Management of Hematuria After Streptokinase Thrombolysis

Initial Assessment and Management

The American Heart Association recommends immediately discontinuing 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), and activated partial thromboplastin time (aPTT) 2, 3
Type and cross-match should also be performed 2

The American College of Cardiology recommends administering antifibrinolytic agents, such as tranexamic acid 1000 mg IV infused over 10 minutes, for active bleeding 1
Alternative antifibrinolytic agents, such as ε-aminocaproic acid, can be used at a dose of 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 4
For severe bleeding with hemodynamic compromise, consider administration of 6-8 units of cryoprecipitate containing factor VIII or 6-8 units of platelets 2

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 5
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 5

Underlying pathology should be investigated once the patient is stable, as up to 25% of patients presenting with gross hematuria while on anticoagulant therapy may have underlying neoplastic disease 4, 5
Consider urological evaluation with cystoscopy after stabilization if hematuria persists 4

Elderly patients (>75 years) have a higher risk of bleeding complications with thrombolytic therapy and may require more aggressive management 2, 6

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) 6, 3
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 3, 7
Avoid combination of fibrinolytics with glycoprotein IIb/IIIa inhibitors as this significantly increases bleeding risk, especially in elderly patients 6

Do not restart thrombolytic therapy after a significant bleeding episode, as recommended by the American College of Cardiology 8, 9
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 4
Avoid using automatic blood pressure cuffs on the same arm as venous access to prevent hematoma formation 2