Nursing Considerations

• Prior to administration
  • Carefully lower blood pressure (BP) to maintain systolic BP less than 185 mmHg and diastolic BP less than 110 mmHg before initiating fibrinolytic therapy.
  • Due to an increased risk of intracranial bleeding, check INR, aPTT and blood glucose prior to administration.
    • Alteplase should not be administered to patients who have received a full dose of low-molecular-weight heparin (LMWH) within the prior 24 hours.
    • In AIS patients without recent use of oral anticoagulants or heparin, alteplase can be started prior to coagulation study results. Discontinue alteplase if pretreatment INR is greater than 1.7 or aPTT is elevated (Genentech, 2018).
    • IV aspirin should not be administered within 90 minutes after the start of IV alteplase in AIS patients.
  • For PE patients who are hemodynamically unstable, discontinue any prior anticoagulant therapy before and during the thrombolytic infusion to minimize risk of bleeding (Tapson & Weinberg, 2020).
  • Assess for exclusion criteria/contraindications.
  • Admit to the intensive care unit (ICU) for monitoring.
• During administration
  • Maintain strict bedrest during treatment.
  • Measure BP and perform neurological assessment every 15 minutes during infusion for 2 hours, then every 30 minutes for 6 hours, then hourly until 24 hours after treatment.
    • Increase frequency of BP measurements if systolic BP greater than 180 mm Hg or if diastolic BP greater than 105 mm Hg; administer antihypertensive as needed to maintain these levels.
  • If patient develops a severe headache, acute hypertension, nausea or vomiting, or has a worsening neurological examination, stop the alteplase administration and obtain an emergency CT scan.
  • Avoid invasive procedures and I.M. injections, and perform venipunctures carefully and only as required, avoiding internal jugular and subclavian venous punctures.
  • IV aspirin should not be administered within 90 minutes after the start of IV alteplase when treating AIS patients.
  • Closely monitor the patient for bleeding and frequently assess all puncture sites.
  • If serious bleeding occurs, stop the alteplase infusion immediately.
  • Monitor for hypersensitivity and discontinue alteplase immediately if signs develop.
  • Extravasation of alteplase can cause ecchymosis or inflammation. If this occurs, stop the infusion and apply local therapy.
• After administration
  • Monitor BP and perform neurologic assessment every 15 minutes during infusion for 2 hours, then every 30 minutes for 6 hours, then hourly until 24 hours after treatment.
  • After the initial 24 hours, monitor vital signs, control blood pressure, and perform neurological assessments frequently, per hospital policy.
  • Maintain BP less than 180/105 mmHg for at least 24 hours after treatment in AIS patients.
  • For AIS patients, hold antiplatelet or anticoagulation therapy and invasive procedures for 24 hours following administration.
  • For AMI and PE patients, concomitant IV unfractionated heparin is recommended near the end or immediately following alteplase infusion when the PTT or thrombin time returns to twice normal or less to prevent re-occlusion (Genentech, 2018; Gibson & Levin, 2020; Tapson & Weinberg, 2020)
  • Monitor for serious adverse events, such as bleeding and angioedema.
    • Concomitant use of angiotensin-converting enzyme (ACE) inhibitors may increase the risk of orolingual angioedema.
    • Concomitant use of anticoagulants and drugs that inhibit platelet function increase the risk of bleeding.
  • Delay insertion of nasogastric tubes, indwelling bladder catheters, or intra- arterial pressure catheters if patient can be managed without them.
  • For AIS patients, obtain follow-up CT or MRI scan 24 hours after treatment before starting anticoagulants or antiplatelet agents.

Adverse Reactions (Genentech, 2018)

• Bleeding can occur one or more days after infusion – see management below.
  • A dose greater than or equal to 150 mg should not be used to treat AMI as it has been associated with increased intracranial bleeding.
• Hypersensitivity (anaphylactic reactions, laryngeal edema, rash and shock) may occur during and up to 2 hours after infusion.
• Cholesterol embolization may present as acute renal failure, spinal cord infarction, retinal artery occlusion, bowel infarction, rhabdomyolysis, “purple toe” or livedo reticularis.
• Re-embolization of deep venous thrombi (DVT).

• Stop alteplase infusion.
• Obtain CBC, PT (INR), aPTT, fibrinogen level, and type and cross-match.
• Obtain emergent non-enhanced head CT.
• Per order, administer cryoprecipitate (includes factor VIII): 10 U infused over 10-30 minutes (onset in 1 hour, peaks in 12 hours); administer additional dose for fibrinogen level less than 150 mg/dL.
• Per order, administer tranexamic acid 1 g (or 10 to 15 mg/kg) once; administer at a rate not to exceed 100 mg/minute (over about 10-20 min)  OR Ɛ- aminocaproic acid 4-5 g over 1 hour, followed by 1 g per hour IV for 8 hours or until bleeding is controlled.
• Obtain hematology and neurosurgery consult.
• Manage BP, intracranial pressure (ICP), cerebral perfusion pressure (CPP), mean arterial pressure (MAP), temperature, and glucose.

• Maintain airway.
• Intubation may not be needed if edema is limited to anterior tongue and lips.
• Edema involving larynx, palate, floor of mouth, oropharynx with rapid progression (within 30 minutes) poses higher risk of respiratory compromise requiring intubation.
• Awake fiberoptic intubation is preferred.
• As ordered, perform the following:
  • Discontinue IV alteplase infusion and hold ACE-inhibitors.
  • Administer IV methylprednisolone 125 mg.
  • Administer IV diphenhydramine 50 mg.
  • Administer ranitidine 50 mg IV or famotidine 20 mg IV.
  • If there is an increase in angioedema, administer epinephrine (0.1%) 0.3 mL subcutaneously or by nebulizer 0.5 mL.
  • Administer icatibant (selective bradykinin B2 receptor antagonist), 3 mL (30 mg) subcutaneously in abdomen; additional 30 mg doses may be given at 6-hour intervals not to exceed 3 injections in 24 hours.