Management of Haematuria Post-Thrombolysis

Immediate Actions

The American College of Cardiology recommends immediate discontinuation of thrombolytic infusion if haematuria develops, as this represents a bleeding complication requiring urgent intervention 1
Obtain urgent laboratory work including complete blood count with platelets, PT/INR, and aPTT to assess coagulation status in patients with haematuria post-thrombolysis 1
Type and cross-match blood products in preparation for potential transfusion needs in patients with haematuria post-thrombolysis 1
Monitor vital signs closely with particular attention to blood pressure and heart rate to detect hemodynamic compromise in patients with haematuria post-thrombolysis 1

Administer tranexamic acid 1000 mg IV infused over 10 minutes for active bleeding as the first-line antifibrinolytic agent, as recommended by the European Society of Cardiology 1
Alternative antifibrinolytic therapy includes ε-aminocaproic acid at 4-5 g IV over 1 hour, followed by 1 g IV until bleeding is controlled, according to the American Heart Association 1
If the patient was receiving vitamin K antagonists concurrently, administer vitamin K 5-10 mg by slow IV injection, as recommended by the American College of Chest Physicians 1

The European Society of Cardiology recommends not restarting heparin until aPTT has decreased to less than twice the normal control value 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, as recommended by the American College of Cardiology 2
Target aPTT should be 1.5 to 2 times normal with initial dosing typically around 1,300 U/hour, according to the European Heart Journal 2

Maintain adequate hydration to promote urinary flow and prevent clot formation in the urinary tract, as recommended by the American Urological Association 1
Avoid unnecessary invasive procedures for at least 24 hours after thrombolysis to prevent additional bleeding sites, according to the European Society of Cardiology 1, 3
Volume replacement with colloids should be administered if needed, along with RBC transfusion if hemoglobin drops significantly, as recommended by the European Heart Journal 4

Transfuse packed red blood cells to maintain adequate oxygen-carrying capacity based on clinical assessment and hemoglobin levels, as recommended by the European Heart Journal 4, 1
Platelet transfusion should be considered if thrombocytopenia ≤60 × 10⁹/L or thrombopathy is present, according to the American Society of Hematology 4

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, as recommended by the American Urological Association 1
Consider urological evaluation with cystoscopy after stabilization if haematuria persists beyond the acute bleeding episode, according to the European Association of Urology 1

Elderly patients (>75 years) have a higher risk of bleeding complications with thrombolytic therapy and require more aggressive monitoring and management, as recommended by the American Geriatrics Society 1
Patients with renal dysfunction may have prolonged heparin effect and altered clearance of tranexamic acid, requiring dose adjustments, according to the European Heart Journal 4

Never restart thrombolytic therapy after a significant bleeding episode, as recommended by the American College of Cardiology 1
Do not use automatic blood pressure cuffs on the same arm as venous access to prevent hematoma formation, according to the American Society of Anesthesiologists 1

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), as recommended by the American College of Cardiology 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, according to the European Society of Cardiology 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, as recommended by the American College of Chest Physicians 2