Chronic Obstructive Pulmonary
Disease; DYSCR: Blood Dyscrasia; DM: Diabetes Mellitus; TRAUM:
Nasal trauma; URTI: upper respiratory tract infections and ROD:
Rendú-Osler Disease.
that of those who did not present this clinical symptom
(64 and 60 years respectively).
In the 46 cases analyzed, risk factors for the
development of the epistaxis were confirmed, the most
common of which was decompensated, or uncontrolled,
HBP (54.34%). 32.6% of patients were undergoing
anticoagulant or platelet antiaggregation drug
treatment,
acetylsalicylic
acid
(aspirin)
and
acenocumarol being the most common. More than a
quarter of the patients had toxic habits (tobacco or
alcohol) and 23.9% suffered from cardiopathy or
associated cardiac rhythm disturbance. These and other
personal or underlying pathology antecedents such as
diabetes, COPD nasal trauma, blood dyscrasia, upper
respiratory infections and Rendú-Osler disease are
given in figure 1. Around 40% had 2 or more of the
pathologies-associated risk factors described.
The hemoglobin levels varied between 5.8 and
11g/dl, with an average of 7.3 and a deviation of 1.2.
For the hematocrit values, the percentages varied
between 17 and 33%, with an average of 25 and a
deviation of 3. Table 2 shows the number of anemia
cases in relation to degree (slight, moderate or severe).
39.1% of anemia cases (18 patients) required a blood
transfusion, generally of red cell concentrates; the
number of bags used varied between 2 and 6. To
measure the quantity to be transfused and taking into
account that 1U of red cell concentrates is equal to 450cc,
use of the following formula is recommended:
No. of Concentrates (cc) = Kg in weight x Desired
increase in Hct
Table 3 shows the contingency table designed to
study the association between epistaxis with anemia
STATISTICAL STUDY REGARDING ANEMIA IN PATIENTS ADMITTED WITH EPISTAXIS
Table 2: Distribution of the 46 cases of anemia by the hematocrit
and hemoglobin levels given in Table 1
Degree of anemia
Number of patients
Slight
12
Moderate
19
Severe
15
Table 3: Contingency table to study the association between
epistaxis with anemia and risk factors
Risk factors
Epistaxis
Yes
No
Moderate
Anemia
46
0
46
No anemia
123
31
154
Total
169
31
200
Figure 2. Localization of the epistaxis. RN: Right nostril; LN: Left
nostril; BILAT: Bilateral; NOLOC: Not localized; AH: Anterior-half;
POS: Posterior; SUP: Superior.
and the presence of risk factors, taking the total of the
200 patients admitted as the value n. Applying the Chisquared formula with Yates’ correction (Χ2γ) we obtain
the following value:
Χ2γ =
n (Iad-bcI – n/2) 2
= 10.8
(a+b) (c+d) (a+c) (b+d)
In the corresponding statistical table for γ =1 and α
=0.01, we obtain a theoretical value of Χ2=6.63. As Χ2γ is
greater than the value obtained in said table, we can
conclude, with p<0.01 or a certainty of at least 99%, that
the variables studied are not independent but
associated. Therefore we reject the null hypothesis (Ho)
and accept the alternative hypothesis (Ha).
In regard to the location of the point of bleeding,
(Figure 2), there were no statistically significant
differences in relation to the affected nostril, but there
were statistically significant differences if we highlight
the number of confirmed cases of posterior-inferior
epistaxis (29) and that of superior origin (7), compared
to those of anterior or middle third origin. Bilateral
epistaxis was diagnosed in one case which
corresponded to hereditary hemorrhagic telangiectasia
(HHT) (Rendú-Osler). The localization of the bleeding
vessel was not clearly determined in two patients.
Finally, to summarize, 28 of the 46 cases of epistaxis
with anemia required posterior packing, generally
pneumatic, and sometimes Endoscopic Sinus Surgery
(ESS) with ligation or arterial cauterization.
Furthermore, a male with posterior epistaxis
(sphenopalatine artery) underwent a selective arterial
embolization with the Interventionist Radiology
Department of our hospital.
The average hospital stay of the 46 patients with
epistaxis and anemia was 7 days, somewhat longer than
the others. We follow an action protocol consisting of a
series of gradual actions which depend on whether the
bleeding is controlled or not with the different nasal
packings. It basically advises taking action using general
anesthetic and ESS in cases of resistant epistaxis on
account of the failure of the anterior or posterior,
generally pneumatic, packing based on the localization
of the bleeding. The most common hemorrhages,
originating in the area of the sphenopalatine, are
candidates for arterial ligation with hemoclips and/or
cauterization with good results in general to date.
DISCUSSION
Nosebleeds are one of the most common symptoms
of the general population and patients go to both
hospitals and Primary Care Clinics alike with this
complaint. In the majority of cases the quantity of blood
is small, and the nosebleed is self-limited or
spontaneously resolves itself; however, on some
occasions it can be more serious and even compromise
the hemodynamic state of the patient, putting his/her
life in serious danger1,2. In our experience, just like that
of other specialists, the most serious cases of epistaxis
make up less than 5-10% of the total and normally
originate in the posterior third of the nostrils - the
territory of the sphenopalatine, or from the superior
third - ethmoidal territory3-5. In this very study we wish
to emphasize the general risk factors and anemia that
can occur in cases of recurrent epistaxis. We also want
to stress that, following a detailed medical history, none
of the latter were cataloged as idiopathic, while the
figure of epistaxis cases without an apparent cause
within the general group that did not suffer anemia
reached 20.1%. In more than half of the anemia cases of
our casuistic, the risk factor identified was HBP and the
majority had high blood pressure levels with a systolic
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V. PINO RIVERO ET AL.
TA > 180mm Hg and/or diastolic > 110. This finding is
similar to that given by other authors6,7.
It is obvious and is made clear from the literature8-10
that the systemic causes and analytical changes require
suitable control by the ENT doctor as part of the whole
treatment (local and general) which should include the
valuable collaboration of other specialists (hematologist,
internist, cardiologist, etc).
With a patient who is hemodynamically unstable
from acute anemia secondary to recurrent or severe
epistaxis it is necessary to proceed correctly from the
beginning. This means first of all ensuring good
peripheral vein access to then be able to immediately
correct, if possible, the cause of the disease; to instill
crystalloid substances or volume expanding colloids;
and to evaluate the urgent transfusion of red cell
concentrates and/or fresh plasma if there is significant
concomitant coagulopathy depending on the results of
the hemogram8,11. Obviously, one should also act at the
local level using nasal packing which should be
sufficient to inhibit the hemorrhage, starting with an
anterior one and reserving the posterior one for
situations in which the hemostasia fails. We should
remember that posterior packing (pneumatic and
classic) is quite annoying while it is in place - usually 72
hours - and always needs good analgesic and antibiotics
to avoid infections12. ESS with cauterization or arterial
endoscopic ligation provides good results and forms a
part of the protocolized therapeutic arsenal of many
ENT departments13-15. Furthermore, ESS can preclude
the need to carry out embolizations or ligations from an
external approach which are not exempt from risks16,17.
We still have not treated a significant number of cases
with this technique, which we hope will be the object of
related studies in the future.
In general, losses of 1 liter of blood or less can be
recovered using only crystalloids. Between 1 and 2 liters
may require a transfusion and with a loss of more than
2-3 liters a transfusion should usually be carried out18,19.
In a healthy adult, a loss less than or equal to 25% of the
total volume (Hct 30%) can be well tolerated and does
not require a transfusion. Following the restoration of
the volume and of course only once the epistaxis is
under control, levels of Hb greater than 7g/dl are
enough to maintain a good perfusion. But in patients
with a risk of cardiac ischemia or cardio-respiratory
pathology, it is advisable to reach hemoglobin levels of
between 9 and 10 g/dl, even if the patient is
asymptomatic20.
CONCLUSIONS
In our study we have demonstrated that there
is a statistically significant association between epistaxis
with anemia and risk factors (p<0.01).
308
In all cases of hospitalized epistaxis, the risk
factors must be controlled and the hemodynamic state
of the patient should be checked regularly. Ensuring a
vein approach in cases of severe epistaxis is of vital
importance.
HBP was the most common disease associated
with epistaxis and acute anemia. A thorough medical
history should not be missed out in any case.
- Blood transfusions were not uncommon,
prescribed depending on the drop in Hct, Hb and the
underlying pathology of the patients.
Collaboration between different specialists and
ensuring a good peripheral approach initially prove to
be essential as part of the whole treatment (local and
general).
The ESS techniques with cauterization and
arterial ligation can resolve untreatable epistaxis or
those cases that do not improve with the usual packing.
In exceptional cases one can turn to arterial
embolization or ligation from an external approach.
- Untreated severe anemia can seriously
compromise the clinical state of the patient or cause
permanent sequelae derived from the resulting
ischemia.
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