Pharmacologic Profile

General Use

Acute management of ST-segment-elevation MI. Alteplase is also used in the management of acute pulmonary embolism and acute ischemic stroke.

General Action and Information

Converts plasminogen to plasmin, which then degrades fibrin in clots. Alteplase, reteplase, and tenecteplase directly activate plasminogen. Results in lysis of blood clots.

Contraindications

Hypersensitivity. Active internal bleeding, history of cerebrovascular accident, recent CNS trauma or surgery, neoplasm, or arteriovenous malformation, severe uncontrolled hypertension, and known bleeding tendencies.

Precautions

Recent (within 10 days) major surgery, trauma, GI or GU bleeding. Severe hepatic or renal disease. Subacute bacterial endocarditis or acute pericarditis. Use cautiously in geriatric patients. Safety not established in pregnancy, lactation, or children.

Interactions

Concurrent use with antiplatelet agents, NSAIDs, warfarin, dabigatran, rivaroxaban, apixaban, edoxaban, betrixaban, or heparins may ↑ the risk of bleeding, although these agents are frequently used together or in sequence. Risk of bleeding may also be ↑ by concurrent use with cefotetan, cefoperazone, and valproic acid.

Nursing Implications

Assessment

• Begin therapy as soon as possible after the onset of symptoms.
• Monitor vital signs, including temperature, continuously for coronary thrombosis and at least every 4 hr during therapy for other indications. Do not use lower extremities to monitor BP.
• 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 (↓ neurologic status; abdominal pain with coffee-ground emesis or black, tarry stools; hematuria; joint pain). If uncontrolled bleeding occurs, stop medication and notify physician immediately.
• Assess neurologic status throughout therapy.
• Altered sensorium or neurologic changes may be indicative of intracranial bleeding.
• Monitor ECG continuously. Notify physician if significant arrhythmias occur. IV lidocaine or procainamide may be ordered prophylactically. Cardiac enzymes should be monitored. Coronary angiography may be ordered following therapy to monitor effectiveness of therapy.
• Monitor heart sounds and breath sounds frequently. Inform physician if signs of HF occur (rales/crackles, dyspnea, S3 heart sound, jugular venous distention).
• Monitor pulse, BP, hemodynamics, and respiratory status (rate, degree of dyspnea, arterial blood gases).
• 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.
• Assess neurologic status. Determine time of onset of stroke symptoms. Alteplase must be administered within 3–4.5 hr of onset (within 3 hr in patients >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).
• 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 prior to and frequently throughout therapy. Bleeding time may be assessed prior to therapy if patient has received platelet aggregation inhibitors. Obtain type and cross match 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.
• 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, as it has antiplatelet activity. Aminocaproic acid may be used as an antidote.

Potential Nursing Diagnoses

• Ineffective tissue perfusion (Indications)
• Risk for injury (Side Effects)
• Deficient knowledge related to disease processes and medication regimen (Patient/Family Teaching)

Implementation

• This medication should be used only in settings in which hematologic function and clinical response can be adequately monitored.
• Starting two IV lines prior to 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).
• Systemic anticoagulation with heparin is usually begun several hours after the completion of thrombolytic therapy.
• Acetaminophen may be ordered to control fever.

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.