Hematuria

手術後病人血尿須想到下列問題

是術後第幾天血尿，若手術剛從POR回來，可能是手術過程引起(可能bladder or ureter injury)，處理方式record urine output, on Foley, I/O, fluid challenge, or Transamine use 且須注意病人是否anemia，是否coagulation abnormalities.

若是手術後幾天才發生，則考慮病人是否 urethral catheter inserted? If yes, Why? What are the vital sign? Fever? Or other infection sign? Is the patient receiving anticoagulant drugs?

1.   Urethral trauma---Inadvertent or partial removal of the catheter with the balloon still inflated.

2.   Drugs—heparin or warfarin use

3.   Coagulation abnormalities---Sepsis or DIC sign, thrombocytopenia

處理—check CBC/DC, U/A, even blood culture or urine culture if any infection sign, and antibiotics use, or 輸血(PRBC or FFP or platelet)

通常術後發生之gross hematuria不太會有因血塊引起Foley阻塞情形。

若非手術病人，則考慮是否曾或正接受radiation therapy或為cancer合併bladder invasion

1.  Hematuria due to bladder invasion supportive treatment，缺甚麼就補甚麼, PRBC or FFP or platelet

2.  若是radiation cystitis 則須密切注意，check U/A, CBC/DC，如果有infection sign，則blood culture or antibiotics use if appropriate，

且必須on Foley or even使用three-way Foley keep irrigation with L-R.200ml/hr，把bladder的blood clots 洗出來，並注意Foley是否有阻塞，urine是否有出來，一定要到bedside觀察病人有無low abdominal pain, suprapubic pain, nausea, vomiting, bladder有無漲大，不可一味打Demerol。

3.   如因Foley tip被bladder 內的blood阻塞，則先milking foley tube，若無效則先用Normal saline irrigation 30~50ml再回抽，反復把blood colts 抽出，若還是無效則使用suction tube接到suction bottle, under ultrasound image, 把suction tube經由尿道(此時無suction 力量)進入膀胱內，再開啟suction power，把膀胱內血塊及一些necrotic tissues吸出，並注意不要吸到bladder wall，（此步驟須由已有經驗者執行）若仍是無法將blood clots取出，urine 仍出不來，最後則須考慮consult urologist for PCN insertion。