MASSACHUSETTS GENERAL HOSPITAL, Department of Pharmacy, Department of Nursing
Critical Care
Generic Name: Alteplase
Trade Name: Activase
Action: Tissue Plasminogen Activator (tPA)
Indications: Acute Myocardial Infarction (* use requires cardiology approval * * or Emergency Department attending *)
Pulmonary embolism
Embolic stroke: *Neurology approval or ER attending
Peripheral arterial or venous thrombosis
Catheter occlusion
Administration Guidelines:
Usual Dosage Range and Route:
FOR ACUTE MYOCARDIAL INFARCTION
Initial Or Loading Dose Must Be Administered By Physician
Patient Weight > 67kg:
15mg bolus, then 50mg over the next 30 minutes. Institute heparin therapy with a bolus. Infuse remaining 35mg of TPA over the next hour (total dose of TPA = 100mg.)
Patient Weight < 67kg:
15mg bolus, then 0.75mg/kg (max 50mg) over 30 minutes. Initiate heparin therapy with a bolus. Then 0.5mg/kg (max 35mg) over the next hour.
For Pulmonary Embolism
100mg continuous infusion over 2 hours
Start heparin near the end of or immediately following infusion when PTT returns to 2X normal or less.
For Embolic Stroke (confirmed by CT scan)
Total dose will be 0.9mg/kg (maximum 90mg) administer 10% as a bolus and the remainder over 60 minutes .
Do not start heparin within 24 hours of TPA.
Peripheral Venous Thrombosis-Systemic Thrombolysis Approach
Loading dose: None
Infusion: 0.5-4 mg/h for 24 h (recommended max 50mg/24 hours)
Heparin should be started after alteplase infusion is completed (no loading dose) to maintain the aPTT in a therapeutic range .
Peripheral Venous Thrombosis-Catheter-directed Thrombolysis
Initial Or Loading Dose Must Be Administered By Physician
Loading dose: 4-10mg administered during procedure
Maintenance Infusion: 0.5-4mg/hr for 4-24 hours IV. Recommended cumulative maximum of 50 mg (Load plus infusion).
Heparin should be used at a low non-weight adjusted dose (eg 250 units/hr) keeping aPTT <1.5 times baseline during alteplase infusion.
Peripheral Arterial Thrombosis (for more information see Nursing Procedure for Intraarterial Medication administration)
All medications administered directly through the intra-arterial catheter must be initiated by the MD. RN may adjust infusion rate only via the infusion pump.
RN may administer medications via the side port of the introducer if ordered by the MD
Loading dose: 4-10mg administered during procedure
Maintenance Infusion: 0.5-4mg/hr for 4-24 hours through arterial line. Recommended cumulative maximum of 50 mg (Load plus infusion).
Heparin should be used at a low non-weight adjusted dose (eg 250 units/hr) keeping aPTT <1.5 times baseline during alteplase infusion.
Catheter occlusion
Patients <30 kg: 110% of the internal lumen volume of the catheter, not to exceed 2 mg/2 mL; retain in catheter for 0.5-2 hours; may instill a second dose if catheter remains occluded
Patients =30 kg: 2 mg (2 mL); retain in catheter for 0.5-2 hours; may instill a second dose if catheter remains occluded
Restoration of PICC lines may be implemented only by an IV Nurse
Standard Concentration:
Pulmonary Embolism, Stroke, myocardial infarction;100 mg / 100 mL
Peripheral arterial or venous thrombosis: 50mg/500mL, 25mg/250mL
Catheter occlusion: 2mg/2mL (Cathflo) - Add 2.2 mL sterile water for injection to vial. DO NOT use bacteriostatic water.Mix gently until contents are dissolved. DO NOT shake. Final concentration: 1 mg/mL.
EW Standard
Pulmonary Embolism: 100 mg/ 100mL
See above for other disease states
Suggested Maximum Dose:
Total 24 hour dose not to exceed 100 mg for infusions
Special Considerations:
Infusions
- Infusion should not be interrupted and should not be administered in the same IV line as other medications.
- Avoid intramuscular injections and vascular punctures at non-compressible sites before, during and after therapy.
- Check neuro vital signs every hour.
- Contraindicated in patients with recent trauma, hemorrhagic stroke, surgery, active GI bleed within 2 months, coagulopathy or known bleeding diathesis.
- Should be used with caution in patients who have received chest compressions.
- Should be used with caution in patients who are currently on Heparin, Coumadin or antiplatelet drugs
-Peripheral arterial or venous thrombosis; Check fibrinogen levels every 6 hours and consider holding when less than 100 mg/dl
Catheter occlusion:
- Instill and let dwell for 30 minutes. Do not force solution into catheter.
-leave syringe in place and do not close clamps on the catheter t allow the t-Pa to move freely into the catheter as the fibrin dissolves.
-Aspirate for blood return. If catheter is functional aspirate and discard 4-5 mL of blood for patients > 10 kg or 3 mL of blood from patients < 10 kg to remove the medication and residual clot.
-Gently irrigate the catheter with normal saline flush.
-If catheter is non functional after 30 minute dwell, continue to allow t-PA to dwell for up to 2 hours- then aspirate for blood return. If catheter still not functional withdraw instilled solution. May instill second dose.
-On rare occasions the t-Pa dose may not be aspirated, but flushing of catheter may be possible.
Precautions and Side Effects for infusions:
- Hemorrhage, bleeding from iv sites
- Fever
- Hypotension
- Reperfusion arrhythmias
- Anaphylaxis
-Hemorrhagic stroke
Critical Care
Generic Name: Alteplase
Trade Name: Activase
Action: Tissue Plasminogen Activator (tPA)
Indications: Acute Myocardial Infarction (* use requires cardiology approval * * or Emergency Department attending *)
Pulmonary embolism
Embolic stroke: *Neurology approval or ER attending
Peripheral arterial or venous thrombosis
Catheter occlusion
Administration Guidelines:
Usual Dosage Range and Route:
FOR ACUTE MYOCARDIAL INFARCTION
Initial Or Loading Dose Must Be Administered By Physician
Patient Weight > 67kg:
15mg bolus, then 50mg over the next 30 minutes. Institute heparin therapy with a bolus. Infuse remaining 35mg of TPA over the next hour (total dose of TPA = 100mg.)
Patient Weight < 67kg:
15mg bolus, then 0.75mg/kg (max 50mg) over 30 minutes. Initiate heparin therapy with a bolus. Then 0.5mg/kg (max 35mg) over the next hour.
For Pulmonary Embolism
100mg continuous infusion over 2 hours
Start heparin near the end of or immediately following infusion when PTT returns to 2X normal or less.
For Embolic Stroke (confirmed by CT scan)
Total dose will be 0.9mg/kg (maximum 90mg) administer 10% as a bolus and the remainder over 60 minutes .
Do not start heparin within 24 hours of TPA.
Peripheral Venous Thrombosis-Systemic Thrombolysis Approach
Loading dose: None
Infusion: 0.5-4 mg/h for 24 h (recommended max 50mg/24 hours)
Heparin should be started after alteplase infusion is completed (no loading dose) to maintain the aPTT in a therapeutic range .
Peripheral Venous Thrombosis-Catheter-directed Thrombolysis
Initial Or Loading Dose Must Be Administered By Physician
Loading dose: 4-10mg administered during procedure
Maintenance Infusion: 0.5-4mg/hr for 4-24 hours IV. Recommended cumulative maximum of 50 mg (Load plus infusion).
Heparin should be used at a low non-weight adjusted dose (eg 250 units/hr) keeping aPTT <1.5 times baseline during alteplase infusion.
Peripheral Arterial Thrombosis (for more information see Nursing Procedure for Intraarterial Medication administration)
All medications administered directly through the intra-arterial catheter must be initiated by the MD. RN may adjust infusion rate only via the infusion pump.
RN may administer medications via the side port of the introducer if ordered by the MD
Loading dose: 4-10mg administered during procedure
Maintenance Infusion: 0.5-4mg/hr for 4-24 hours through arterial line. Recommended cumulative maximum of 50 mg (Load plus infusion).
Heparin should be used at a low non-weight adjusted dose (eg 250 units/hr) keeping aPTT <1.5 times baseline during alteplase infusion.
Catheter occlusion
Patients <30 kg: 110% of the internal lumen volume of the catheter, not to exceed 2 mg/2 mL; retain in catheter for 0.5-2 hours; may instill a second dose if catheter remains occluded
Patients =30 kg: 2 mg (2 mL); retain in catheter for 0.5-2 hours; may instill a second dose if catheter remains occluded
Restoration of PICC lines may be implemented only by an IV Nurse
Standard Concentration:
Pulmonary Embolism, Stroke, myocardial infarction;100 mg / 100 mL
Peripheral arterial or venous thrombosis: 50mg/500mL, 25mg/250mL
Catheter occlusion: 2mg/2mL (Cathflo) - Add 2.2 mL sterile water for injection to vial. DO NOT use bacteriostatic water.Mix gently until contents are dissolved. DO NOT shake. Final concentration: 1 mg/mL.
EW Standard
Pulmonary Embolism: 100 mg/ 100mL
See above for other disease states
Suggested Maximum Dose:
Total 24 hour dose not to exceed 100 mg for infusions
Special Considerations:
Infusions
- Infusion should not be interrupted and should not be administered in the same IV line as other medications.
- Avoid intramuscular injections and vascular punctures at non-compressible sites before, during and after therapy.
- Check neuro vital signs every hour.
- Contraindicated in patients with recent trauma, hemorrhagic stroke, surgery, active GI bleed within 2 months, coagulopathy or known bleeding diathesis.
- Should be used with caution in patients who have received chest compressions.
- Should be used with caution in patients who are currently on Heparin, Coumadin or antiplatelet drugs
-Peripheral arterial or venous thrombosis; Check fibrinogen levels every 6 hours and consider holding when less than 100 mg/dl
Catheter occlusion:
- Instill and let dwell for 30 minutes. Do not force solution into catheter.
-leave syringe in place and do not close clamps on the catheter t allow the t-Pa to move freely into the catheter as the fibrin dissolves.
-Aspirate for blood return. If catheter is functional aspirate and discard 4-5 mL of blood for patients > 10 kg or 3 mL of blood from patients < 10 kg to remove the medication and residual clot.
-Gently irrigate the catheter with normal saline flush.
-If catheter is non functional after 30 minute dwell, continue to allow t-PA to dwell for up to 2 hours- then aspirate for blood return. If catheter still not functional withdraw instilled solution. May instill second dose.
-On rare occasions the t-Pa dose may not be aspirated, but flushing of catheter may be possible.
Precautions and Side Effects for infusions:
- Hemorrhage, bleeding from iv sites
- Fever
- Hypotension
- Reperfusion arrhythmias
- Anaphylaxis
-Hemorrhagic stroke
