alteplase

Activase

Cathflo Activase

tissue plasminogen activator

t-PA

Indications

Action

Pharmacokinetics

Time/action profile (fibrinolysis)

Contraindications/Precautions

Adverse Reactions/Side Effects

Central nervous system

• intracranial hemorrhage (life-threatening)

Ear, Eye, Nose, Throat

• epistaxis
• gingival bleeding

Respiratory

• bronchospasm
• hemoptysis

Cardiovascular

• reperfusion arrhythmias
• hypotension
• recurrent ischemia/thromboembolism (life-threatening)

Gastrointestinal

• GI bleeding (life-threatening)
• nausea
• retroperitoneal bleeding (life-threatening)
• vomiting

Genitourinary

• GU tract bleeding (life-threatening)

Dermatologic

• ecchymoses
• flushing
• urticaria

Hematologic

• bleeding (life-threatening)

Local

• hemorrhage at injection site
• phlebitis at injection site

Musculoskeletal

• musculoskeletal pain

Miscellaneous

• allergic reactions including anaphylaxis (life-threatening)
• fever

Interactions

Drug-Drug interaction

Route/Dosage

Myocardial Infarction (Accelerated or Front-Loaded Regimen)

Myocardial Infarction (Standard Regimen)

Acute Ischemic Stroke

Pulmonary Embolism

Occluded Venous Access Devices

Availability

Nursing implications

Nursing assessment

• Begin therapy as soon as possible after the onset of symptoms.
  • Monitor vital signs, including temperature, continuously for myocardial infarction and at least every 4 hr during therapy for other indications. Do not use lower extremities to monitor BP. Notify health care professional if systolic BP >180 mm Hg or diastolic BP >110 mm Hg. Thrombolytic therapy should not be given if hypertension is uncontrolled. Inform health care professional if hypotension occurs. Hypotension may result from the drug, hemorrhage, or cardiogenic shock.
  • Assess patient carefully for bleeding every 15 min during the 1st hr of therapy, every 15–30 min during the next 8 hr, and at least every 4 hr for the duration of therapy. Frank bleeding may occur from sites of invasive procedures or from body orifices. Internal bleeding may also occur (decreased neurologic status; abdominal pain with coffee-grounds emesis or black, tarry stools; hematuria; joint pain). If uncontrolled bleeding occurs, stop medication and notify health care professional immediately.
  • Assess patient for hypersensitivity reaction (rash, dyspnea, fever, changes in facial color, swelling around the eyes, wheezing). If these occur, inform health care professional promptly. Keep epinephrine, an antihistamine, and resuscitation equipment close by in the event of an anaphylactic reaction.
  • Assess neurologic status throughout therapy. Altered sensorium or neurologic changes may be indicative of intracranial bleeding.
• Myocardial Infarction: Monitor ECG continuously. Notify health care professional if significant arrhythmias occur. IV lidocaine or procainamide (Pronestyl) may be ordered prophylactically. Monitor cardiac enzymes. Radionuclide myocardial scanning and/or coronary angiography may be ordered 7–10 days after therapy to monitor effectiveness of therapy.
  • Assess intensity, character, location, and radiation of chest pain. Note presence of associated symptoms (nausea, vomiting, diaphoresis). Administer analgesics as directed. Notify health care professional if chest pain is unrelieved or recurs.
  • Monitor heart sounds and breath sounds frequently. Inform health care professional if signs of HF occur (rales/crackles, dyspnea, S₃ heart sound, jugular venous distention, relieved CVP).
• Acute Ischemic Stroke: Assess neurologic status. Determine time of onset of stroke symptoms. Alteplase must be administered within 3–4.5 hr of onset (within 3 hrs in patients older than 80 years, those taking oral anticoagulants, those with a baseline National Institutes of Health Stroke Scale score 25, or those with both a history of stroke and diabetes).
• Pulmonary Embolism: Monitor pulse, BP, hemodynamics, and respiratory status (rate, degree of dyspnea, ABGs).
• Deep Vein Thrombosis/Acute Arterial Occlusion: Observe extremities and palpate pulses of affected extremities every hour. Notify health care professional immediately if circulatory impairment occurs. Computerized tomography, impedance plethysmography, quantitative Doppler effect determination, and/or angiography or venography may be used to determine restoration of blood flow and duration of therapy; however, repeated venograms are not recommended.
• Cannula/Catheter Occlusion: Monitor ability to aspirate blood as indicator of patency. Ensure that patient exhales and holds breath when connecting and disconnecting IV syringe to prevent air embolism.
• Lab Test Considerations: Hematocrit, hemoglobin, platelet count, fibrin/fibrin degradation product (FDP/fdp) titer, fibrinogen concentration, prothrombin time, thrombin time, and activated partial thromboplastin time may be evaluated before and frequently during therapy. Bleeding time may be assessed before therapy if patient has received platelet aggregation inhibitors.
  • Obtain type and crossmatch and have blood available at all times in case of hemorrhage.
  • Stools should be tested for occult blood loss and urine for hematuria periodically during therapy.
high alert: If local bleeding occurs, apply pressure to site. If severe or internal bleeding occurs, discontinue infusion. Clotting factors and/or blood volume may be restored through infusions of whole blood, packed RBCs, fresh frozen plasma, or cryoprecipitate. Do not administer dextran; it has antiplatelet activity. Aminocaproic acid (Amicar) may be used as an antidote.

Potential Nursing Diagnoses

Implementation

• high alert: Overdose and under-dosage of thrombolytic medications have resulted in patient harm or death. Have second practitioner independently check original order, dose calculations, and infusion pump settings. Clarify orders that contain any of these abbreviations.
• Do not confuse the abbreviation t-PA for alteplase (Activase) with the abbreviations TNK t-PA for tenecteplase (TNKase) and r-PA for reteplase (Retevase). Do not confuse Activase with Cathflo Activase or TNKase.
• Thrombolytic agents should be used only in settings in which hematologic function and clinical response can be adequately monitored.
  • Starting two IV lines before therapy is recommended: one for the thrombolytic agent, the other for any additional infusions.
  • Avoid invasive procedures, such as IM injections or arterial punctures, with this therapy. If such procedures must be performed, apply pressure to all arterial and venous puncture sites for at least 30 min. Avoid venipunctures at noncompressible sites (jugular vein, subclavian site).
  • Acetaminophen may be ordered to control fever.

• Intravenous Administration

• pH: 7.3.
• Intermittent Infusion: Vials are packaged with sterile water for injection (without preservatives) to be used as diluent. Do not use bacteriostatic water for injection. Reconstitute 50-mg vials with 50 mL and 100–mg with 100 mL using an 18-gauge needle. Avoid excess agitation during dilution; swirl or invert gently to mix. Solution may foam upon reconstitution. Bubbles will resolve upon standing a few min. Solution will be clear to pale yellow. Stable for 8 hr at room temperature. Concentration: May be administered as reconstituted (1 mg/mL). Diluent: May be further diluted immediately before use in an equal amount of 0.9% NaCl or D5W.
• Rate: Flush line with 20–30 mL of saline at completion of infusion to ensure entire dose is received. See Route and Dosage section for specific rates.
• Y-Site Compatibility: eptifibatide, lidocaine, metoprolol, propranolol
• Y-Site Incompatibility: bivalrudin, dobutamine, dopamine, heparin, nitroglycerin
• Cathflo Activase: Reconstitute by withdrawing 2.2 mL of sterile water (provided) and injecting into Cathflo Activase vial, directing diluent into powder for a concentration of 1 mg/mL. Allow slight foaming to dissipate by letting vial stand undisturbed. Do not use bacteriostatic water. Mix by gently swirling to dissolve; complete dissolution should occur within 3 min. Do not shake. Solution should be colorless to pale yellow. Use solution within 8 hr.
  • Withdraw 2.0 mL of reconstituted solution and instill into occluded catheter. After 30 min dwell time, attempt to aspirate blood. If catheter remains occluded, allow 120 min dwell time. If catheter function is not restored after one dose, second dose may be instilled. If catheter function is restored, aspirate 4–5 mL of blood in patients ≥10 kg or 3 mL in patients <10 kg to remove Cathflo Activase and residual clot. Gently irrigate catheter with 0.9% NaCl.

Patient/Family Teaching

• Explain purpose of medication and the need for close monitoring to patient and family. Instruct patient to report hypersensitivity reactions (rash, dyspnea) and bleeding or bruising.
• Explain need for bedrest and minimal handling during therapy to avoid injury. Avoid all unnecessary procedures such as shaving and vigorous tooth brushing.

Evaluation/Desired Outcomes

• Lysis of thrombi and restoration of blood flow.
• Prevention of neurologic sequelae in acute ischemic stroke.
• Cannula or catheter patency.