Transcript 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
Thrombin
Activation of coagulation
cascade
Production of fibrinogen
Fibrin
Fibrin strands cross-link and trap red blood cells and platelets
Clot is formed
FIBRINOLYSIS
Plasminogen activation
Fibrin clot
Convert to Plasmin
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

1.
2.
3.
4.
5.
6.
Gather equipment:
Phillips monitor
Zoll at bedside
Ambu bag ready
Suction
Crash cart nearby
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 reocclusion
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