Thrombolytic therapy

Alteplase general teaching

Explain the need for thrombolytic therapy to patients and/or family. Give support, as conditions warranting thrombolytics can be very stressful for the patient and family.

Alteplase directly decreases the action of which blood products?

Fibrinogen clotting factors fibrin

Which documented finding for Mr. Zappetti indicates receiving thrombolytic therapy would place him at a high risk for complications?

History of a fall due to confusion

Other medical conditions may contribute to bleeding associated with thrombolytic therapy. To determine whether a patient is an ideal candidate for thrombolytic therapy, the health care provider should carefully evaluate the risk versus benefits of therapy.

History of severe uncontrolled hypertension (>180/110 mm Hg) History of ischemic stroke, dementia, or intracerebral disease Use of anticoagulants (international normalized ratio [INR] 2 to 3 or greater) or bleeding disorders Prolonged cardiopulmonary resuscitation (CPR) (>10 minutes) or major surgery (<3 weeks) Internal bleeding (within 2 to 4 weeks) Vascular puncture not able to be compressed Pregnancy Active peptic ulcer

Alteplase is given IM

IV at an accelerated rate over 90 minutes divided into three phases. The dosage is determined by weight; however, the total dose should not exceed 100 mg. Doses over 100 mg are associated with an increased risk for intracranial hemorrhage.

Which time frame describes the onset of action of alteplase when administered intravenously?

Immediately

Alteplase side effects

Instruct the patient to report any side and adverse drug effects, such as difficulty breathing, lightheadedness, dizziness, rapid or fluttering heartbeat, and itching or rashes during therapy. Instruct patients that this medication causes an increased risk for bleeding.Bruising is common with alteplase, but patients should report any unusual bruising.Patients should avoid activities that increase the risk for bruising and bleeding. The nurse should advise patients to shave with an electric razor.Patients should also be instructed to report signs of bleeding gums, coughing up blood, nosebleeds, prolonged bleeding from cuts, and blood in urine or stool.

Interactions with Thrombolytics Herb

Interactions that increase the risk for bleeding due to antiplatelet activity: Cat's claw, garlic, ginkgo, ginseng, green tea, and red clover

Interactions with Thrombolytics drugs

Interactions that increase the risk for bleeding: Heparin and other anticoagulants Clopidogrel and nonsteroidal antiinflammatory drugs (NSAIDs) (alter platelet function)

A nurse is preparing to administer alteplase. The nurse would gather equipment knowing that alteplase would be administered by which route?

Intravenously (IV)

Interactions with Thrombolytics Food

None known

A patient who has a pulmonary embolism is prescribed alteplase. The review of the patient history reveals an ischemic stroke 4 months ago. Which action would the nurse take?

Notify the health care provider.

Pharmacodynamic Profile alteplase

Onset: Immediate Peak: 5-10 minutes Duration: 3 hours Half-life: 35 minutes

Absolute Contraindications

Prior intracranial hemorrhage, known cerebral vascular lesion, or intracranial neoplasm History of ischemic stroke within the past 3 months Active internal bleeding (excluding menses) Suspected aortic dissection Current severe uncontrolled hypertension

Which adverse effects would the nurse teach the patient to report during thrombolytic therapy?

Rapid heartbeat Rashes Lightheadedness Dizziness

A patient who was found unconscious was found to have a large, acute pulmonary embolism and was given alteplase. The patient's family asks the nurse why alteplase was given rather than warfarin. Which response would the nurse make?

"Alteplase is a thrombolytic that is used to dissolve large clots to restore circulation. Warfarin only prevents clots from forming."

A patient is being discharged 2 days after being treated with alteplase for acute myocardial infarction (MI). Which statement made by the patient indicates a need for additional teaching?

"I will need to continue to shave with an electric razor."

A patient with healing stab wounds to the arms and legs is brought to the emergency department with complaints of chest pain. The patient was diagnosed with acute myocardial infarction, and alteplase was prescribed. The nurse would closely monitor the patient for which complications following the administration of alteplase?

Bleeding

How many minutes after infusion is most alteplase eliminated? minutes

10 mins

Alteplase is contraindicated with which conditions?

Cerebrovascular accident (CVA) 2 months ago History of intracranial hemorrhage Brain tumor

A total dose of alteplase 80 mg is prescribed to a patient with an acute ischemic stroke. How many milligrams would the nurse initially administer?

8 The initial dose of alteplase for acute ischemic stroke is 10% of the total dose. The patient is to receive a total of 80 mg. Ten percent of 80 mg is 8 mg.

Prompt interventions with alteplase in acute conditions provide for the best outcomes. These conditions are as follows:

Acute MI Acute ischemic stroke Acute PE (large in size) Also, alteplase is used to clear clots from central venous catheters.

Alteplase is indicated for which emergent conditions?

Acute ischemic stroke Acute large pulmonary embolus Acute ST-elevated myocardial infarction

Alteplase given in Clearing a Central Venous Catheter

Alteplase, in lower doses, can be used to dissolve a thrombus in a central venous catheter to restore patency. Dosages are weight based but should not exceed 2 mg. If the catheter is not restored after 120 minutes, a second dose may be given. After instillation, follow guidelines to access return of patency.

A patient on thrombolytic therapy experiences severe bleeding. The nurse anticipates the administration of which medication?

Aminocoproic acid

Thrombolytics are also referred to as fibrinolytics or clot busters. These drugs present a serious risk for bleeding and require careful monitoring by the clinician and nursing staff. Although thrombolytic drugs are the focus of this lesson, it is helpful to understand how their mechanism of action differs from other drug classes presented in this module that affect the clotting cascade.

Antiplatelet drugs prevent clot formation by preventing platelet aggregation before the clotting cascade occurs. Anticoagulants work in the clotting cascade, preventing the formation of the fibrin (clot). Thrombolytics "lyse" or dissolve a currently existing clot

Alteplase is a high-risk drug. Once it is given intravenously, the effects are immediate. Nurses must continuously assess during and after administration. The nurse must anticipate for possible complications, such as bleeding.

Assess for signs and symptoms of an allergic reaction. Assess for evidence of bleeding through continuous vital sign monitoring, including oxygen saturation. Assess for evidence of overt bleeding (insertion site, incision, orifices, and urinary catheter) or hidden bleeding (headache or abdominal pain). Monitor cardiac rate and rhythm for atrial and ventricular arrhythmias due to acute myocardial post-perfusion. Monitor BP, level of consciousness, and development of headache (increased intracranial pressure). Monitor respiratory status carefully, including respiratory rate, dyspnea, pulse oximetry, and blood gas findings. Avoid medications, such as aspirin and NSAIDs, for pain. Avoid additional venous or arterial punctures. Avoid subcutaneous (SQ) and intramuscular (IM) injections.

Side and Adverse Drug Effects of Alteplase

Common side effects are superficial bleeding at the puncture site and/or decreased BP. Bleeding is the major adverse drug effect of alteplase. Bleeding can even occur at various puncture sites caused by needles. Bruising may also occur. Occasional adverse drug effects are allergic reactions (rash or wheezing). Severe adverse drug effects include internal bleeding, atrial or ventricular arrhythmias, or stroke caused by the dissolution of the coronary thrombus.

Obtain complete medical history, including current situation and health status:

Determine any absolute contraindications, such as hemorrhagic cerebrovascular accident or internal bleeding. Coronary artery syndrome: When did symptoms begin? Have cardiac enzymes been collected? Is cardiac catheterization anticipated? Alteplase should be given within 6 hours of onset. Possible stroke: When did symptoms begin? Has a computerized axial tomography (CAT) scan indicated ischemic, rather than hemorrhagic, stroke? Alteplase should be given within 4.5 hours of onset. PE: Are there clinical symptoms? Is there presence of pain, dyspnea, anxiety, and hypoxia? Has a ventilation-perfusion (VQ) scan and/or D-dimer been done? Clot in central line catheter: Can blood be drawn from the catheter?

Establish multiple IV access for the following:

Drug administration Fluid maintenance Laboratory draw

Evaluation for Alteplase

During and after administration of alteplase, the nurse must continuously evaluate the effectiveness of the drug. Expected outcomes include the following: Restored circulation (stable vital signs, pain diminished/eliminated) Blood clot disintegration The nurse also must monitor for any side and adverse effects from the drug, such as bleeding. The nurse should anticipate giving aminocaproic acid, an antifibrinolytic drug, for excessive bleeding.

Alteplase given PE

The recommended dose is 100 mg given intravenously over 2 hours.

Alteplase given Acute Ischemic Stroke

The recommended dose is determined by weight, and 10% of the total dose is given intravenously over 1 minute. The remaining 90% is given intravenously over 60 minutes.

Interactions with Thrombolytics Laboratory Values

Thrombolytic therapy affects laboratory values: Decreases plasminogen and fibrinogen levels during infusions Increases clotting times May decrease hemoglobin and hematocrit

Perform a complete assessment, including laboratories:

Vital signs, including blood pressure (BP), apical pulse, respiration, and pulse oximetry to determine risk for shock 12-Lead electrocardiogram (ECG) and continuous 5-lead cardiac monitoring, to ascertain status Current weight to calculate medication dosage Baseline laboratory data drawn: Cardiac enzymes, electrolytes, hematocrit, platelet count, and blood glucose Coagulation values: Thrombin time (TT), prothrombin time (PT), activated partial thromboplastin time (aPTT), and fibrinogen Type and cross blood products Notation of any puncture sites, incision, and wounds or lacerations

Alteplase absorption

direct IV

Blood clots, or thrombi, are serious medical conditions that require immediate treatment. Thrombolytics are drugs that

disintegrate existing blood clots. Thrombolytics are high-alert medications, as indicated by the Institute for Safe Medication Practices. For this reason, thrombolytics should only be given in a setting where patients can be closely monitored (e.g., intensive care unit). A trained health care provider administers thrombolytic drugs according to protocols. Continuous assessment and monitoring before, during, and after administration are essential for safe and effective patient care.

Thrombolytic drugs, such as alteplase, reteplase, tenecteplase, and urokinase, dissolve

existing thrombi in the body. These drugs are used to treat life-threatening thrombi in an acute ST-elevation myocardial infarction (MI); thromboembolism, including pulmonary emboli (PE); and ischemic stroke.

Alteplase metabolism

liver

Alteplase, or tissue plasminogen activator (tPA), is manufactured by using

recombinant DNA technology and acts identically to human tPA. Alteplase binds with plasminogen and forms a complex that activates plasmin, an enzyme that disintegrates the fibrin network of blood clots. In this process, alteplase also contributes to decrease the action of fibrinogen and clotting factors, thereby increasing the risk for bleeding.

Alteplase distribution

unknown

Alteplase excretion

urine