What to do if a patient develops a hematoma at the intravenous (IV) cannula site while receiving streptokinase (fibrinolytic agent)?

Management of Hematoma at IV Cannula Site During Streptokinase Therapy

Immediately stop the streptokinase infusion, apply direct manual pressure to the hematoma site for at least 30 minutes, apply ice, and perform a comprehensive assessment of the hematoma size, vascular access patency, and distal circulation. 1

Immediate Actions

Stop Streptokinase and Apply Local Measures

• Discontinue the streptokinase infusion immediately as bleeding at puncture sites is a known and significant complication of thrombolytic therapy 1
• Apply direct manual pressure to the bleeding/hematoma site for a minimum of 30 minutes 1
• Apply ice to the site for at least 10 minutes to minimize further bleeding and swelling 2
• Avoid any trauma or manipulation of the affected area 1

Assess Hematoma Severity and Complications

Perform a close assessment that includes: 2

• Measurement of the hematoma size and extent of swelling to determine if it is small/moderate versus significantly large
• Assessment of vascular flow both proximal and distal to the hematoma site
• Evaluation of distal circulation in the associated extremity, including pulses, capillary refill, temperature, and sensation
• Monitoring for signs of compartment syndrome or vascular compromise

Risk Stratification and Ongoing Management

For Small to Moderate Hematomas

• Continue manual pressure and ice application 2
• Do not attempt further cannulation at or near the site until the hematoma resolves 2
• Monitor closely for expansion over the next several hours 2

For Significantly Large Hematomas

• After applying manual pressure and ice for 30 minutes minimum, assess whether continued therapy is absolutely necessary 2
• If the patient requires ongoing IV access, establish a new site proximal to the hematoma or use an alternative extremity 2
• Do not reattempt cannulation at the area of injury 2
• Consider whether the bleeding constitutes "serious bleeding" requiring termination of all thrombolytic therapy 1

Hemorrhage Management Considerations

When to Terminate Streptokinase Completely

The FDA label states that if serious bleeding occurs, terminate the thrombolytic infusion and treat appropriately 1. Serious bleeding in this context includes:

• Bleeding that cannot be controlled with local pressure measures
• Expanding hematomas that compromise vascular flow or limb circulation
• Any bleeding requiring transfusion 3

Monitoring for Delayed Complications

• Hemorrhage can occur 1 or more days after streptokinase administration while patients are still receiving anticoagulant therapy 1
• Continue close monitoring of the hematoma site even after initial stabilization
• Be vigilant for rare but serious complications such as compartment syndrome or vascular occlusion 2

Special Considerations

Avoid High-Risk Puncture Sites

• The streptokinase label specifically warns to avoid internal jugular and subclavian venous punctures to minimize bleeding from noncompressible sites 1
• If arterial puncture is necessary during infusion, use an upper extremity vessel accessible to manual compression, apply pressure for at least 30 minutes, and monitor closely 1

Concomitant Anticoagulation

• Patients receiving streptokinase are often on concurrent heparin and aspirin, which significantly increases bleeding risk 1
• Carefully monitor for bleeding, especially at arterial puncture sites when these agents are used together 1
• Consider whether anticoagulation needs to be held or reversed depending on hematoma severity

Documentation and Prevention

• Large hematomas may require deferral of further vascular access attempts for up to 3 months until complete resolution 2
• A hematoma requiring transfusion or resulting in very large size is suggestive of underlying venous outflow stenosis and requires referral for diagnostic angiogram 2
• Minor bleeding from puncture sites occurred in 30% of patients receiving selective streptokinase infusions, while major hemorrhages requiring intervention occurred in 8% 3

Clinical Pitfalls to Avoid

• Do not perform venipunctures except when absolutely required during active streptokinase therapy 1
• Do not apply pressure in a way that occludes distal vascular flow, as this can increase intraluminal pressure to dangerous levels 2
• Do not underestimate the risk of delayed bleeding that can occur days after streptokinase administration 1
• Do not ignore expanding hematomas, as rare but serious complications including compartment syndrome, vascular occlusion, and even fatal hemorrhage have been reported with streptokinase therapy 4, 5, 6, 7