C-5: Intravenous Thrombolytic Therapy

• Venous Thrombolytic Infusion Orders
  1. Bed rest (w/ hob elevated 30 to 60 degrees if subclavian thrombosis)
  2. Vital signs (RR, HR, BP)
     • q 15 min x 2; then
     • q 30 min x 4; then
     • q 2 hr. until MN; then
     • q 4 hr. after MN
  3. Check all puncture sites for bleeding, hematoma, swelling or bruising w/ VS checks
  4. Monitor and record ____ extremity pulses, color, temperature, motion and sensitivity w/ VS checks.
  5. Guaiac all urine, emesis and stools.
  6. CBC, PT, PTT, Fibrinogen baseline, at 4 hr, and q am
  7. Call H/O if Hgb. drops 2 gm., if PTT >80, if fibrinogen drops >100 mg or to below 200 mg, or for deterioration in extremity pulses
  8. If bleeding or hematoma occurs, apply pressure to site, call H/O and notify Special Procedures or radiologist on call
  9. Patient to remain on clear liquid diet during infusion.
  10. No IM injections during infusion.
  11. Patient to return to Special Procedures at _________a.m..
  12. H/O to adjust heparin dose to maintain PTT between 60 and 80 sec.
  13. H/O to review and cosign these orders.
• Medication Orders
  1. Acetaminophen 1000 mg PO 30 min before beginning infusion
  2. Diphenhydramine (Benadryl) 50 mg PO or IV prior to infusion
  3. Urokinase:    (See Appendix B-34 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)
  4. Heparin:
     • Usually 5000 unit bolus, then 1000 units/hour initial infusion rate.
     • Adjust rate to maintain PTT between 60 and 80 sec
  5. IV Fluid
     • Orders are to be individualized
     • Consider that full dose UK and Heparin infusions equal 70cc/hr.
  6. Tylenol #3 1 tab PO q3-4 hours PRN for mild to moderate pain
  7. 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

See Appendix B-26 for procedural information.
See Appendix B-34 for TPA protocols