The effect of cooling on coagulation and haemostasis: Should “Ice” be part of treatment of acute haemarthrosis in haemophilia?

Abstract

Repeated haemarthroses and the consequences of blood in the joint contribute to blood induced joint disease (BIJD) in people with haemophilia (PWH). Prevention of bleeding, through medical management, is the standard of care in developed countries, but is not universally available due to financial and other barriers. Ice application, as part of R.I.C.E. (Rest, Ice, Compression, Elevation) or alone, is commonly recommended as an adjunct treatment to decrease bleeding, pain, tissue metabolism, oedema, and inflammation. This article will review evidence regarding local cooling by commonly used ice application methods, to decrease the temperature of the skin and intra-articular (IA) joint space and the resultant effects on haemostasis and coagulation. The general literature was reviewed for articles in English describing temperatures achievable in the skin and IA space using clinically relevant ice protocols, and the effect of cooling on haemostasis and coagulation. The literature demonstrates that typical methods of ice application can cool both the skin and IA space. Published, general literature studies have also consistently demonstrated that experimental cooling of blood and/or tissue, both in vitro and in vivo in humans and in animal models, can significantly impair coagulation and prolong bleeding. In PWH with acute haemarthrosis, ice application has potential to increase haemorrhage morbidity by further impairing coagulation and haemostasis. Ice has not been shown to improve overall outcome, stop bleeding nor swelling from haemarthrosis. Although ice can help manage acute, haemarthrosis-related pain, there are other available interventions that will not impair coagulation and haemostasis.

Does Advanced Cryotherapy Reduce Pain and Narcotic Consumption After Knee Arthroplasty?

“…Cryotherapy could have an immediate reduction of bleeding by vasoconstriction and compression but later lead to cold-induced vasodilatation and interfere with secondary hemostasis. There is also some evidence that application of ice locally impairs hemostasis [7]. This has been seen in humans and in animal models showing prolonged bleeding time, decreased platelet aggregation, increased clotting time, and increased clot formation time [7].…”

“…There is also some evidence that application of ice locally impairs hemostasis [7]. This has been seen in humans and in animal models showing prolonged bleeding time, decreased platelet aggregation, increased clotting time, and increased clot formation time [7]. Hemostasis and coagulation are biochemical reactions that are most efficient at basal body temperature.…”

Warfarin-related recurrent knee haemarthrosis treated with arterial embolisation and intra-articular injection of tranexamic acid

“…We ceased the use of warfarin for 3 days, and her knee was kept at rest and cooled. Rest, ice, compression and elevation (RICE) together or alone is commonly recommended as an adjunct treatment for the treatment of haemarthrosis, to decrease bleeding and pain 9. Haemarthrosis of the knee continued in this patient following this routine treatment.…”

Clinician's Commentary on Bech et al.

“…Chesterton also mentioned reducing tissue temperature to <12. 5 C to reduce nerve conduction velocity and to [10][11] C to reduce enzyme activity. 2 It is thought that decreasing intramuscular temperatures by [7][8] C reduces blood flow and metabolic requirements.…”

“…Indeed, some authors have argued that cryotherapy is not indicated after trauma because cold prolongs bleeding and therefore delays haemostasis, and, furthermore, that blunting inducement of stress proteins may be detrimental to normal tissue repair. 11 Further research is needed to address cryotherapy usage. Future device studies should include placebo groups using pads filled with room-temperature water, both to determine whether there is any role for cryotherapy after deep-tissue injury and to enable blinding of investigators.…”