What is the management of hematuria post stroke thrombolysis?

Management of Haematuria Post Stroke Thrombolysis

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

Immediate Actions and Assessment

Stop thrombolysis immediately upon recognition of haematuria, as continued infusion will worsen bleeding. 1, 2

Obtain urgent laboratory work including:

• Complete blood count with platelets 1, 2
• PT/INR and aPTT to assess coagulation status 1, 2
• Type and cross-match blood products in preparation for potential transfusion 1, 2

Monitor vital signs closely with particular attention to blood pressure and heart rate to detect hemodynamic compromise. 1, 2

Pharmacological Reversal

Administer tranexamic acid 1000 mg IV infused over 10 minutes as the first-line antifibrinolytic agent for active bleeding. 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, 2 Tranexamic acid competitively inhibits the activation of plasminogen and can reverse thrombolysis in the setting of hemorrhage after IV thrombolytic therapy. 3

If the patient was receiving vitamin K antagonists concurrently, administer vitamin K 5-10 mg by slow IV injection. 1, 2

For severe bleeding with hemodynamic compromise, consider administration of 6-8 units of cryoprecipitate containing factor VIII or 6-8 units of platelets. 2

Supportive Care and Monitoring

Maintain adequate hydration to promote urinary flow and prevent clot formation in the urinary tract. 1, 2

Consider urinary catheterization with gentle irrigation if clots are causing obstruction, but use caution as this may exacerbate bleeding. 2

Avoid unnecessary invasive procedures for at least 24 hours after thrombolysis to prevent additional bleeding sites. 1, 2

Volume replacement with colloids should be administered if needed, along with RBC transfusion if hemoglobin drops significantly. 1

Transfusion Thresholds

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

Platelet transfusion should be considered if thrombocytopenia ≤60 × 10⁹/L or thrombopathy is present. 1

Resuming Anticoagulation After Bleeding Resolution

Do not restart heparin until aPTT has decreased to less than twice the normal control value. 1, 2

When restarting anticoagulation is necessary after bleeding resolution, initiate heparin without a loading dose when aPTT falls below 2× the upper limit of normal. 1, 2

Target aPTT should be 1.5 to 2 times normal (55 to 80 seconds) with initial dosing typically around 1,300 U/hour. 1, 2

Monitor aPTT closely: check four times every 6 hours for the first 24 hours, then three times every 8 hours, then daily due to rapidly changing levels of fibrinogen and heparin binding proteins. 4

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, 2

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, 2

Consider urological evaluation with cystoscopy after stabilization if haematuria persists beyond the acute bleeding episode. 1, 2

Special Considerations

Elderly patients (>75 years) have a higher risk of bleeding complications with thrombolytic therapy and require more aggressive monitoring and management. 1, 2 However, renal dysfunction itself does not increase the risk of bleeding complications or poor outcomes after thrombolysis. 5, 6

Patients with renal dysfunction may have prolonged heparin effect and altered clearance of tranexamic acid, requiring dose adjustments. 1

Critical Pitfalls to Avoid

Never restart thrombolytic therapy after a significant bleeding episode. 1, 2

Do not use automatic blood pressure cuffs on the same arm as venous access to prevent hematoma formation. 1, 2

Do not overlook the possibility of underlying urological pathology as the cause or contributor to haematuria. 2

Avoid invasive procedures such as arterial punctures or insertion of catheters for at least 24 hours after thrombolytic therapy. 2