B-26: Thrombolytic Therapy, Venous

Contraindications for Thrombolytic Therapy

Absolute
  Active internal bleeding
  CVA, intracranial or spinal surgery within 60 days
  Intracranial process with potential for bleeding
  Known hypersensitivity to thrombolytic agent
  Devitalized limb with sensory and/or motor loses

Relative
  Non-compressible arterial puncture site
  Recent GI bleeding
  Severe uncontrolled arterial bleeding
  Recent trauma including CPR
  Left heart thrombus
  Subacute bacterial endocarditis
  Cerebrovascular disease
  Diabetic hemorrhagic retinopathy
  Pregnancy
  Post partum (<10 days)
  Uncorrected hemostatic defects

  • Indications
    • Acute or chronic symptomatic venous thrombosis
    • Catheter related central venous thrombosis
  • Contraindications
    • Contrast allergy (premedicate)
    • See Table of Contraindications for Thrombolytic Therapy
  • Preprocedure Orders
  • Tools
    • Micropuncture access set
    • Vascular sheath (5 or 6 Fr.), or Balkin sheath
    • Multiple sidehole infusion catheter (Mewissen, Angiodynamics, Cook, etc.)
    • Infusion wire (Katzen, etc.) for coaxial system
    • 2 or 3 infusion pumps
  • Entry site
    • Femoral, popliteal, basilic or jugular vein
  • Technique
    • Following diagnostic venogram obtain additional access if required using micropuncture technique. Place a 5 or 6 Fr. vascular sheath. Probe thrombus with guide wire and catheter. Once thrombosed segment is traversed, place exchange wire and introduce infusion catheter. If single catheter is adequate, place a Bentson wire to occlude end hole. Otherwise, place coaxial infusion device. Begin Urokinase infusion and heparin infusion through side arm of sheath.
    • If thrombus is hard, pre-dilate with a 6-8mm angioplasty balloon, then proceed as above
  • Post-procedure Note
    • Note extent of thrombus, type of infusion system and location of catheters
  • Post-procedure Orders
    • Use preprinted intravenous thrombolytic therapy orders (see Appendix C5)
  • Guidelines for Medication Orders
    • Urokinase:    (See Appendix B34 for TPA protocols)
      • Individualize infusion rate(s) based on catheter system and appearance of occlusion
      • Usually 1000 - 2000 units per min. divided between proximal and distal ports
      • Order urokinase at 4000 units/cc (usually 1 million units in 250cc's IVF)
    • Heparin:
      • 5000 unit bolus, then 1000 units/hour initial infusion rate.
      • Adjust rate to maintain PTT between 60 and 80 sec
    • IV Fluid:
      • Orders are to be individualized
      • Consider that full dose UK and Heparin infusions equal 70cc/hr
    • ADD: Demerol 50mg IV or Zantac 50mg IV for shaking chills
      • IV Demerol is usually more effective but must be used with caution in elderly or debilitated patients

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