How to manage haematuria (blood in urine) within 24 hours after thrombolysis (treatment to dissolve blood clots)?

Management of Haematuria Within 24 Hours Post-Thrombolysis

Immediately discontinue the thrombolytic infusion if haematuria develops, as this represents a bleeding complication requiring urgent intervention. 1

Immediate Actions

Stop all thrombolytic therapy immediately upon recognition of haematuria, as continued infusion will worsen bleeding. 1

• Obtain urgent laboratory work including complete blood count with platelets, PT/INR, and aPTT to assess coagulation status. 1
• Type and cross-match blood products in preparation for potential transfusion needs. 1
• Monitor vital signs closely with particular attention to blood pressure and heart rate to detect hemodynamic compromise. 1

Pharmacological Reversal

Administer tranexamic acid 1000 mg IV infused over 10 minutes for active bleeding as the first-line antifibrinolytic agent. 1, 2

• Alternative antifibrinolytic therapy includes ε-aminocaproic acid at 4-5 g IV over 1 hour, followed by 1 g IV until bleeding is controlled. 1
• If the patient was receiving vitamin K antagonists concurrently, administer vitamin K 5-10 mg by slow IV injection. 1
• For severe bleeding with hemodynamic compromise, consider administering 6-8 units of cryoprecipitate containing factor VIII or 6-8 units of platelets. 1, 3
• Target fibrinogen level of 1 g/L is desirable with cryoprecipitate infusion. 3

Anticoagulation Management

Do not restart heparin until aPTT has decreased to less than twice the normal control value. 4

• When restarting anticoagulation is necessary after bleeding resolution, initiate heparin without a loading dose when aPTT falls below 2× the upper limit of normal. 4
• Target aPTT should be 1.5 to 2 times normal with initial dosing typically around 1,300 U/hour. 4
• Check aPTT four times every 6 hours during the first 24-48 hours after stopping thrombolysis due to rapidly changing levels of fibrinogen and heparin-binding proteins. 4

Supportive Care and Monitoring

Maintain adequate hydration to promote urinary flow and prevent clot formation in the urinary tract. 1

• Avoid unnecessary invasive procedures for at least 24 hours after thrombolysis to prevent additional bleeding sites. 1, 5
• Consider gentle urinary catheterization with irrigation if clots are causing obstruction, but use extreme caution as this may exacerbate bleeding. 1
• Volume replacement with colloids should be administered if needed, along with RBC transfusion if hemoglobin drops significantly. 6
• Fresh frozen plasma can be used as a plasma expander but not as a reversal agent. 6

Transfusion Thresholds

Transfuse packed red blood cells to maintain adequate oxygen-carrying capacity based on clinical assessment and hemoglobin levels. 6, 1

• Platelet transfusion should be considered if thrombocytopenia ≤60 × 10⁹/L or thrombopathy is present. 6
• Reassess clinically and with laboratory studies after each transfusion product administration. 3

Investigation of Underlying Pathology

Once the patient is stabilized, investigate for underlying urological pathology, as up to 25% of patients with gross haematuria while on anticoagulant therapy may have underlying neoplastic disease. 1

• Consider urological evaluation with cystoscopy after stabilization if haematuria persists beyond the acute bleeding episode. 1
• This investigation should be deferred until coagulation parameters have normalized and bleeding has completely resolved. 1

Special Considerations for High-Risk Patients

Elderly patients (>75 years) have a higher risk of bleeding complications with thrombolytic therapy and require more aggressive monitoring and management. 1

• Avoid combination of fibrinolytics with glycoprotein IIb/IIIa inhibitors as this significantly increases bleeding risk, especially in elderly patients. 1
• Patients with renal dysfunction may have prolonged heparin effect and altered clearance of tranexamic acid, requiring dose adjustments. 6, 2

Critical Pitfalls to Avoid

Never restart thrombolytic therapy after a significant bleeding episode. 1

• Do not use automatic blood pressure cuffs on the same arm as venous access to prevent hematoma formation. 1
• Avoid invasive procedures such as arterial punctures or insertion of catheters for at least 24 hours after thrombolytic therapy. 1, 5
• Do not overlook the possibility of underlying urological pathology as the cause or contributor to haematuria. 1
• Antifibrinolytic agents should only be used as a last alternative after other conservative measures have failed, as they carry their own risks. 3

Long-Term Anticoagulation After Resolution

After resolution of haematuria, if continued anticoagulation is necessary, consider switching to unfractionated heparin with careful aPTT monitoring (target 1.5-2.0 times control). 1

• 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. 1
• Warfarin may be started once bleeding has completely resolved and the patient is stable, with target INR of 2.5 to 3.5 for most indications. 4