<div>A new device for managing refractory epistaxis in ICU</div><div>patients with COVID19</div><div>Key words: epistaxis treatment, COVID-19, recurrent epistaxis</div><div>Five Key points</div><div>COVID 19 treatment generate nose bleeding</div><div>Covid 19 treatment necessitate prone position</div><div>Nasal packing is useful but sometimes insufficient</div><div>CAVI-T is a new treatment of epistaxis</div><div>CAVI-T is especially adapted to COVID patient in prone position due to
its specific form</div><div>Introduction :</div><div>Epistaxis is a common and a well-known symptom. Nasal packing is an
effective treatment in most cases. (1)</div><div>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.</div><div>CAVI-T (Picture 1 &amp; 2) is a new asymmetrical low-pressure balloon that
have shown promising results to control epistaxis in emergency.</div><div>We report herein the management of severe epistaxis in two COVID 19
patients admitted to ICU for severe respiratory failure.</div><div>Patient 1</div><div>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).</div><div>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<sup>@</sup> bleeding continued and hemoglobin level
dropped to 8.0g/l.</div><div>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.</div><div>Patient 2</div><div>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.</div><div>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<sup>@</sup> was ineffective. Hemoglobin dropped and
patient was transfused.</div><div>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.</div>