sign in sign up
<<
Home , Alteplase

Thrombolytic (alteplase – tPA) Orders for (PE) Pt. Identifier Page 1 of 2

1. Inclusion: Abbreviations  Massive PE: OR  Imminent/actual Acute PE with sustained (SBP with presumed PE DO <90 for > 15 min or requiring inotropic NOT USE support, not due to a cause other than PE), USE pulselessness, or persistent profound bradycardia (HR <40 with s/s shock)

Q.D..QD 2. Major Contraindications: Daily q.d.,qd Active hemorrhage in the following sites at the time of diagnosis: intraperitoneal, Yes No retroperitoneal

Head trauma causing loss of consciousness within previous 7 days Yes No Q.O.D. Every Any history of hemorrhagic Yes No QOD Other q.o.d. Day Ischemic stroke within the last 3 months Yes No qod Known structural cerebral vascular lesion Yes No Known malignant intracranial neoplasm Yes No

U Known inherited or acquired disorder (hemophilia, platelet <50,000/uL Units Yes No u or liver failure with INR >1.7)

Surgery that required opening of the chest cavity, peritoneum, skull or spinal Yes No canal within the previous 14 days No 3. Relative Contraindications: Trailing 2 mg Zero Age > 75 Yes No Surgery more than 14 days but less than 21 days Yes No Any prior stroke or symptoms suggesting transient ischemic attack > 3 months Yes No Lack of Leading 0.2 mg Pericarditis or Pericardial fluid Yes No Zero INR > 1.7 from use Yes No (Eliquis), (Savaysa) or (Xarelto) within the past 48 Yes No

hours; (Pradaxa) within with past 96 hours (4 days) Morphine MS Sulfate Dementia Yes No Magnesium Sulfate Pregnancy Yes No Severe uncontrolled hypertension on initial exam: SBP > 180 or DBP > 110 Yes No

Traumatic or prolonged cardiopulmonary resuscitation Yes No

Morphine MS04 Internal bleed within 28 days (e.g., GI bleed requiring transfusion or endoscopy) Yes No Sulfate Diabetic retinopathy; History of intraocular hemorrhage Yes No 4. The following conditions increase the risk of bleeding and should be considered:

Current use of a P2Y12 inhibitor: (Plavix), (Effient), Magnesium Yes No MgSO4 Sulfate (Brilinta) (Ticlid)): Magnitude of increased risk not defined Low body weight (≤ 65 kg women and ≤ 80 kg men) Relative risk of increased 61% vs heavier patients Yes No Risk of all bleeding also increased; ~ 1% per kg as body weight decreases

Origin: 6/15 Female sex: Relative risk of bleeding increased 48% vs males Yes No Black race: Relative risk of bleeding increased 36% vs whites Yes No Rate of moderate/severe bleeding = 14.2%: Based on > 32,000 who receiving tPA for STEMI (Am J Med 2011;124(1)48-57) Rate of ICH hemorrhage = 1.43%: Based on > 31,000 who received tPA for AMI (Stroke 2000;31(8):1802-11)

Completed by: ______Date: ______Time: ______

*1773* Pt. Identifier Thrombolytic (alteplase – tPA) Orders for Pulmonary Embolism (PE) Page 2 of 2

Prior to initiating tPA: Abbreviations  2 patent IVs (18 gauge) tPA Administration: Imminent/actual cardiac arrest with DO Massive PE: presumed PE: NOT USE   USE tPA (alteplase) 100 mg/100 mL IV STAT tPA (alteplase) 50 mg/50 mL IV bolus over 2 hrs STAT

Q.D..QD IV Fluids after tPA infused : ______Daily q.d.,qd

Anticoagulation:  If receiving infusion - hold heparin infusion while tPA infusing  After tPA infusion completed, check PTT STAT. Q.O.D. Every QOD Other  If ≤ 65 seconds: q.o.d. Day qod  Begin heparin infusion with no initial bolus. See completed Heparin Infusion Protocols - High Dose Protocol with NO INITIAL BOLUS  If > 65 seconds, check PTT Q2h until < 65 seconds. After PTT < 65 seconds:

U Units  Begin heparin infusion with no initial bolus. See completed Heparin u Infusion Protocols - High Dose Protocol with NO INITIAL BOLUS Labs:  CBC now and Q6h No Trailing 2 mg  BMP, fibrinogen now and Q12h Zero  Type and crossmatch 3 units PRBC and HOLD EXCEPTION: IF BLOODLESS MEDICINE PATIENT - obtain ABORh if agreed to any alternative treatment in the Blood Transfusion

Lack of Liability Release Leading 0.2 mg Zero Vital Signs and Neuro Checks (document on the tPA administration/monitoring flowsheet)

 Every 15 min during and after tPA infusion for 2 hours, then

 Every 30 min for 6 hours, then Morphine  MS Sulfate Every 1 hr until 24hr after tPA treatment started, then Magnesium Sulfate  As indicated by patient status or per nursing unit routine

Monitoring (No automated BP cuffs x 24h from end of tPA infusion):

Morphine MS04  Telemetry  SpO2  Strict I&O  Bed rest for 24 hrs Sulfate  Place sign over the HOB and on door to alert that the patient is receiving or has received (within 24 hrs) thrombolytic therapy

 No IM Injections x 24h from end of tPA infusion Magnesium MgSO4 Sulfate For Signs/Symptoms of bleeding  Stop tPA infusion  Notify ordering physician STAT  Send STAT labs: PT/INR, PTT, CBC, fibrinogen, type and cross match 2 units RBCs  Diagnostic study: ______If suspected intracranial bleed:  STAT non-contrast heat CT; Indication: “emergency, possible bleed due to thrombolytic therapy” MD Signature: Date: Time:

RN Signature: Date: Time:

Originated: 6/15

*1773* [Patient Identifier]

Pulmonary Embolism (PE) – tPA Administration/Monitoring Flowsheet

Page 1 of 1

Date/Time tPA infusion started: Administering Nurse Initials:______Witnessing Nurse Initials:______

Monitor neurological status and vital signs: • Every 15 minutes during tPA infusion and one hour after (total of 2 hours) • Then every 30 minutes X 6 hours • Then every 1 hours X 16 hours, and then • As indicated by patient status or per nursing unit routine Date: 15 30 45 60 75 90 105 120 2.5 3.5 4.5 5.5 6.5 Baseline 3h 4h 5h 6h Expected Time Interval: m m m m m m m m h h h h h Actual Time: Nurse Initials: BP: Pulse: Resps: O2 Sat: Neuro Intact (Y/N) Nursing Signature/Initials: ______/______/______/______/______/_____

Date: Expected Time Interval: 7h 7.5 8h 9h 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Actual Time: Nurse Initials: BP: Pulse: Resps: O2 Sat: Neuro Intact (Y/N) Nursing Signature/Initials: ______/______/______/______/______/_____

Originated: 6/15

*1774*