Download - FIBRINOLYTIC THERAPY
FIBRINOLYTIC THERAPY
(Thrombolytic Therapy)
OBJECTIVES
Identify the indications for use in AMI Identify the indications for use in
acute non-hemorrhagic stroke Have knowledge of patient selection
criteria Have an enlarged scope of knowledge
with regard to fibrinolytics
INTRODUCTION
The goal of fibrinolytic therapy is to dissolve occlusive clots.
Thrombus occlusion leads to cessation of blood flow to the affected area leading to oxygen deprivation and tissue damage distal to the occlusion, leading to irreversible damage and possibly death.
THROMBOGENESIS
Traumatized tissue Activation of coagulation cascade
Thrombin Production of fibrinogen Fibrin
Fibrin strands cross-link and trap red blood cells and platelets
Clot is formed
FIBRINOLYSIS
Plasminogen activation Convert to Plasmin
Fibrin clot
Fibrinolytic therapy in AMI
Clot can be dissolved
Institute early Limits infarct size Preserve
myocardial function Decrease mortality
and morbidity
Patient selection criteria
Continuous CP lasting at least 30 min Symptom onset within 12 hours ST elevation in 2 contiguous leads CP unrelieved by NTG or nifedipine No absolute contraindications present Initiation of therapy can be prompt
Absolute Contraindications
Any hx of intracranial hemorrhage Known intracranial neoplasm or AV
malformation Suspected aortic dissection Active bleeding
General pre-fibrinolytic procedures
Obtain orders Explain to pt and
family Obtain informed
consent Baseline labs and
diagnostic tests At least 2 IV lines
Gather equipment:1. Phillips monitor2. Zoll at bedside3. Ambu bag ready4. Suction 5. Crash cart nearby6. Infusion pumps (3)
Tenecteplase (TNK)
Binds to fibrin and converts plasminogen to plasmin
Decreases circulating fibrinogen and plasminogen
TNK
Weight based One dose Reconstitute TNK vile with 10cc
sterile H2O Gently swirl Give single bolus over 5 seconds Maximum dose 50MG
TNK-Adverse reactions
Bleeding-internal or superficial
Reperfusion arrhythmias
Allergic rxn Coronary artery
re-occlusion
Surface Bleeding
Establish all peripheral IV sites prior to fibrinolytic infusion
Avoid IM injections Monitor all venous and arterial
sites frequently Apply direct pressure to all
bleeding for a minimum of 30 min. or homeostasis achieved
Coronary Artery Reperfusion
Normalization of the ST segment Resolution of the CP or ischemic
symptoms Reperfusion arrhythmias May not have any of the above
Reperfusion Arrhythmias
Bradycardia
V- tach
Heart Blocks
Eftifibatide (Integrilin)
A cyclic amino acid that binds to the platelet receptor glycoprotein GP IIb/IIIa of human platelets and inhibits platelet aggregation by preventing the binding of fibrinogen
Used in combination with heparin and ASA
Integrilin
Weight based dosing, use insert chart
Initial bolus 180mcg/kg-single dose over 1-2 minutes
Infusion of 2mcg/kg/min. Glass 100 ml bottle. Need vented spike
Refrigerated Option of low dose renal dose
Compatible With…
Alteplase Atropine Dobutamine
Heparin Lidocaine Metoprolol
Morphine Nitroglycerine
Verapamil
Tissue Plasminogen Activator (Activase,t-PA)
Activase binds to fibrin in a thrombus and converts the entrapped plasminogen to plasmin
Then initiates local fibrinolysis
Give within 3 hours of stroke s/s
Indications for MI
Lysis of thrombi obstruction in the coronary arteries
Reduction of infarct size Improvement of ventricular
function Reduction of incidence of CHF
Indications for stroke
Improve neurologic recovery Reduce incidence of disability
t-PA Reconstitution
Open Activase powder and 100cc sterile H2o
Using piercing pin, push into Activase vial
Attach sterile water bottle to top Allow the entire contents of water
to flow down , invert gently
t-PA Administration
Use a separate IV line, use IV pump Dosing different for stroke, pulmonary
emboli, CVAD occlusions, and AMI STROKE-0.9 mg/kg IV over one hour.
With 10% of the dose given IV push over one minute
Max dose is 90mg
T-PA for MI
100 mg over 90 min.
Bolus 15mg over 2 min.
Then 50 mg over 30 min.
Infuse last 35 mg over 60 min.
Heparin
Combines with other factors in the blood to inhibit the conversion of prothrombin to thrombin, and fibrinogen to fibrin
Adhesiveness of platelets is reduced
Well-established clots are not dissolved, growth is prevented and newer clots may be resolved
Heparin
Compatible with NTG and morphine at Y-site
Antidote – Protamine
sulfate
Nitroglycerin
A vascular smooth –muscle relaxant and vasodilator.
Affects arterial and venous beds
Reduces myocardial O2 consumption, preload and afterload
Nitroglycerin Administration
Glass bottle, vented spike
IV pump required. Given as mcg/min Usually 10-30mcg,
titrate to pain Lasts only 3-5
minutes
Compatible at Y-site with morphine and t-PA,heparin
Side effects: abdominal pain, allergic rxn, dizzy, HA, low BP
Metoprolol (Lopressor)
Cardioselective adrenergic blocking agent
Reduces incidence of recurrent MI Reduces size of the infarct and the
incidence of fatal arrhythmias Lasts 4 hours Contraindicated in HR < 45
Lopressor Administration
Five milligrams at five minute intervals to a total dose of 15 mg
Monitor rhythm, BP and HR between all doses
Hold for SBP less than 100 Compatible at Y-site with morphine
Concurrent Drugs
Aspirin
NTG sublingual
Lidocaine
Nifedipine
Door to drug time is
30 minutes