Pharmacologic Profile

General Use

Acute ST-segment-elevation MI and acute ischemic stroke. Alteplase is also used in the management of acute pulmonary embolism and for occluded central venous access devices.

General Action and Information

Directly convert plasminogen to plasmin, which then degrades fibrin in clots, resulting in lysis of the clot.

Contraindications

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

Precautions

Recent (within 10 days) major surgery, trauma, or GI or GU bleeding. Severe hepatic or renal disease. Subacute bacterial endocarditis or acute pericarditis. Use cautiously in older adults.

Interactions

Concurrent use with antiplatelet agents, NSAIDs, warfarin, dabigatran, rivaroxaban, apixaban, edoxaban, 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 and valproic acid.

Nursing Implications

Assessment

• Begin therapy as soon as possible after the onset of symptoms.
• Monitor vital signs 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 BP, HR, and ECG continuously. Notify physician if significant arrhythmias occur. Cardiac enzymes should be monitored. Coronary angiography may be ordered following therapy.
• Monitor heart sounds and breath sounds frequently. Inform physician if signs of HF occur (rales/crackles, dyspnea, S3 heart sound, jugular venous distention).
• Assess neurologic status. Determine time of onset of stroke symptoms. Must be administered within 3–4.5 hr of onset (within 3 hr in patients >80 yr, 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).
• Monitor BP, HR, 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.
• Hematocrit, hemoglobin, platelet count, fibrin/fibrin degradation product titer, fibrinogen concentration, PT, and aPTT 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 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.
• 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.

Implementation

• 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 ≥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.

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.