Parenteral Manual

Alteplase

Disclaimer: Official controlled document is the CHEO online copy. It is the responsibility of user to ensure that any paper copy version is the same as the online version before use.

Alternate Name(s): 
Activase rt-PA, Tissue plasminogen activator (TPA), Cath-Flo
Classification: 
Thrombolytic/Fibrinolytic Agent
Original Date: 
August 2005
Revised Date: 
May 2017
Indications: 
  • Lysis of suspected occlusive coronary artery thrombi associated with evolving myocardial infarct (MI)
  • Management of complete occlusion of blocked central venous access devices
  • Management of an occluded drain (percutaneous or transrectal drain)
Reconstitution and Stability: 

VIAL SIZE  

STERILE WATER for INJECTION REQUIRED

FINAL CONCENTRATION 

50 mg (with vacuum)

50 mL provided

1 mg/mL

2 mg (in fridge)

2.2 mL

1 mg/mL

   

 

  • Slight foaming may occur; allow vial to stand undisturbed for several minutes until large bubbles disappear.  Swirl gently to dissolve. DO NOT SHAKE.
  • Reconstituted solutions are stable for 8 hours at room temperature or refrigerated
Compatibility: 
  • Solutions Compatible: 0.9% NaCl, D5W
  • Additives/Above Cassette Compatible: morphine
  • Y-site Compatible: lidocaine HCl, metoprolol, propanolol

Incompatible: dobutamine, dopamine, heparin, ringer's lactate, preservative-containing solutions  (e.g., bacteriostatic water for injection)

 

Administration: 

(For approved routes of administration by nursing personnel, refer to Policy for the Administration of Intravenous Medications.)

SC NO
IM NO
IV Direct YES
Infusion time: 2 minutes
IV Intermittent Infusion NO
IV Continuous Infusion

YES
Usual dilution: 1 mg/mL

  • Can be given via drain or intra central venous access and left for instillation (may be administered by RN)
  • Can be given into the pleural space via chest tube and left for instillation (physician only)
Dosage: 

(For neonatal dosages, refer to Neonatal IV Drug Manual.)

Pediatrics:

NOTE:  DO NOT administer to patient awaiting cardiovascular surgery (up to 1 week prior to surgery) and up to two months post operatively without contacting the cardiovascular service

  • Systemic Thrombosis:
    •  Initial: 0.1 mg/kg/hr IV for 6 hours- monitor closely for bleeding and fibrinogen levels
    •  If no response after 6 hours, increase by 0.1 mg/kg/hr at 6 hour intervals to maximum of 0.5  mg/kg/hr
    •  Duration of therapy based on clinical response
  • Management of blocked central venous access devices: 
    • 0.2 - 2 mL (depending on caliber and length of catheter) and leave in place for 1-2 hours before attempting to aspirate.
      • For tunneled, non-tunneled and PIC catheters:  1 mL instilled as above
      • Dialysis catheters:  Instill alteplase equivalent to lumen volume + 0.2 mL as above
      • Totally implanted devices: 2 mL instilled as above
  • Pleural Effusion via chest tube: 
    • Infants less than 2 years:  2 mg (2 mL) added to 4 mL 0.9% NaCl daily x 3 days. Flush tube with 10 - 20 mL 0.9% NaCl immediately following alteplase
    • Children 2 years and older:  4 mg (4 mL) added to 8 mL 0.9% NaCl daily x 3 days.  Flush tube with 20 - 40 mL 0.9% NaCl immediately following alteplase
  • Occluded percutaneous or transrectal drain:
    • Infants less than 2 years: 2mg (2ml) added to 8ml 0.9% NS (total 10ml) once.  Flush tube with 10ml 0.9% NS immediately following Alteplase and clamp drain for prescribed time.
    • Children 2 years and older: 4mg (4ml) added to 6ml 0.9% NS (total 10ml) once.  Flush tube with 10ml 0.9% NS immediately following Alteplase and clamp drain for prescribed time.

                                              

Potential hazards of parenteral administration: 
  • Bleeding  complications, re-perfusion arrhythmias, re-infarction
  • Extravasation can cause ecchymosis (small hemorrhagic spot) and/or inflammation: terminate infusion at the site and apply local therapy
Notes: 
  • Local Instillation:
    • See Infusion Therapy Manual, Section I, for step-by-step management of blocked central venous devices
    • DO NOT force an obstruction since it could cause emboli to enter venous system
  • For occluded percutaneous or transrectal drain:
    • Monitor for pain and bleeding at drain site
  • Monitor blood pressure, CBC, reticulocyte, platelet count, fibrinogen level, plasminogen, fibrin/fibrinogen degradation products, D-dimer, PT, PTT, antithrombin III, protein C, urinalysis, signs of bleeding
  • Pleural Instillation:
      Patient is to be placed on cardio/respiratory monitor for procedure
      -  Pre-instillation:  monitor baseline vital signs - temperature, heart rate, respiratory rate and blood pressure
      -  Post instillation:  monitor vital signs and chest tube system Q20 minutes x 2 , then Q1H x 2

     Notify the physician if the patient experiences any of the following symptoms:
     -  Difficulty breathing during/after irrigation/instillation
     -  Signs and symptoms of bleeding
     -  Significant pain during/after irrigation/instillation
     -  Chest tube drainage greater than 3 mL/kg/hour over 3 continuous hours or greater than 5 mL/kg/hour over 1 hour

 

 

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