Cover
Alteplase Treatment of
Acute Pulmonary Embolism
in the Intensive Care Unit
PAMELA L. SMITHBURGER, PharmD, BCPS
SHAUNA CAMPBELL, MSN
SANDRA L. KANE-GILL, MS, PharmD, MSC
Acute pulmonary embolism accounts for 50 000 to 100 000 deaths each year in the United States. Because
of the wide spectrum of clinical manifestations, ranging from massive pulmonary embolism to small
peripheral emboli, stratifying and treating patients according to their signs and symptoms is important
when an acute embolism is suspected. Patients’ clinical findings can range from no signs or symptoms to
unstable hemodynamic status and shock. The 3-month mortality is 10% to 15%, but can be as high as 60%
in patients with hemodynamic shock. This article reviews the classifications of acute peripheral emboli,
explains the treatment of acute peripheral emboli, reviews the pharmacology of alteplase, and presents
an assessment of the literature evaluating alteplase for the treatment of acute peripheral emboli. Clinical
pearls for the administration, monitoring, and care of a patient receiving alteplase in an intensive care
unit also are discussed. (Critical Care Nurse. 2013;33[2]:17-27)
A
cute pulmonary embolism is a deadly event that occurs in 1 per 1000 persons and is
responsible for 50 000 to 100 000 deaths each year in the United States.1-3 A pulmonary
embolism is an obstruction of the pulmonary artery or one of its branches by a thrombus. The signs and symptoms range from massive pulmonary embolism that results
in unstable hemodynamic status to a small peripheral embolus that can be asymptomatic. To aid in the delineation of the types of pulmonary embolism, the American Heart Association
has proposed several definitions4 (Table 1). These definitions have been used in clinical trials and
practice guidelines to help stratify patients and aid in treatment selection.
Approximately 44% of patients who have pulmonary embolism have a confirmed deep vein thrombosis.5 The pathogenesis of venous thromboembolism can be explained on the basis of the Virchow triad6:
stasis, endothelial injury, and hypercoagulability. Table 2 provides risk factors for pulmonary embolism.7-12
CNE Continuing Nursing Education
This article has been designated for CNE credit. A closed-book, multiple-choice examination follows this article,
which tests your knowledge of the following objectives:
1. Identify signs and symptoms when acute embolism is suspected
2. Discuss the medical management of acute peripheral emboli
3. Differentiate the classifications of acute peripheral emboli
©2013 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2013626
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Table 1
Definitions of an acute pulmonary embolisma
Category
Description
Massive
Acute pulmonary embolism with
Sustained hypotension (systolic blood pressure
<90 mm Hg for at least 15 min)
Requirement for inotropic support, not
because of other causes
Persistent or pulseless, bradycardia (heart rate
<40/min) with shock
Submassive
Acute pulmonary embolism with myocardial
necrosis or right ventricular dysfunction but no
systemic hypotension
Low risk
Acute pulmonary embolism with normal levels
of biomarkers, no systemic hypotension or
right ventricular dysfunction
a
Based on information from Jaff et al.4
Table 2
Selected risk factors for thromboembolisma
Component of the
Virchow triad
Risk factor
Stasis
Immobilization
Paralysis
Atrial fibrillation
Long-distance travel
Venous insufficiency
Endothelial injury
Recent central venous instrumentation
Hypertension
Atherosclerosis
Trauma or surgery
Indwelling catheter
Hypercoagulability
Malignant neoplasms
History of heavy smoking
Pregnancy
Obesity
Estrogen therapy
Sepsis
Trauma or surgery of a lower extremity
a
Based on information from Stein et al,7 PIOPED Investigators,8 Darze et al,9
Heit et al,10 Green et al,11 and Goldhaber et al.12
Thrombi from the iliofemoral vein are the most commonly involved source of pulmonary embolism.13,14 After
traveling to the lungs, large thrombi often lodge in the
bifurcation of the main pulmonary artery or the lobar
branches, obstructing perfusion in the artery or its
branches. The thrombus causes a blockage in the lung,
resulting in an increase in pulmonary pressure, which
increases the resistance to blood flow in the right ventricle. The result is increased right ventricular workload
and decreased perfusion to the lung. If the right ventricle
cannot pump against the increased pressure, right-sided
heart failure can occur, which is manifested as hypoxemia,
hypotension, and shortness of breath.15 Impaired gas
exchange is also commonly associated with pulmonary
embolism. The impairment is not solely due to the
mechanical obstruction of the vasculature. Numbers of
neutrophils and levels of platelet-activating factor are
increased, and functional intrapulmonary shunting (area
in the lung where perfusion exceeds ventilation), atelectasis, and surfactant dysfunction may occur, which can
contribute to impaired gas exchange.16
In the United States, acute pulmonary embolism is
the third leading cause of death in hospitalized patients.17
Unfortunately, the manifestations of an acute pulmonary
embolism can be highly variable and nonspecific, ranging from no signs or symptoms to unstable hemodynamic
status and shock. Patients with acute pulmonary embolism
can have a wide range of signs and symptoms, including
dyspnea at rest or with exertion (73%), sharp chest pain
that may radiate to the shoulder (44%), calf or thigh pain
(44%), calf or thigh swelling (41%), cough (34%), 2+ pillow
orthopnea (28%), and wheezing (21%). Clinical manifestations of a deep vein thrombosis are apparent in 44% of
patients.15,18 Approximately 8% of patients experience circulatory collapse, and among these patients, dyspnea
Authors
Pamela L. Smithburger is an assistant professor of pharmacy and therapeutics, University of Pittsburgh, School of Pharmacy, and a critical
care clinical specialist in the medical ICU, University of Pittsburgh Medical Center Presbyterian Hospital, Pittsburgh, Pennsylvania.
Shauna Campbell is the director of the medical ICU, University of Pittsburgh Medical Center.
Sandra L. Kane-Gill is an associate professor of pharmacy and therapeutics, Center for Pharmacoinformatics and Outcomes Research,
University of Pittsburgh, School of Pharmacy, and a critical care patient safety officer, Department of Pharmacy, University of Pittsburgh
Medical Center.
Corresponding author: Pamela Smithburger, PharmD, BCPS, University of Pittsburgh School of Pharmacy, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh
PA 15213 (e-mail: smithburgerpl@upmc.edu).
To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949)
362-2049; e-mail, reprints@aacn.org.
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has been reported in 82% and dyspnea or tachypnea in
92%.18 In adults, the rate of asymptomatic acute pulmonary
embolisms ranges from 28% to 58%.11
In addition to signs and symptoms, the gold standard
for diagnosis of a pulmonary embolism is pulmonary
angiography.19 This study is performed by injecting contrast material into a branch of the pulmonary artery.
Normal findings on pulmonary angiograms exclude a
diagnosis of pulmonary embolism. Pulmonary angiography and computed tomography of the lungs can reveal
pulmonary abnormalities that may explain a patient’s
signs and symptoms. According to Wolf et al,19 66% to
93% of pulmonary embolisms can be detected by using
computed tomography or pulmonary angiography.
A D-dimer test can aid in the diagnosis of pulmonary
embolism. D-dimers are specific degradation products of
cross-linked fibrin. In patients with an acute clot, the serum
level of D-dimer is elevated because of the simultaneous
increase in coagulation and fibrinolysis.20 The D-dimer
level has a high negative predictive value for venous
thromboembolism and pulmonary embolism and therefore can be used to rule out these conditions.2 However,
the test has poor specificity and a low positive predictive
value. Therefore, other means of diagnosing pulmonary
embolism are necessary.20
Clinical outcomes of pulmonary embolism vary greatly
depending on patients’ characteristics and the type of
pulmonary embolism. The estimated 3-month mortality
rate after diagnosis is 10% to 15%.21 However, 5% to 10%
of patients with pulmonary embolism have an unstable
hemodynamic status and shock and compared with
patients without these characteristics have a higher mortality rate of almost 60%.9,12 Therefore, stratifying patients
on the basis of their clinical signs and symptoms when
pulmonary embolism is suspected is important.
Acute Pulmonary Embolism
Initial Treatment
Treatment of pulmonary embolism includes both
initial stabilization and anticoagulation, with consideration given to the use of a thrombolytic agent. In patients
with suspected pulmonary embolism, stabilization of
hemodynamic status should be the primary focus.3,4
Patients with hypoxemia should be given supplemental
oxygen. For patients with hypotension, fluid boluses are
used initially to replace fluids; vasopressors are given if
fluid replacement is inadequate. Anticoagulation is the
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mainstay of treatment for patients with a high probability of pulmonary embolism. Patients with objectively
confirmed pulmonary embolism or strongly suspected
pulmonary embolism and no contraindications should
receive anticoagulation therapy with low-molecularweight heparin, subcutaneous fondaparinux, or intravenous unfractionated heparin.3,4 Anticoagulants, such
as heparin, prevent the thrombus that is already formed
from increasing in size. These medications cannot decrease
the size of a thrombus that has already formed, but they
can be used to stop clot growth and the development of
new clots.21
Although anticoagulants prevent both growth of
established thrombus and formation of new thrombus,
thrombolytics actually decrease the size of the already
formed thrombus by dissolving fibrin. The 2011 guidelines of the American Heart Association4 and the guidelines of the
American
In addition to signs and symptoms, the
College of
gold standard for diagnosis of a pulmonary
Chest Physi- embolism is pulmonary angiography.
cians3 recommend that patients with massive pulmonary embolism,
evidence of hemodynamic compromise, and acceptable
bleeding risk receive a thrombolytic. Use of a thrombolytic not only accelerates the lysis of the thrombus in
acute pulmonary embolisms but also improves physiological parameters such as pulmonary perfusion and right
ventricular function via dissolution of the thrombus.
Alteplase
Alteplase initiates local fibrinolysis by binding to the
fibrin in a clot and converting the trapped plasminogen
to plasmin.22 The result is dissolution of the thrombus.22,23
When alteplase is administered, more than 50% of the
drug concentration in the plasma is cleared within 5 minutes after the infusion is stopped. Alteplase is primarily
cleared hepatically.23 The Food and Drug Administration
(FDA) has approved this thrombolytic agent for management of ST-elevation myocardial infarction (lysis of
thrombi in coronary arteries), acute stroke, and acute
pulmonary embolism.23 Alteplase was approved for management of acute pulmonary embolism in 2002, and it
can be used for management of acute, massive pulmonary
embolism in adults for the lysis of acute pulmonary
emboli accompanied by unstable hemodynamic status,
such as hypotension.23
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Contraindications and Interactions. Patients
treated with alteplase should be evaluated; bleeding,
especially at the catheter puncture site; and hemorrhages, including gastrointestinal, intracranial, and
retroperitoneal hemorrhages should be considered.4
Most of the absolute and relative contraindications for
use of alteplase (Table 3) are characteristics that would
predispose a patient to a bleeding event.23 Clinicians
should also be mindful of possible drug interactions.
Concurrent administration of alteplase with an anticoagulant, such as heparin and vitamin K antagonists, or
other medications that alter platelet function, such as
aspirin and clopidogrel, may increase the risk of bleeding if administered before, during, or after alteplase
therapy. The length of time the bleeding risk is increased
depends on the agent used in addition to alteplase and
can range from 1 hour for heparin to up to 5 days for
clopidogrel.3,4 Therefore, patients given these combinations of drugs should be carefully monitored if the drugs
are administered together.3,4,23
Use With Heparin. The FDA-approved regimen of
alteplase for an acute, massive pulmonary embolism is
100 mg administered by intravenous infusion over 2
hours.22 Heparin therapy should be stopped during the
alteplase infusion and reinstituted after the infusion
when the activated partial thromboplastin time (aPTT)
or thrombin time returns to twice normal or less.23-27
With thrombolysis, patients may have an increased risk
for bleeding. However, in a comparison of the bleeding
rates after the administration of alteplase in patients
who received heparin only and patients who received
alteplase plus heparin, the rates of bleeding in the 2
groups did not differ significantly.24-30 Overall, compared
with heparin alone, alteplase decreased total peripheral
resistance and ventricular dilatation and increased cardiac output, ejection fraction, and oxygen saturation.24,26,28
Table 4 reviews the grading criteria for clinical trials.
Table 5—available online only at www.ccnonline.org—
summarizes clinical trials on the use of alteplase in
patients with massive pulmonary embolism.
Treatment of Submassive
Pulmonary Embolism
Thrombolysis should be considered for patients with
submassive pulmonary embolism if they have a poor
prognosis and a low risk for bleeding.4 The guidelines3
of the American College of Chest Physicians recommend
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Table 3
Contraindications to use of alteplasea
Absolute contraindications Relative contraindications
Internal bleeding
Previous intracranial
hemorrhage
History of a cerebral vascular
accident within the past 3
months
Recent intracranial or
intraspinal surgery or trauma
Intracranial neoplasm
Arteriovenous malformation
or aneurysm
Known bleeding diathesis
a Based
Age >75 y
Current use of anticoagulation
Pregnancy
Noncompressible vascular
punctures
Traumatic or prolonged cardiopulmonary resuscitation
(<10 min)
Recent internal bleeding
(within 2-4 wk)
History of chronic, severe, and
poorly controlled hypertension
Severe uncontrolled hypertension on initial examination
(systolic blood pressure
>180 mm Hg or diastolic
blood pressure >110 mm Hg)
Dementia
Remote ischemic stroke (>3 mo)
Major surgery within preceding
3 weeks
on information from Jaff et al4 and Ouellette and Patocka.22
the use of thrombolytic agents in these patients. Administration of a thrombolytic agent in addition to heparin
requires assessment of a patient’s characteristics and of
the risks and benefits of thrombolytic use, such as right
ventricular strain and predisposition for bleeding.
Of note, use of alteplase for treatment of submassive
pulmonary embolism has not been approved by the FDA
and is a widely debated topic. In patients with acute
right ventricular dysfunction, use of alteplase can result
in a 2- to 3-fold increase in death due to the embolism.33
Among patients with submassive pulmonary embolism,
those who received heparin plus alteplase had less deterioration in clinical status, shorter hospital stays, an increase
in pulmonary perfusion, shorter time to improved right
ventricular function, and lower hospital mortality than
Table 4
Grading criteria for clinical trialsa
Assessment
Grade
Grade description
Risk vs benefit
1
2
Benefit > risk
Risk > benefit
Quality of the data available
A
B
C
Good
Fair
Poor
a Based
on information from Ansani et al.31
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did those who received heparin
alone.34-36 In addition, primary
PE is diagnosed
thrombolysis with alteplase
and treatment is necessary
decreased the need for treatment
escalation, such as emergently
administering a thrombolytic after
Massive PE
Submassive PE
Low-risk PE
heparin therapy alone was unsuccessful.35 Differences in bleeding
between patients who received
RV strain or a possibility
Hemodynamic compromise
No RV strain
heparin alone and patients who
of poor prognosis
(SBP <90 mm Hg
received heparin plus alteplase were
for >15 minutes or
need inotropic support)
not significant.34-36 Table 6—available
online only at www.ccnonline.org—
summarizes the use of alteplase in
patients with submassive pulAnticoagulation
Anticoagulation
Anticoagulation
monary embolism. The Figure is a
proposed treatment algorithm
based on a patient’s risk of bleeding
Consider thrombolytic agents if:
and severity of the pulmonary
1. Patient has shock or respiratory distress
2. RV dysfunction
embolism as reflected by hemody3. Elevated levels of biomarkers (troponin, BNP)
3,4
namic compromise.
In systemic thrombolytic therapy,
the drug is given through a peripheral intravenous catheter. When sysLow or acceptable bleeding risk and no
contraindications to thrombolytic therapy
temic thrombolytic therapy is
contraindicated because of increased
risk for bleeding or insufficient time
for systemic thrombolysis, other
1. Discontinue heparin infusion
2. Administer alteplase 100 mg IV for 2 hours
therapies, such as catheter-directed
3. Check aPTT
thrombolysis (CDT), may be neces4. Restart heparin infusion when aPTT ≤2 times normal
sary.3,39,40 In CDT, the thrombolytic
agent is administered directly into
the pulmonary artery via a pulFigure Treatment algorithm for acute pulmonary embolism. Based on information
from Kearon et al3 and Jaff et al.4
monary artery catheter23; the usual
Abbreviations: aPTT, activated partial thromboplastin time; BNP, brain natriuretic peptide; IV, intravenous;
thrombolytic agent is full-dose
PE, pulmonary embolism; RV, right ventricle; SBP, systolic blood pressure.
heparin. Table 7 is a summary of the
clinical trials and assessments of the
mechanical thrombectomy, which can involve either
efficacy of CDT with alteplase.31,39,41-46 Overall, CDT
spinning wires or jets of physiological saline aimed at the
appears safe and effective. With CDT, medications can
thrombus, to increase the rate of dissolution.47 Currently,
be delivered directly to the thrombus at a high concenCDT with alteplase is an “off-label” use of the drug. When
tration. Lower doses of a thrombolytic and shorter duraused in CDT, alteplase has been infused at 0.5 to 1 mg/h
tions of infusions are used to achieve complete
for up to 48 hours.39 No clinical trials have been done to
thrombolysis. In theory, compared with systemic thromcompare systemic thrombolysis with CDT. In a review of
bolysis, the use of lower doses and shorter infusions
several methods of catheter-directed approaches with or
times with alteplase reduces the risk of bleeding compli3,40,41
without local or systemic thrombolytic therapy in patients
cations.
Thrombolytic methods have also been comwith acute massive pulmonary embolism, Kuo et al39
bined with mechanical methods such as percutaneous
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Table 7 Summary of clinical trials and assessments of the efficacy of
catheter-directed thrombolysis (CDT) in patients with pulmonary embolism (PE)
Study
Study design
n
Type of PE
Treatment
Chamsuddin et al, 2008
RE
10
Acute massive
Catheter-directed infusion of urokinase 60 000 IU in 12 hours,
then 90 000 IU/h (n = 1); alteplase mean dose 0.88 mg/h
(n = 8); reteplase 0.5 mg/h then 0.25 mg/hr (n = 1)
Mean infusion time was 24.76 hours
Kuo et al,39 2009
RE
594
Acute massive,
treated with
modern CDT
Modern CDT included low-profile devices; mechanical
fragmentation and/or aspiration of emboli, including
rheolytic thrombectomy, and intraclot thrombolytic
injection if a local drug was infused
Griffith et al,43 2009
CR
1
Massive
Catheter-directed infusion of alteplase 1 mg/h + VA-ECMO +
inhaled nitric oxide 20 ppm + mechanical thrombolysis
Bechtel et al,44 2005
CR
1
Massive bilateral
Catheter-directed alteplase initial infusion of 12 mg followed
by an infusion of 0.7 mg/h
Lin et al,45 2009
RE
25
Massive
Catheter-directed alteplase at dose 0.93 mg/h for a mean
total dose of 25.43 mg (range 16-45 mg)
Mean duration of the infusion was 26.7 hours (range 14-46
hours) vs catheter-directed therapy + EkoSonic Endovascular System
Kuo et al,46 2008
RE
12
Massive
Among the 12 patients, 7 received CDT thombolysis: 5
received alteplase (mean dose 20 mg) and 2 received
tenecteplase (mean dose 12 mg) with catheter-directed
fragmentation and suction embolectomy
41
Abbreviations: CR, case report; RE, retrospective; VA-ECMO, venoarterial extracorporeal membrane oxygenation.
a Grading is based on criteria of the Agency for Healthcare Research and Quality.31
Table 8
Guideline recommendations for the use of thrombolytic agents to treat massive
and submassive pulmonary embolism (PE) and in catheter-directed thrombolysis (CDT)
Guideline
Massive PE
Gradea
IIA,B
Gradea
Submassive PE
American Heart
Association4
The use of thrombolytic agents is
reasonable for patients with massive acute PE and an acceptable
risk for bleeding complications
The use of thrombolytics may be considered for patients with submassive PE judged to have clinical evidence of adverse prognosis (new unstable hemodynamic status, worsening respiratory
insufficiency, severe right ventricular dysfunction, or major
myocardial necrosis) and low risk for bleeding complications
American College
of Chest
Physicians3
For patients with evidence of hemodynamic compromise, use of thrombolytic therapy is recommended
unless patient has major contraindications because of risk for bleeding
1B
In selected high-risk patients without hypotension who are
judged to have a low risk for bleeding, administration of
thrombolytic therapy is suggested
2B
European Society
of Cardiology48
Thrombolytic therapy is the first-line
treatment in patients with high-risk
PE presenting with cardiogenic
shock and/or persistent arterial
hypotension, with very few absolute
contraindications.
NA
Routine use of thrombolysis in patients not at high risk for
bleeding is not recommended, but may be considered in
selected patients with intermediate-risk PE and after thorough
consideration of conditions increasing the risk for bleeding
NA
Abbreviations: NA, not applicable; VA-ECMO, venoarterial extracorporeal membrane oxygenation.
a Grading is based on criteria of the Agency for Healthcare Research and Quality.31
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IIB,C
Results
Gradea
Lysis of thrombus was 69%, with a mean lysis time of
23.4 hours
The treatment group had no major hemorrhagic events
1B
In 60% to 67% of patients, a local thrombolytic agent was
infused during the mechanical maneuvers
The pooled success rate was 86.5% (95% CI, 82.2%-90.2%;
q = 60.3, P = .004 for heterogeneity; I 2 = 40.3%)
1C
VA-ECMO was stopped and patient was extubated
1C
Patient recovered completely and was discharged taking
enoxaparin 1 mg/kg twice a day
1C
EkoSonic Endovascular System treatment was a success
compared with the CDT group (P < .02)
The alteplase dosage and infusion time were lower in the
EkoSonic group than in the CDT group (P < .001).
1B
Mean systolic pulmonary pressure improved from 57.6 to
44 mm Hg (P < .05); shock index improved (<0.9) in
83% of patients
Clinical success was achieved in 83% of patients
1C
reported that clinical success was achieved in 71% to
100% of patients who underwent a catheter-directed
embolectomy with either systemic or local thrombolysis.
In patients who underwent catheter-directed embolectomy alone, the success rate was 67% to 88%. Therefore,
local experience with CDT and the expertise of the
physician performing the procedure should be taken
into account when CDT is being considered for a patient.
Use of Alteplase in Patients With
Acute Pulmonary Embolism
CDT
Gradea
Direct intra-arterial delivery of thrombolytics, such as alteplase
0.6 mg/kg (up to 50 mg), over 15 minutes, may be helpful
when mechanical thrombectomy strategies are ineffective
NA
Infusion of alteplase directly into a pulmonary artery rather than
via a peripheral vein does not accelerate thrombolysis but does
cause more frequent bleeding at the catheter insertion site
When a lytic agent is appropriate for PE, thrombolytic agents
should be infused into a peripheral vein over 2 hours or less
NA
Direct local infusion of tissue plasminogen activator via a
catheter in the pulmonary artery (at a reduced dosage) did
not have any advantages over systemic intravenous thrombolysis
This approach should generally be avoided, because it is associated with an increased risk for bleeding at the puncture site
NA
Table 8 provides a summary of the recommendations
of the American Heart Association,4 the American College of Chest Physicians,3 and the European Society of
Cardiology48 for use of a thrombolytic agent in patients
with massive pulmonary embolism or submassive pulmonary embolism and in CDT. For patients with massive
pulmonary embolism, all 3 guidelines recommend use
of a thrombolytic agent when the patients have no risk
for bleeding. In patients with submassive pulmonary
embolism, the 3 guidelines recommend use of thrombolytic agents in patients at high risk for death who have
a low risk for bleeding. Neither the American College of
Chest Physicians nor the European Society of Cardiology
recommends the use of CDT. The American Heart Association suggests that CDT may be helpful when other
mechanical thrombectomy strategies are unsuccessful.
Currently, 3 meta-analyses49-51 (Table 9) have been
conducted to evaluate thrombolysis for the treatment of
pulmonary embolism. Agnelli et al49 found a lower composite end point of death and recurrence of embolism
with thrombolysis than with heparin therapy alone.
Wan et al50 reported a possible benefit for the use of
thrombolysis in patients with unstable hemodynamic
status and the highest risk for death or recurrence of
embolism. Therefore, these authors50 recommend use of
a thrombolytic agent in patients with a major pulmonary
embolism and hemodynamic compromise. Dong et al51
did not find any benefit of thrombolysis or any difference
in hemorrhagic events between control and interventional
groups. They concluded that evidence of any benefit from
the use of thrombolytic agents rather than heparin in the
treatment of acute pulmonary embolism is insufficient.
Bedside Nursing Management
Patients receiving alteplase for the treatment of acute
pulmonary embolism require specific nursing monitoring
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Table 9
Summary of 3 meta-analyses on the use of thrombolysis for the treatment of pulmonary embolism (PE)
Study
No.
Type of PE
Treatments
Results
Any
A total of 241 patients (52.3%)
received thrombolytic therapy
with streptokinase (n = 31),
urokinase (n = 102 ), or
alteplase (n = 108)
A total of 220 patients received
heparin
A total of 11 deaths (4.6%) occurred in the thrombolysis group and 17 deaths (7.7%) occurred in
the heparin group (RR, 0.59; 95% CI, 0.27-1.25)
Five fatal bleeding episodes (2.1%) occurred in
the thrombolysis group; none occurred in the
heparin group
Agnelli et al,49
2002
461 patients,
9 clinical trials
Wan et al,50
2004
748 patients,
11 trials
Acute
Dong et al,51
2006
679 patients,
8 trials
Confirmed
Patients in the included trials
Thrombolytic therapy resulted in a nonsignificant
were randomized to receive a
reduction in recurrent PE or death (6.7% vs 9.6%;
systemic thrombolytic agent,
OR, 0.67, 95% CI, 0.40-1.12, P for heterogeneincluding urokinase, streptokiity = .48), a nonsignificant increase in major
nase, alteplase, or heparin
bleeding (9.1% vs 6.1%; OR, 1.42; 95% CI,
0.81-2.46), and a significant increase in nonmajor bleeding (22.7% vs 10.0%; OR, 2.63; 95% CI,
1.53-4.54)
When a thrombolytic agent was used in patients
with unstable hemodynamic status, a reduction
in recurrent PE or death occurred (9.4% vs
19.0%; OR, 0.45; 95% CI, 0.22-0.92)
Patients were included in trials Results were similar between the heparin and
that used a thrombolytic, includthrombolytic groups for the following: death
ing streptokinase, urokinase,
(OR, 0.89; 95% CI, 0.45-1.78), PE recurrence
recombinant tissue plasmino(OR, 0.63; 95% CI, 0.33-1.20), major hemorgen activator, and alteplase
rhagic events (OR, 1.61; 95% CI, 0.91-2.86),
Results were compared with
minor hemorrhagic events (OR, 1.98; 95% CI,
those of patients who had
0.68-5.75)
heparin alone or placebo or
surgical intervention
Abbreviations: OR, odds ratio; RR, relative risk.
and care. Because of the high risk for bleeding, these
patients should be cared for in a critical care setting for
at least 24 hours, depending on their clinical status.50
Close monitoring for bleeding and hypertension are
required during this time.
Alteplase should be diluted with sterile water to a
final concentration of 1 mg/mL for injection.22 The
manufacturer provides a transfer device that should be
used to add the sterile water to the alteplase powder.
Foaming may occur when the sterile water is added but
will dissipate if the mixture is allowed to stand undisturbed for
Patients should be monitored closely several minutes. Of note,
for bleeding and hypertension in a
critical care setting for at least 24
alteplase
hours after administration of alteplase should not be
because of the high risk for bleeding. shaken during
dilution and
mixing. In order to thoroughly mix the medication, the
vial should be gently swirled or inverted. Alteplase is
stable at room temperature for 8 hours after it is
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reconstituted and contains no antibacterial preservatives. For these reasons, the drug should be reconstituted immediately before use and should be
administered within 8 hours of dilution.26
In most patients, a continuous heparin infusion will
already have been started while the decision to use
alteplase is being made or while the alteplase is being
dispensed by the pharmacy. In these patients, in order to
decrease the risk for bleeding, the heparin infusion
should be stopped when the alteplase infusion is started.
Alteplase should be administered as a continuous infusion over a 2-hour period. During the infusion, patients’
neurological status should be monitored frequently
because of the increased risk for cerebral hemorrhage.
Neurological checks should be completed every 15 minutes during administration of the drug, then every 30
minutes for 6 hours, and then hourly for 24 hours after
initiation of treatment.3,4,52 Alert patients should be
instructed to report any changes in headache, vision,
and sensorium. Any change in neurological status is
reason to discontinue the infusion to investigate the
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possibility of intracranial bleeding,22 and computed
tomography of the head should be conducted immediately. Bleeding remains a risk for up to 36 hours after
completion of the alteplase infusion.4 Heart rate and
blood pressure should be monitored continually, because
these physiological indicators could alert bedside nurses
to the occurrence of bleeding.22,52 Monitoring of heart
rate and blood pressure is recommended for 24 hours
after the administration of alteplase.
Upon completion of the alteplase infusion, continuous infusion of heparin should be reinitiated. Before the
infusion is restarted, blood should be obtained for determination of aPTT. In order to reduce the risk for bleeding, the heparin should not be started until the aPTT is
twice the normal level or less.23 As the heparin infusion
is restarted, monitoring for signs and symptoms of bleeding should continue. The aPTT should be monitored per
institutional protocol to ensure the attainment of therapeutic anticoagulation and to prevent overanticoagulation.
Other important nursing considerations include
refraining from venous or arterial punctures and placement of invasive tubes during the first 24 hours after
administration of alteplase.50 Existing insertion sites of
invasive catheters should be assessed hourly for bleeding.
At times, alteplase may be administered via a CDT
method. In these situations, a smaller dose of alteplase
(0.5-1 mg/h) is infused into the pulmonary artery via a
pulmonary artery catheter for an extended time (14-46
hours).39,41-46 As with systemic administration of alteplase,
bedside nurses should monitor patients for any signs or
symptoms of bleeding. Specific attention should be paid
to the insertion site of the pulmonary catheter.43
The efficacy of alteplase can be monitored by noting
the resolution of signs and symptoms related to the pulmonary embolism. For example, a patient should begin
to have improvement in hemodynamic parameters, including blood pressure, heart rate, and right end-diastolic
function. Improvement in the patient’s subjective symptoms should also occur, such as less chest pain, shortness
of breath, and wheezing or cough.23
Summary
Acute pulmonary embolisms are life-threatening
abnormalities with a wide range of signs and symptoms.
Because of the wide spectrum, from no signs or symptoms
to hypotension and shock, diagnosis can be difficult.
Early diagnosis and treatment are necessary to provide
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the best care and improve patients’ outcomes.53 Alteplase
is efficacious in the treatment of acute massive and submassive pulmonary embolisms, although it has not been
approved by the FDA for treatment of submassive pulmonary embolism. The risk for and development of
bleeding should always be taken into account when
therapy is started. CCN
Financial Disclosures
None reported.
Now that you’ve read the article, create or contribute to an online discussion
about this topic using eLetters. Just visit www.ccnonline.org and click “Submit a
response” in either the full-text or PDF view of the article.
To learn more about caring for patients with pulmonary
embolism, read “Massive Pulmonary Embolism” by Shaughnessy
in Critical Care Nurse, February 2007;27(1):39-50. Available at
www.ccnonline.org.
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