Read Mosby's 2014 Nursing Drug Reference Online
Authors: Linda Skidmore-Roth
Mosby's 2014 Nursing Drug Reference (28 page)
Canada only Side effects:
italics
= common;
bold
= life-threatening 
Nurse Alert
HIGH ALERT(al-ti-plaze′)
Activase, Cathflo
Func. class.:
Thrombolytic enzyme
Chem. class.:
Tissue plasminogen activator (TPA)
Do not confuse:
alteplase
/Altace
Produces fibrin conversion of plasminogen to plasmin; able to bind to fibrin, convert plasminogen in thrombus to plasmin, which leads to local fibrinolysis, limited systemic proteolysis
Lysis of obstructing thrombi associated with acute MI, ischemic conditions that require thrombolysis (i.e., PE, unclotting arteriovenous shunts, acute ischemic CVA), central venous catheter occlusion (Cathflo)
Unlabeled uses:
Arterial thromboembolism, deep vein thrombosis (DVT), occlusion prophylaxis, percutaneous coronary intervention (PCI), subarachnoid hemorrhage
Active internal bleeding, history of CVA, severe uncontrolled hypertension, intracranial/intraspinal surgery/trauma (within 3 mo), aneurysm, brain tumor, platelets <100,000 mm
3
, bleeding diathesis including INR >1.7 or PR >15 sec, arteriovenous malformation, subarachnoid hemorrhage, intracranial hemorrhage, uncontrolled hypertension, seizure at onset of stroke
Precautions:
Pregnancy (C), breastfeeding, children, geriatric patients, neurologic deficits, mitral stenosis, recent GI/GU bleeding, diabetic retinopathy, subacute bacterial endocarditis, arrhythmias, diabetic hemorrhage retinopathy, CVA, recent major surgery, hypertension, acute pericarditis, hemostatic defects, significant hepatic disease, septic thrombophlebitis, occluded AV cannula at seriously infected site
Calculator
• Adult >65 kg:
100 mg total given over 3 hr as follows: 6- to 10-mg IV BOL over 1-2 min; remaining 50-54 mg given over the remainder of the hr; during 2nd, 3rd hr 20 mg given by
CONT IV INF
(20 mg/hr)
• Adult <65 kg:
1.25 mg/kg over 3 hr: 60% during 1st hr (6%-10% as bolus); remaining 50% given over remainder of hr; during 2nd hr, 20% of dose given by CONT IV INF; 20% given during 3rd hr by CONT IV INF
• Adult >67 kg:
100 mg total dose: give 15-mg IV bolus, then 50 mg over 30 min, then 35 mg over 60 min
• Adult <67 kg:
15-mg IV bolus, then 0.75 mg/kg (max 50 mg) over 30 min, then 0.5 mg/kg (max 35 mg) over next 60 min
•Adult: IV
100 mg over 2 hr, then heparin
•Adult: IV
0.9 mg/kg, max 90 mg; give as
INF
over 1 hr, give 10% of dose
IV BOL
over 1st min
• Adult/child
≥
30 kg: IV
2 mg/2 ml instilled in occluded catheter, may repeat if needed after 2 hr
• Child 10-29 kg: IV
110% of lumen volume, max 2 mg/2 ml instilled in occluded catheter, may repeat if needed after 2 hr
•Adult: IV
2 mg/hr for up to 5 hr
•Adult: IV
4 mcg/kg/min as 2-hr inf, then 1 mcg/kg/min × 33 hr
• Adult:INTRACARDIAC
20 mg over 5 min then 50 mg over the next 60 min
• Adult >30 kg:
Do not exceed 2 mg in 2 ml; may use up to 2 doses 120 min apart
Available forms:
Powder for inj 50 mg (29 million international units/vial), 100 mg (58 million international units/vial); Cathflo Actinase: lyophilized powder for inj 2 mg
•
After reconstituting with provided diluent, add appropriate amount of sterile water for inj (no preservatives) 20-mg vial/20 ml or 50-mg vial/50 ml to make 1 mg/ml, mix by slow inversion or dilute with NaCl, D
5
W to a conc of 0.5 mg/ml; 1.5 to <0.5 mg/ml may result in precipitation of product; use 18G needle; flush line with NaCl after administration, give over 3 hr for MI, 2 hr for PE
•
Heparin therapy after thrombolytic therapy is discontinued, TT, ACT, or APTT less than 2× control (about 3-4 hr); treatment can be initiated before coagulation study results obtained, inf should be discontinued if pretreatment INR >1.7, PT >15 sec, or elevated aPTT is identified
•
Use reconstituted IV solution within 8 hr or discard
Y-site compatibilities:
Eptifibatide, lidocaine, metoprolol, propranolol
•
Cathflo Actinase:
reconstitute by using 2.2 ml of sterile water provided and injecting in vial, direct flow into powder (1 mg/ml), foam will disappear after standing; swirl, do not shake, sol will be pale yellow or clear, use within 8 hr, instill 2 ml of reconstituted sol into occluded catheter, try to aspirate after 1/2 hr; if unable to remove, allow 2 hr, a 2nd dose may be used; aspirate 5 ml of blood to remove clot and product, irrigate with normal saline
CV:
Sinus bradycardia, cholesterol microembolization, ventricular tachycardia, accelerated idioventricular rhythm, bradycardia, recurrent ischemic stroke,
hypotension
EENT:
Orolingual angioedema
INTEG:
Urticaria, rash
SYST:
GI, GU, intracranial, retroperitoneal bleeding,
surface bleeding
,
anaphylaxis,
fever
Cleared by liver, 80% cleared within 10 min of product termination, onset immediate, peak 45 min, duration 4 hr, half-life 35 min
Increase:
bleeding—anticoagulants, salicylates, dipyridamole, other NSAIDs, abciximab, eptifibatide, tirofiban, clopidogrel, ticlopidine, some cephalosporins, plicamycin, valproic acid
Increase:
orolingual angioedema—ACE inhibitors
Decrease:
effect—nitroglycerin
Increase:
risk for bleeding—feverfew, garlic, ginger, ginkgo, ginseng, green tea
Increase:
PT, APTT, TT
•
Treatment is not recommended for patients with acute ischemic stroke >3 hr after symptom onset or with minor neurologic deficits or rapidly improving symptoms
•
VS, B/P, pulse, respirations, neurologic signs, temp at least q4hr; temp >104° F (40° C) indicates internal bleeding; monitor rhythm closely; ventricular dysrhythmias may occur with hyperfusion; monitor heart, breath sounds, neurologic status, peripheral pulses; assess neurologic status, neurologic change may indicate intracranial bleeding; those with severe neurologic deficit (NIH SS >22) at presentation have increased risk of hemorrhage
For bleeding
during 1st hour of treatment and 24 hr after procedure: hematuria, hematemesis, bleeding from mucous membranes, epistaxis, ecchymosis; guaiac all body fluids, stools; do not use 150 mg or more total dose because intracranial bleeding may occur
Hypersensitivity:
fever, rash, itching, chills, facial swelling, dyspnea, notify prescriber immediately; stop product, keep resuscitative equipment nearby; mild reaction may be treated with antihistamines
•
Previous allergic reactions or streptococcal infection; alteplase may be less effective
•
Blood studies (Hct, platelets, PTT, PT, TT, APTT) before starting therapy; PT or APTT must be less than 2× control before starting therapy TT or PT q3-4hr during treatment
•
MI:
ECG continuously, cardiac enzymes, radionuclide myocardial scanning/coronary angiography; chest pain intensity, character; monitor those with major early infarct signs on CT scan with substantial edema, mass effect, midline shift
•
PE: pulse, B/P, ABGs, rate/rhythm of respirations
•
Occlusion:
have patient exhale then hold breath when connecting/disconnecting syringe to prevent air embolism
•
Cholesterol embolism:
purple toe syndrome, acute renal failure, gangrenous digits, hypertension, livedo reticularis, pancreatitis, MI, cerebral infarction, spinal cord infarction, retinal artery occlusion, bowel infarction, rhabdomyolysis
•
Avoidance of invasive procedures, inj, rectal temp
•
Pressure for 30 sec to minor bleeding sites; 30 min to sites of atrial puncture followed by pressure dressing; inform prescriber if this does not attain hemostasis; apply pressure dressing
•
Storage of powder at room temperature or refrigerate; protect from excessive light
•
Therapeutic response: lysis of thrombi
•
The purpose and expected results of the treatment; to report adverse reactions