NURSING DEPARTMENT CRITICAL CARE POLICY MANUAL CRITICAL CARE PROTOCOLS ACTIVASE (t-pa) FOR ACUTE MYOCARDIAL INFARCTION I. PURPOSE: A. To reduce the extent of myocardial infarction by lysing the clot in the coronary artery, salvaging the myocardium and preserving ventricular function. B. To reduce morbidity and mortality in acute myocardial infarction. II. PATIENT SELECTION: A. The patient must manifest the clinical signs and symptoms of acute myocardial infarction including typical electrocardiographic changes of acute injury. III. CONTRAINDICATIONS: A. Uncontrolled hypertension with systolic blood pressure of more than 180 mmhg, diastolic blood pressure of more than 110 mmhg. B. Recent CVA, intracranial neoplasm, AV malformation and aneurysm. C. Recent (within two months) intracranial or spinal injury, trauma or surgery. D. Pregnancy Date of Original: 1/85 Reviewed Revised 3/97 3/08 3/08 10/1 10/10 9/11 9/11 9/13 7-9-14 7-9-14 10/14 10/15 10/16 6/17 17
t-pa (ACTIVASE) E. Contraindication to anticoagulation. 1. Active internal bleeding including G.I., G.U. bleed, dissecting aortic aneurysm. 2. Bleeding diathesis. 3. Recent (within ten days) trauma or major surgery, including coronary artery bypass surgery, intra-abdominal surgery, organ biopsy, obstetrical delivery, prolonged traumatic external cardiac compression, traumatic endotracheal intubation, etc. IV. RELATIVE CONTRAINDICATIONS: A. Recent puncture of non-compressible blood vessel, i.e., subclavian vein, etc. B. Advanced liver and kidney disease. C. Infectious endocarditis. D. Pericarditis. E. Known or high likelihood of left heart thrombus. F. Diabetic hemorrhagic retinopathy or other hemorrhagic ophthalmic conditions. G. Septic thrombophlebitis or occluded AV cannula at seriously infected site. H. Patients currently receiving oral anticoagulants, i.e., warfarin sodium. I. Active peptic ulcer disease. V. PROCEDURE: A. The patient and/or patient s family should be well informed by the physician of the potential complications of acute thrombolytic therapy including bleeding complications. B. I.V. t-pa should be infused as soon as possible after the diagnosis of acute myocardial infarction is established. Any physician may prescribe I.V. t-pa, however, a cardiology consultation is recommended. 17a
C. Initial diagnostic work-up (STAT): 1. CBC and differential 2. Protime and PTT 3. Thrombin time 4. Fibrinogen 5. Blood typing 6. Routine CCU lab 7. EKG on admission and immediately before the procedure. D. Insert two peripheral venous lines in different arms, one in a large peripheral vein for I.V. t-pa infusion, the other for infusion of drugs. A separate heparin lock will be inserted for blood sampling. E. Patient may be given Lidocaine at the discretion of the physician. F. I.V. t-pa administration: Follow reconstitution directions for 100 mg dose vial. 1. Accelerated dose: For patients weighing more than 67kg: 15mg/BOLUS (15cc over 1-2 min.) 50mg/30 min. (Rate 100cc/hr, volume to be infused = 50mg) 35mg/60 min. (Rate 35cc/hr, volume to be infused = 35 mg) TOTAL: 100 mg/90 min. (t-pa I.V. bolus may be given by R.N.) 17b
2. Accelerated dose: For patients weighing less than 67 kg: 15 mg BOLUS - 0.75mg/kg/30 min. - 0.5mg/kg/60 min.) See scale below. WGT. IN LBS. WGT. IN KGS. 15 MG. BOLUS TOTAL MG. FOR MAINTEN- ANCE 0.75 MG/KG 20 MIN INF RATE 0.5 MG/KG 60 MIN INF RATE TOTAL DOSE 90-94 95-97 98-104 105-109 110-114 115-119 120-124 125-129 130-134 135-139 140-144 145-149 150-154 155-159 160-Up 41 43 45 48 50 52 55 57 59 61 64 66 68 70 15ml. 52 mg. 54 mg. 57 mg. 60 mg. 63 mg. 65 mg. 68 mg. 71 mg. 73 mg. 76 mg. 80 mg. 83 mg. 84 mg. 85 mg. 85 mg. 62 ml/hr 64 ml/hr 68 ml/hr 72 ml/hr 75 ml/hr 78 ml/hr 82 ml/hr 86 ml/hr 88 ml/hr 92 ml/hr 96 ml/hr 99 ml/hr 21 ml/hr 22 ml/hr 23 ml/hr 23 ml/hr 25 ml/hr 26 ml/hr 27 ml/hr 28 ml/hr 29 ml/hr 30 ml/hr 32 ml/hr 33 ml/hr 34 ml/hr 35 ml/hr 35 ml/hr 67 mg. 69 mg. 72 mg. 75 mg. 78 mg. 80 mg. 83 mg. 86 mg. 88 mg. 91 mg. 95 mg. 98 mg. 99 mg. 100 mg. 100 mg. G. Administration of I.V. Heparin with I.V. t-pa infusion is recommended. The dosage of Heparin to be given is at the discretion of the Physician. The suggested dose of Heparin is 5,000 units I.V. bolus (given concurrently with the t-pa) followed by 1,000 units per hour with subsequent dose adjustments to maintain PTT 46-70 seconds. I.V. heparin is recommended for at least 48 hours. (Heparin must be given through a separate I.V. site than Activase). H. Hold all venipuncture sites for at least five minutes. I. Test all stools for occult blood. H & H and PTT should be checked q 6 hours for at least 24 hours or at the discretion of the physician. J. Strict bed rest for 24 hours. 17c
K. Blood pressure should be monitored at least every 15 minutes during t-pa administration and the patient should be observed carefully for bleeding complications. L. Follow strict anticoagulation precaution protocol. 17d