Management of Hematoma at IV Cannula Site During Streptokinase Therapy

Immediate Actions

Apply ice to the site for at least 10 minutes to minimize further bleeding and swelling, as recommended by the American Journal of Kidney Diseases 1, 2
Perform a close assessment that includes measurement of the hematoma size and extent of swelling to determine if it is small/moderate versus significantly large 1
Assess vascular flow both proximal and distal to the hematoma site, and evaluate distal circulation in the associated extremity, including pulses, capillary refill, temperature, and sensation 2
Monitor for signs of compartment syndrome or vascular compromise 2

For small to moderate hematomas, continue manual pressure and ice application, and do not attempt further cannulation at or near the site until the hematoma resolves 1, 2
Monitor closely for expansion over the next several hours 1, 2
For significantly large hematomas, after applying manual pressure and ice for 30 minutes minimum, assess whether continued therapy is absolutely necessary, and consider establishing a new site proximal to the hematoma or using an alternative extremity 1

If serious bleeding occurs, including bleeding that cannot be controlled with local pressure measures, or expanding hematomas that compromise vascular flow or limb circulation, terminate the thrombolytic infusion and treat appropriately 2
Consider whether anticoagulation needs to be held or reversed depending on hematoma severity 2

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
Do not apply pressure in a way that occludes distal vascular flow, as this can increase intraluminal pressure to dangerous levels 2