Thrombolytics for pulmonary embolism: Difference between revisions

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**100 mg over 15 min<ref>Abu-Laban R, Christenson J, Innes G, et al. Tissue plasminogen activator in cardiac arrest with pulseless electrical activity. N Engl J Med. 2002;346(20):1522-1528.</ref>
**100 mg over 15 min<ref>Abu-Laban R, Christenson J, Innes G, et al. Tissue plasminogen activator in cardiac arrest with pulseless electrical activity. N Engl J Med. 2002;346(20):1522-1528.</ref>
*Tenecteplase in at 50 mg bolus or 0.5 mg/kg bolus <ref>Fatovich D, Dobb G, Clugston R. A pilot randomised trial of thrombolysis in cardiac arrest (The TICA trial). Resuscitation. 2004;61(3):309-313.</ref><ref>Bozeman W, Kleiner D, Ferguson K. Empiric tenecteplase is associated with increased return of spontaneous circulation and short term survival in cardiac arrest patients unresponsive to standard interventions. Resuscitation. 2006;69(3):399-406.</ref><ref>Böttiger B, Arntz H, Chamberlain D, et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med. 2008;359(25):2651-2662.</ref>
*Tenecteplase in at 50 mg bolus or 0.5 mg/kg bolus <ref>Fatovich D, Dobb G, Clugston R. A pilot randomised trial of thrombolysis in cardiac arrest (The TICA trial). Resuscitation. 2004;61(3):309-313.</ref><ref>Bozeman W, Kleiner D, Ferguson K. Empiric tenecteplase is associated with increased return of spontaneous circulation and short term survival in cardiac arrest patients unresponsive to standard interventions. Resuscitation. 2006;69(3):399-406.</ref><ref>Böttiger B, Arntz H, Chamberlain D, et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med. 2008;359(25):2651-2662.</ref>
===Related Instructions===
*Review contraindications (below)
*After infusion complete measure serial aPTTs
*After infusion complete measure serial aPTTs
**Almost all studies of thrombolysis administration included heparin anticoagulation
**Almost all studies of thrombolysis administration included heparin anticoagulation
**Once value is <2x upper limit restart anticoagulation
**Once value is <2x upper limit restart anticoagulation
*Review contraindications
*Ongoing CPR from 2010 AHA Guidelines is not an absolute contraindication, and some studies suggest permiting 15 min of CPR to allow thrombolysis to work<ref>Hayes BD. What’s the Code Dose of tPA? Updated August 2016. https://www.aliem.com/2013/whats-code-dose-of-tpa/.</ref>
*Ongoing CPR from 2010 AHA Guidelines is not an absolute contraindication, and some studies suggest permiting 15 min of CPR to allow thrombolysis to work<ref>Hayes BD. What’s the Code Dose of tPA? Updated August 2016. https://www.aliem.com/2013/whats-code-dose-of-tpa/.</ref>
*Discontinue heparin during infusion
*Discontinue heparin during infusion


===Absolute contraindications===
===Absolute contraindications===
*Any prior intracranial hemorrhage
*Any prior [[intracranial hemorrhage]]
*Known structural intracranial cerebrovascular disease (e.g. AVM)
*Known structural intracranial cerebrovascular disease (e.g. AVM)
*Known malignant intracranial neoplasm
*Known malignant intracranial neoplasm
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*Active bleeding or bleeding diathesis
*Active bleeding or bleeding diathesis
*Recent surgery encroaching on the spinal canal or brain
*Recent surgery encroaching on the spinal canal or brain
*Recent closed-head or facial trauma with radiographic evidence of bony fracture or brain injury
*Recent closed-head or [[facial trauma]] with radiographic evidence of bony fracture or brain injury


===Relative contraindications===
===Relative contraindications===
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*[[PE in Pregnancy]]
*[[PE in Pregnancy]]
*Noncompressible vascular punctures
*Noncompressible vascular punctures
*Traumatic or prolonged CPR (>10min)
*Traumatic or prolonged [[CPR]] (>10min)
*Recent internal bleeding (within 2 to 4 weeks)
*Recent internal bleeding (within 2 to 4 weeks)
*History of chronic, severe, and poorly controlled hypertension
*History of chronic, severe, and poorly controlled hypertension

Revision as of 18:44, 18 December 2018

Background

  • Major controversy exists regarding thrombolytic therapy in submassive PE. Therapy should be individualized to patients.[1][2][3] 'The mortality benefit may be greatest in patients with right ventricular dysfunction. [4]
  • Bleeding risk is increased with increasing age especially in the group ≥ 65 yo[5]

Indications

  • Patients with massive PE and acceptable risk of bleeding complications
  • Patient with submassive PE with evidence adverse prognosis + low risk of bleeding complications
    • Hemodynamic instability
    • Worsening respiratory insufficiency
    • Severe Right Ventricular dysfunction
    • Major myocardial necrosis

Thrombolytic Instructions

Administration regimens differ widely in the literature, options not in any particular order, include:

  • Alteplase 0.6 - 1 mg/kg or 100 mg with any of the three possibilities
    • Two 50 mg boluses, 30 min apart[6][7]
    • 15 mg bolus, followed by 85 mg over 90 min[8]
    • 100 mg over 15 min[9]
  • Tenecteplase in at 50 mg bolus or 0.5 mg/kg bolus [10][11][12]

Related Instructions

  • Review contraindications (below)
  • After infusion complete measure serial aPTTs
    • Almost all studies of thrombolysis administration included heparin anticoagulation
    • Once value is <2x upper limit restart anticoagulation
  • Ongoing CPR from 2010 AHA Guidelines is not an absolute contraindication, and some studies suggest permiting 15 min of CPR to allow thrombolysis to work[13]
  • Discontinue heparin during infusion

Absolute contraindications

  • Any prior intracranial hemorrhage
  • Known structural intracranial cerebrovascular disease (e.g. AVM)
  • Known malignant intracranial neoplasm
  • Ischemic stroke within last 3 months
  • Suspected aortic dissection
  • Active bleeding or bleeding diathesis
  • Recent surgery encroaching on the spinal canal or brain
  • Recent closed-head or facial trauma with radiographic evidence of bony fracture or brain injury

Relative contraindications

  • Age >75 years
  • Current use of anticoagulation
  • PE in Pregnancy
  • Noncompressible vascular punctures
  • Traumatic or prolonged CPR (>10min)
  • Recent internal bleeding (within 2 to 4 weeks)
  • History of chronic, severe, and poorly controlled hypertension
  • Severe uncontrolled hypertension on presentation (sys BP >180 or dia BP >110)
  • Dementia
  • Remote (>3 months) ischemic stroke
  • Major surgery within 3 weeks

References

  1. ↑ Elliott C. et al. Fibrinolysis of Pulmonary Emboli — Steer Closer to Scylla.
  2. ↑ Sharifi M et al. Moderate pulmonary embolism treated with thrombolysis (from the “MOPPETT trial). J Cardiol 2013; 111: 273-7
  3. ↑ Meyer G. Fibrinolysis for patients with intermediate-risk pulmonary embolism. NEJM 2014; 370(15): 1402-1411
  4. ↑ Chatterjee. S et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA 2014; 311(23):2414-21. PubMed ID: 24938564.
  5. ↑ EBQ:Thrombolysis_in_Pulmonary_Embolism_Metanalysis#Outcomes
  6. ↑ Kürkciyan I, Meron G, Sterz F, et al. Pulmonary embolism as a cause of cardiac arrest: presentation and outcome. Arch Intern Med. 2000;160(10):1529-1535.
  7. ↑ Ruiz-Bailén M, Aguayo-de-Hoyos E, Serrano-Córcoles M, et al. Thrombolysis with recombinant tissue plasminogen activator during cardiopulmonary resuscitation in fulminant pulmonary embolism. A case series. Resuscitation. 2001;51(1):97-101.
  8. ↑ Kürkciyan I, Meron G, Sterz F, et al. Pulmonary embolism as a cause of cardiac arrest: presentation and outcome. Arch Intern Med. 2000;160(10):1529-1535.
  9. ↑ Abu-Laban R, Christenson J, Innes G, et al. Tissue plasminogen activator in cardiac arrest with pulseless electrical activity. N Engl J Med. 2002;346(20):1522-1528.
  10. ↑ Fatovich D, Dobb G, Clugston R. A pilot randomised trial of thrombolysis in cardiac arrest (The TICA trial). Resuscitation. 2004;61(3):309-313.
  11. ↑ Bozeman W, Kleiner D, Ferguson K. Empiric tenecteplase is associated with increased return of spontaneous circulation and short term survival in cardiac arrest patients unresponsive to standard interventions. Resuscitation. 2006;69(3):399-406.
  12. ↑ Böttiger B, Arntz H, Chamberlain D, et al. Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med. 2008;359(25):2651-2662.
  13. ↑ Hayes BD. What’s the Code Dose of tPA? Updated August 2016. https://www.aliem.com/2013/whats-code-dose-of-tpa/.
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