How to manage hematuria in a patient post thrombolysis with Streptokinase (STK)?

Management of Hematuria After Streptokinase Thrombolysis

For patients who develop hematuria after streptokinase (STK) thrombolysis, discontinue the thrombolytic infusion immediately and administer tranexamic acid 1000 mg IV over 10 minutes to control bleeding. 1

Initial Assessment and Management

• Immediately discontinue streptokinase infusion if hematuria develops, as this is a sign of bleeding complication 2
• Obtain urgent laboratory work including:
  • Complete blood count with platelets
  • Prothrombin time/international normalized ratio (PT/INR)
  • Activated partial thromboplastin time (aPTT)
  • Fibrinogen level
  • Type and cross-match 2

Pharmacological Management

• For active bleeding, administer antifibrinolytic agents:
  • Tranexamic acid: 1000 mg IV infused over 10 minutes 1, 3
  • Alternative: ε-aminocaproic acid: 4-5 g over 1 hour, followed by 1 g IV until bleeding is controlled 1
• Consider vitamin K 5-10 mg by slow IV injection if patient was also receiving vitamin K antagonists 2
• For severe bleeding with hemodynamic compromise, consider:
  • Administration of 6-8 units of cryoprecipitate containing factor VIII
  • Administration of 6-8 units of platelets 2
• Target fibrinogen level of at least 1 g/L with cryoprecipitate infusion 4

Monitoring and Supportive Care

• Monitor vital signs closely, with special attention to blood pressure and heart rate 2
• Maintain adequate hydration to promote urinary flow and prevent clot formation 2
• Avoid unnecessary invasive procedures for at least 24 hours after thrombolysis to prevent additional bleeding sites 2
• Consider urinary catheterization with gentle irrigation if clots are causing obstruction, but use caution as this may exacerbate bleeding 2

Investigation of Hematuria

• While controlling the acute bleeding is the priority, underlying pathology should be investigated once the patient is stable 2
• Studies suggest that up to 25% of patients presenting with gross hematuria while on anticoagulant therapy may have underlying neoplastic disease 2
• Consider urological evaluation with cystoscopy after stabilization if hematuria persists 2

Special Considerations

• Patients with renal impairment require dose adjustment of tranexamic acid as it is primarily excreted through the kidneys 3
• For patients with serum creatinine:
  • 1.4-2.8 mg/dL: Consider reducing tranexamic acid dose by 50%
  • 2.8-5.7 mg/dL: Consider reducing dose by 75%

  • 5.7 mg/dL: Consider reducing dose by 90% 3

• Elderly patients (>75 years) have higher risk of bleeding complications with thrombolytic therapy and may require more aggressive management 2

Prevention of Recurrence

• After resolution of hematuria, if continued anticoagulation is necessary:
  • Consider switching to unfractionated heparin with careful aPTT monitoring (target 1.5-2.0 times control) 2
  • For long-term anticoagulation in high-risk patients, consider low molecular weight heparin at 75-80% of the initial dose rather than vitamin K antagonists 2
• Avoid combination of fibrinolytics with glycoprotein IIb/IIIa inhibitors as this significantly increases bleeding risk, especially in elderly patients 2

Common Pitfalls to Avoid

• Do not restart thrombolytic therapy after a significant bleeding episode 2
• Avoid invasive procedures such as arterial punctures or insertion of catheters for at least 24 hours after thrombolytic therapy 2
• Do not overlook the possibility of underlying urological pathology as the cause or contributor to hematuria 2
• Avoid using automatic blood pressure cuffs on the same arm as venous access to prevent hematoma formation 2