Anticoagulation and a Bleeding Nasal Defect After Mohs
A 79-year-old woman on apixaban (for atrial fibrillation) and aspirin 81 mg undergoes Mohs surgery for a 1.5 cm squamous cell carcinoma of the nasal dorsum. Clearance is achieved in two stages; the defect is 2.2 x 1.8 cm and is repaired with a full-thickness skin graft and a bolster. She has hypertension (BP 168/92 in the office today) and mild renal impairment (eGFR 48). Two hours after repair, the bolster is saturated and there is active oozing from the graft edge. She feels lightheaded.
1. How do you manage the acute bleeding, and what is your approach to her anticoagulants?
Read the worked answer
First, assess and stabilize: vital signs, orthostatics, estimate blood loss, inspect the wound. Apply direct pressure for 10-15 minutes; if bleeding persists, infiltrate local anesthetic with epinephrine and place additional sutures or a pressure dressing; consider topical hemostatic agents (e.g., oxidized cellulose, thrombin) under the bolster. Cautery should be used cautiously on a graft bed to avoid compromising the graft. Address the elevated BP - uncontrolled hypertension is a common driver of post-op bleeding; treat per protocol. Do not empirically reverse apixaban or stop aspirin without a risk-benefit discussion: the bleeding is local and manageable, and reversal risks thromboembolism. Check CBC and renal function; apixaban is renally cleared, and with eGFR 48 dosing and accumulation matter. Contact her prescriber/cardiology to confirm continuation; generally continue anticoagulation and manage locally unless bleeding is severe or life-threatening. Document the event, the interventions, and the shared decision. Give written aftercare instructions and a follow-up plan.
2. What could you have done differently preoperatively to reduce this risk, and what follow-up does she need?
Read the worked answer
Preoperative optimization: (1) blood pressure control - a BP of 168/92 on the day of surgery is a modifiable risk factor; defer or coordinate with her primary care if persistently elevated; (2) medication review - confirm whether aspirin is indicated (primary vs secondary prevention) and discuss with the prescriber; for apixaban, confirm timing of the last dose and consider whether a brief perioperative hold is appropriate in consultation with cardiology, weighing stroke risk (CHA2DS2-VASc) against bleeding; (3) renal dosing - eGFR 48 affects apixaban clearance; ensure appropriate dose; (4) technique - meticulous hemostasis, a secure bolster, and a pressure dressing; consider a slightly larger graft or a flap if the bed is poorly hemostatic. Follow-up: wound check in 24-48 hours (or sooner if bleeding recurs), graft take assessment at 5-7 days, suture removal per site, and pathology/surveillance plan. Counsel on signs of hematoma, infection, and graft failure, and provide an emergency contact. Document the risk discussion.