Name of the Fibrinolytics drugs:
- Streptokinase
- Reteplase
- Alteplase
- Tenecteplase
Mechanism of Action:
Activation of plasminogen to form plasmin, a proteolytic enzyme that promotes the breakdown of fibrin clots into fibrin degrading products leading to clot dissolution and reperfusion.
Indications:
- Acute MI
- Massive pulmonary embolus (alteplase)
- Acute ischemic stroke (under specialist supervision by stroke physician)
Cautions & contraindications:
- Aortic dissection
- Active Bleeding
- Active Peptic ulcer disease
- Previous haemorrhagic stroke or recent ischemic stroke
- Coagulation defects
- Recent surgery/ trauma
- Active intracranial neoplasm
- Uncontrolled hypertension (relative contraindication)
| Streptokinase |
| Availability: Available forms Injection: 250,000, 750,000, 1,500,000 IU in vials for reconstitution |
| Administration and handling: The administration of streptokinase may be by systemic intravenous infusion or by local intra-arterial catheter-directed infusion. The contents should be dissolved in 4-5 ml of physiological saline or water for injection. The solution should be swirled gently to facilitate quick reconstitution, but care should be taken to avoid foaming. Physiological saline, 5% glucose solution, 5% fructose solution, or Ringer-lactate solution can be used as a diluent for administration with an infusion pump. Storage: Do not store above +25°C and do not freeze. Do not store the reconstituted solution for more than 24 hours in a refrigerator at +2°C to +8°C. |
| Acute myocardial infarction: IV: Adult: within 12 hours of onset with persistent ST- segment elevation or recent left-bundle branch block;1500000 units as a single dose via infusion over 60 minutes. |
| Arteriovenous cannula occlusion— Adult: 250,000 IU in 2 ml IV solution in each cannula limb over 25-35 min. Clamp cannula 2 hr. Aspirate, flush, and reconnect |
| Venous thrombosis, PE, arterial thrombosis and embolism—Adult: 250,000 IU IV over 30 min. Then 100,000 IU/hr IV 72 hr for DVT and 100,000 IU/hr 24- 72 hr for PE and arterial thrombosis or embolism |
| Lysis of coronary artery thrombi associated with MI—Adult: 20,000 IU IV bolus via coronary catheter; then 2,000 IU/min infusion over 60 min. Or as IV infusion, usually 1.5 million IU IV over 60 min. |
| Peripheral arterial occlusive disease: IV: Adult: via intra- arterial infusion/:1000-2500 units every 3-5 minutes for a maximum of 10 hrs. Max dose: 250000 units. prolonged continuous low dose infusion: 5000-10000units hourly; max treatment duration :5 days. |
| Alteplase |
| Availability: Injection, Powder for Reconstitution: 2 mg, 50 mg, 100 mg. |
| Administration/handling: IV Reconstitution: Reconstitute immediately before use with Sterile Water for Injection. • Reconstitute 100-mg vial with 100 mL Sterile Water for Injection (50-mg vial with 50 mL sterile water) without preservative to provide a concentration of 1 mg/ ml. • Avoid excessive agitation; gently swirl or slowly invert vial to reconstitute. |
| Rate of administration • Give by IV infusion via infusion pump. If minor bleeding occurs at puncture sites, apply pressure for 30 sec; if unrelieved, apply pressure dressing. • If uncontrolled haemorrhage occurs, discontinue infusion immediately (slowing rate of infusion may produce worsening haemorrhage). • Avoid undue pressure when drug is injected into catheter (can rupture catheter or expel clot into circulation). • Instill dose into occluded catheter. • After 30 min, assess catheter function by attempting to aspirate blood. • If still occluded, let dose dwell an additional 90 min. • If function not restored, a second dose may be instilled. Storage: Store vials at room temperature. • After reconstitution, solution appears colourless to pale yellow. • Solution is stable for 8 hours after reconstitution. Discard unused portions. |
| Acute MI IV infusion: Adults weighing more than 67 kg: Total dose: 100 mg over 90 min, starting with 15-mg bolus over 1–2 min, then 50 mg over 30 min, then 35 mg over 60 min. Adults weighing 67 kg or less: Total dose: Start with 15-mg bolus over 1–2 min, then 0.75 mg/kg over 30 min (maximum: 50 mg), then 0.5 mg/kg over 60 min (maximum: 35 mg). Maximum total dose: 100 mg. |
| Acute Ischemic Stroke: Dose should be given within the first 3 hrs of the onset of symptoms. Recommended total dose: 0.9 mg/kg. Maximum: 90 mg. IV infusion: Adults weighing 100 kg or less: 0.09 mg/kg as IV bolus over 1 min, then 0.81 mg/kg as continuous infusion over 60 min. Weighing more than 100 kg: 9 mg bolus over 1 min, then 81 mg as continuous infusion over 60 min. |
| Acute Pulmonary Emboli IV infusion: Adults: 100 mg over 2 hrs. May give as a 10-mg bolus followed by 90 mg over 2 hrs. Institute or reinstitute heparin near end or immediately after infusion when activated partial thromboplastin time (aPTT) or thrombin time (TT) returns to twice normal or less. |
| Central Venous Catheter Clearance IV: Adults, elderly: Up to 2 mg; may repeat after 2 hrs. If catheter functional, withdraw 4–5 mL blood to remove drug and residual clot. |
| Usual Neonatal Dosage Occluded IV catheter: Use 1 mg/mL conc (maximum: 2 mg/2 mL) leave in lumen up to 2 hrs, then aspirate. Systemic thrombosis: 0.1–0.6 mg/kg/ hr for 6 hrs. Usual dose: 0.5 mg/kg/hr. |
| Reteplase |
| Availability: powder for injection: Adults: 10.4 units (18.1mg) 10 units as a lyophilized powder in single-use vials for reconstitution co-packaged with Sterile Water for Injection, USP in 10 mL prefilled syringe. |
| Administration and handling: Reconstitute using diluent, needle, syringe & dispensing pin provided to obtain 1 U/mL solution IV Administration: Bolus over 2 min •Do not administrate solutions that are discoloured or contain precipitate. Slight foaming may occur •May need to stand undisturbed for several minutes to dissipate bubbles •Flush before & after each bolus. Line to contain D5W Stability: Stable for 4 hr at room temp |
| Acute Myocardial Infarction: As soon as possible after the onset of STEMI, administer 10 units intravenously over 2 minutes. Administer a second dose of 10 units 30 minutes after the first dose. (for total cumulative dose of 20 units) Treatment should be initiated ASAP after onset of AMI Give each bolus injection via an IV line in which no other medication is being simultaneously injected or infused |
| Tenecteplase |
| Availability: powder for injection: Adult :50mg |
| Administration and handling: IV Preparation Add 10 mL SWI to a 50 mg vial using diluent into powder. If foaming (usually slight) occurs, leave vial undisturbed for several minutes to allow dissipation of any large bubbles. Gently swirl (do not shake) until contents are completely dissolved. Do not discard shield assembly Use immediately or may be refrigerated up to 8 hours. |
| Acute MI: Administer ASAP (within 30 minutes) after onset of acute MI 30-50 mg IV bolus over 5 sec once (based on weight) •<60 kg: 30mg 60-70 kg: 35 mg, 70-80 kg: 40 mg, 80-90 kg: 45 mg, >90 kg: 50 mg |
Consider the Rule of 5s for safe administration:
| 5 mg/ml | 5 ml max dose | 5 flushes | 5 administer | 5 flushes |
| Reconstitute 50mg vial with 10ml sterile water | 5ml max dose 0.25mg/kg (max 25mg per 5 ml) | Flush IV with 5 ml saline before administration | Administer bolus over 5 seconds | Flush IV with 5ml saline after administration. |
Side- Effects:
- Bleeding (including cerebral haemorrhage)
- Nausea and vomiting
- Reperfusion cardiac arrhythmias and ischemia
- Cerebral and pulmonary Oedema
- Anaphylaxis
- Severe hypotension
- Cardiac reinfarction
- Cardiogenic shock
- Muscle pain
Metabolism and Half- life:
Variable- t ½ for streptokinase is 18 – 23 min; t ½ for alteplase is 4-5 min.
Metabolized predominantly by the liver.
Monitoring:
Monitor for signs of bleeding, anaphylaxis and intracranial haemorrhage.
Drug Interactions:
- Risk of haemorrhage is increased with oral anticoagulants.
- Patients on ACEIs are at an increased risk of anaphylactoid reaction when streptokinase is administered.
Important Points:
- Fibrinolytics are licensed for ST-elevation MI within 12h of the onset of chest pain (administered ideally within one hour)
- Streptokinase is derived from Beta- haemolytic streptococci of Lancefield group C; persistence of antibodies to streptokinase may reduce the effect of subsequent doses. It has effectively been superseded by the newer fibrinolytics (e.g., Reteplase) in acute MI (where primary percutaneous coronary intervention is not available)
- Alteplase is a recombinant tissue – type plasminogen activator.
- Does not cause allergic reactions and can be used in patients with recent streptococcal infections or recent use of streptokinase.
NURSING CONSIDERATIONS
Baseline assessment
- Assess for contraindications to therapy.
- Obtain baseline B/P, apical pulse.
- Record weight. Evaluate 12-lead ECG, cardiac enzymes, electrolytes.
- Assess Hct, platelet count, thrombin time (TT), prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen level before therapy is instituted. Type and screen blood.
Intervention/evaluation
- Perform continuous cardiac monitoring for arrhythmias.
- Check B/P, pulse, respirations q15min until stable, then hourly. Check peripheral pulses, heart and lung sounds.
- Monitor for chest pain relief and notify physician of continuation or recurrence (note location, type, intensity).
- Assess for bleeding: overt blood, occult blood in any body substance. Monitor aPTT per protocol.
- Maintain B/P; avoid any trauma that might increase risk of bleeding (e.g., injections, shaving).
- Assess neurologic status frequently. An urgent brain CT should be performed if there is any sign of neurological deterioration
- Non-essential handling and puncture should be avoided in the first few hours after medication administration. If an arterial puncture cannot be avoided, the preferred site is an upper extremity blood vessel that can be easily compressed. Direct pressure should be applied for 30 minutes following venipuncture.
Patient Teaching:
- Instruct patient to immediately report signs of GI bleeding
- Teach the client about measures to decrease bleeding & bruising like cold application.
- Self-monitoring for signs and symptoms of bleeding
- Avoid any trauma that might increase risk of bleeding (e.g., injections, shaving).
REFERENCES
- Robert Kizior, Keith Hodgson, Saunders Nursing Drug handbook,1st edition 2024, Elsevier Publications. ISBN-9780443116070
- McGraw Hill- Drug Handbook, Seventh Edition, 2013, McGraw Hill Education Publications,9780071799430.
- April Hazard, Cynthia Sanoski, Davi’s Drug Guide for Nurses -Sixteenth Edition 2019, FA Davis Company Publications,9780803669451.
- Jones and Bartlet, Pharmacology for Nurses, Second Edition, 2020, Jones and Bartlet Learning Publications, ISBN 9781284141986.
- Nursebro.com, Search – Nursebro
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