How do I manage a tranexamic acid (Amicar) drip through a Continuous Bladder Irrigation (CBI) Foley catheter?

Managing Aminocaproic Acid (Amicar) Through Continuous Bladder Irrigation

Critical Safety Warning

Do not administer aminocaproic acid (Amicar) through a continuous bladder irrigation (CBI) system—this is not an evidence-based or guideline-supported route of administration and poses significant risks. Aminocaproic acid must be administered intravenously to achieve therapeutic systemic levels necessary for antifibrinolytic effect 1.

Why IV Administration is Required

• Aminocaproic acid requires continuous IV infusion with a loading dose of 150 mg/kg followed by 15 mg/kg/hour to maintain therapeutic drug levels, as its initial elimination half-life is only 60-75 minutes 1
• Systemic fibrinolysis occurs throughout the body, not just at surface bleeding sites, requiring systemic antifibrinolytic coverage that cannot be achieved through local bladder instillation 2
• Therapeutic plasma levels of 10 μg/ml are necessary to inhibit fibrinolysis systemically, which can only be achieved through IV administration 2

Correct Management Protocol for Bladder Hemorrhage

Intravenous Aminocaproic Acid Dosing

• Loading dose: 150 mg/kg IV administered over 1 hour 1
• Maintenance infusion: 15 mg/kg/hour as continuous IV infusion until bleeding risk diminishes 1
• Alternative dosing: Some protocols use boluses up to 5g per patient with no adverse effects 1

Continuous Bladder Irrigation Management

• Maintain CBI separately through the three-way Foley catheter using sterile normal saline or prescribed irrigant 1
• Change CBI administration sets every 24 hours if lipid-containing solutions are used, or every 72-96 hours for standard solutions 1
• Do not mix medications into CBI fluid unless specifically prescribed and validated for intravesical use 1

Critical Contraindications and Precautions

• Massive hematuria warning: Use aminocaproic acid with extreme caution in massive hematuria due to risk of ureteric obstruction from clot formation 3
• Renal dosing required: Reduce dosage in renal failure as aminocaproic acid is renally excreted and accumulates, increasing toxicity risk 1, 3
• Thrombosis risk: Contraindicated in active thromboembolic disease or history of thrombosis 3

Common Clinical Pitfalls to Avoid

• Never instill aminocaproic acid directly into the bladder through CBI—this bypasses systemic circulation and fails to achieve therapeutic antifibrinolytic levels 1, 2
• Do not use topical hemostatic agents as substitutes for systemic IV antifibrinolytic therapy when systemic hemostatic support is needed 2
• Monitor for hypotension and dizziness, particularly with higher doses; consider dose reduction if systemic side effects occur 4
• Discontinue aminocaproic acid as soon as bleeding is controlled to minimize thrombotic risk 3

Monitoring Requirements

• Regular renal function assessment is essential as impaired clearance increases risk of neurotoxicity and ocular toxicity 3
• Assess for clot obstruction in urinary catheter, particularly with massive hematuria 3
• Monitor for systemic side effects including dizziness, hypotension, syncope, nausea, and vomiting 4