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anticoagulation must be given without delay unless contraindicated

quick links FOR FIBRINOLYSIS DOSING

CONTRAINDICATIONS TO THROMBOLYSISCARDIAC ARREST DOSINGFULL DOSE THROMBOLYSIS (TPA/TNK)HALF DOSE THROMBOLYSIS (TPA/TNK)HEPARIN DOSING POST THROMBOLYSISTRANSITIONING FROM UFH TO LMWH HOW TOHYBRID THERAPY

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PE TERMINOLOGYHIGH-RISK (MASSIVE) PE DEFINITIONTHROMBOLYSIS CONSIDERATIONS FOR INTERMEIDATE HIGH-RISK

PE TERMINOLOGY CHANGES IN THE LITERATURE

MASSIVE = HIGH-RISK

SUBMASSIVE = INTERMEDIATE HIGH-RISK

Contraindications to thrombolysis

Absolute Contraindications

Absolute Contraindications

Absolute Contraindications

  • There are no absolute contraindications in an arresting patient 


  • For a patient who is about to arrest you may consider adjusting your dose if contraindications exist


  • Clinical judgement still must be used when considering contraindications and relative contraindications

  1. is there time for embolectomy
  2. is there time for catheter directed thrombolysis
  3. Might a small dose be considered
  4. Might a hybrid approach be necessary?



Contraindications

Absolute Contraindications

Absolute Contraindications

  • Spinal cord injury this admission


  • TBI this admission


  • ICH this admission


  • Known Brian Neoplasm


  • Known Brain AVM/Aneurysm


  • Stroke within 2 months


  • Surgery within 2 months


  • Aortic Dissection


  • Active Internal Bleeding


  • Bleeding Diathesis

Relative Contraindications

Absolute Contraindications

Relative Contraindications

  • Age >75 (consider dose adjustment)


  • Recent internal bleeding


  • Recent ICH


  • Recent Trauma


  • Recent CPR


  • Venipuncture at non compressible site


  • Stoke within 2 months


  • SBP >180


  • DBP>110


  • Pregnancy


  • Currently fully anticoagulated


  • Syncopal episode preceding presentation where trauma to the head is suspected or patient cannot recall event

Cardiac arrest from HIGH-RISK (MASSIVE) PE

TPA

TPA

TPA

BOLUS:  

  • 50mg IV bolus over 15 minutes (or IV push)


  • May repeat 50mg bolus if still arresting after first bolus


INFUSION:  

  • if full dose not given during arrest


  • infuse remaining 50mg over 1 hour

TNK

TPA

TPA

BOLUS:  Roughly 0.5mg/kg


  • <60 kg: 30 mg


  • ≥60 to <70 kg: 35 mg


  • ≥70 to <80 kg: 40 mg


  • ≥80 to <90 kg: 45 mg


  • ≥90 kg: 50 mg


  • IV over 10 seconds


  • NO INFUSION

HIGH-RISK (MASSIVE) PE DEFINITION

Official Definition (but clinical impression/interpretation is required)

Any of the following: 


  • Systolic blood pressure (BP) <90 mmHg for a period >15 minutes 


  • Drop in systolic blood pressure substantially below baseline (generally a drop of >40 mmHg,


  • Hypotension requiring vasopressors


  • Clear clinical evidence of shock (altered LOC, cool, mottled, lactate, elevated creatinine etc)

Full-Dose THROMBOLYSIS (HIGH-RISK OR INTERMEDIATE HIGH-RISK)

TPA

TPA

TPA

BOLUS:  

  • 10-20mg IV bolus over 15 minutes


INFUSION:  

  • 80-90mg IV infusion over 1 hour


  • Consider half-dose (see next section below) for patients >75  (increased risk of ICH and you can always give more)

TNK

TPA

TPA

BOLUS:  Roughly 0.5mg/Kg


  • <60 kg: 30 mg


  • ≥60 to <70 kg: 35 mg


  • ≥70 to <80 kg: 40 mg


  • ≥80 to <90 kg: 45 mg


  • ≥90 kg: 50 mg


  • IV over 10 seconds


  • NO INFUSION


  • Consider half-dose (see next section below) for patients >75 (increased risk of ICH and you can always give more)

HALF-DOSE THROMBOLYSIS (HIGH-RISK OR INTERMEDIATE HIGH-RISK)

TPA

TPA

TPA

BOLUS:  

  • 10-20mg IV bolus over 15 minutes


INFUSION:  

  • 30-40mg IV infusion over 1 hour


TNK

TPA

TPA

BOLUS:  Roughly 0.25mg/Kg


  • <60 kg: 15 mg


  • ≥60 to <90 kg: 20 mg


  • ≥90 kg: 25mg


  • IV over 10 seconds


  • NO INFUSION

HOW AND WHEN TO START HEPARIN AFTER THROMBOLYSIS

Patient may have received LMWH upfront but use UFH post thrombolysis due to reversibility if bleeding occurs


  • monitor aPTT every 2 hours beginning 2 hours post TNK bolus or post TPA infusion end


  • start UFH protocol once aPTT is 2X upper limit of normal


  • NO BOLUS

WHY YOU MIGHT CONSIDER THROMBOLYSIS FOR INTERMEDIATE HIGH-RISK PE

Why would you consider this?

  • Clot in transit (with or without PFO)


  • As alternative to CDT 


If decision for CDT has been made but:

  • patient deteriorates before CDT


  • patient deteriorates during CDT or Thrombectomy


  • CDT is not immediately available  (another patient is on the table)


  • Patient is in a peripheral hospital and is too high risk to transfer and too high risk not to intervene

Transitioning to LMWH from UFH

  • Use UFH for the first 12-24 hours post thrombolysis for its reversibility  in case major bleeding occurs


  • First dose of LMWH to be given at the same time the unfractionated heparin infusion is turned off


Hybrid Therapy (you can still use your clinical judgement)

  • It is important to remember that not all patients will fit nicely into these categories.  


  • There are no guidelines as to what to do for the patient who is getting worse or not improving while you are intervening


  • You are still allowed to be a clinician and adjust therapy as needed (Major benefit of having the team to consult with if you would like some advice/consensus)


  • You can bolus more or less TPA up front if need be 


  • You can bolus more TPA during an infusion if the patient is still deteriorating


  • You can bolus TPA through the PA catheters (or systemically)  if the patient is deteriorating while the infusions are running 


  • You can repeat the TPA infusions through the PA catheters if the patient has not improved (suggest re-imaging to make sure the catheters are still sitting in clot)


  • If you've chosen to give half-dosing (or less) and the patient has not improve you can give more


  • You can re-image if the patient hasn't improved to decide if further intervention is required (ie thrombectomy/CDT post systemic thrombolytics or vise versa)


  • Embolectomy can be combined with CDT


anticoagulation must be given without delay unless contraindicated

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