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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3865_Библиотеки_им_академика_М_И_Перельмана
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110 Anticoagulation Therapy
should be administered
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Dose based on weight and
given as IV bolus over 5
sec; total dose should not
10 units IV over 2 min; give
second 10-unit dose IV 30
min later unless serious
60–69 kg: 35 mg
exceed 50 mg
<60 kg: 30 mg
bleeding or anaphylaxis is
present
70–79 kg: 40 mg
80–89 kg: 45 mg
≥90 kg: 50 mg
(continued)
Accelerated infusion
NA IV: 1.5 million units given
Patient Group Urokinase Streptokinase Alteplase (rt-PA) Reteplase Tenecteplase (TNK)
TABLE 6-2: Recommended Doses for Thrombolytic Agents by Patient Population
STEMI
regimen: Patients ≤67 kg:
give 15 mg IV over 1–2 min,
then 0.75 mg/kg IV over
30 min, then 0.5 mg/kg IV
over 1 hr
Patients >67 kg: 100 mg IV
over 1.5 hr; give 15 mg over
1–2 min, 50 mg over 30
min, then 35 mg over 1 hr
IV over 60 min
Intracoronary:
20,000 units bolus, then
2,000–4,000 units/min for
30–90 min
within 30 min.
Note: The lytic agent
3-hr infusion regimen:
Patients <65 kg: 1.25 mg/
kg over 3 hr; give 60% of
total dose in first hr with 6%
to 10% as an IV bolus, then
20%/hr for the next 2 hr
Patients ≥65 kg: 100 mg
the next 2 hr
IV over 3 hr; give 60 mg 1
hr with 6–10 mg as an IV
bolus, then 20 mg/hr for
THROMBOLYTIC CONSIDERATIONS WHEN USED WITH ANTICOAGULANTS 111
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Full dose: 30−50 mg
(weight dependent) single
intravenous bolus
>60 kg: 30 mg
≥60 to <70: 35 mg
≥70 to <80: 40 mg
≥80 to <90: 45 mg
≥90 kg: 50 mg
Catheter-directed therapy
after failed systemic lysis:
One single report found
success with a range
of 5–20 mg total dose
administered, in 2.5-mg
increments
30 min later unless serious
bleeding or anaphylaxis
10 units IV over 2 min; give
present
second 10-unit dose IV
(continued)
Full dose: 100 mg over
2 hr (10 mg bolus with
remaining 90 mg over 2 hr)
Load: 250,000 units/kg IV
over 30 min
Maintenance:
kg IV over 10 min
Maintenance:
2 hr) <50 kg, the total dose
Half dose: 50 mg over
2 hr (10 mg bolus with
remaining 40 mg over
100,000 units/kg/hr IV
for 24 hr
4,400 units/kg/hr IV
for 12 hr
is calculated as 0.5 mg/kg,
which is given as a 10-mg
initial bolus followed by the
remainder over 2 hr
Or
50 mg IVP and heparin
initiated immediately with a
2,000−5,000 bolus followed
by a infusion 10 unit/kg/hr
for 24–30 hr unless aPTT
> target range on heparin
already or received a
LMWH dose within 12 hr
Catheter-directed therapy
after failed systemic lysis:
One single report found
success with a range of
10–30 mg total dose
administered, in 5–10 mg
increments (see Chapter 13)
Patient Group Urokinase Streptokinase Alteplase (rt-PA) Reteplase Tenecteplase (TNK)
TABLE 6-2: (Continued)
PE Load: 4,400 units/
112 Anticoagulation Therapy
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NA NA
(continued)
Catheter-directed therapy:
No single dosing regimen
Load: 250,000 IUs/kg IV
over 30 min
kg IV over 10 min
Patient Group Urokinase Streptokinase Alteplase (rt-PA) Reteplase Tenecteplase (TNK)
TABLE 6-2: (Continued)
DVT Load: 4,400 units/
20 mg in 24 hr) for up
has proven superior to
others; dosing options from
small reports include
• 0.01 mg/kg/hr (max
100,000 units/kg/hr IV
for 72 hr
Maintenance:
4,400 units/kg/hr IV
for 12 hr
Maintenance:
to 96 hr
by 0.01-mg/kg/hr
infusion
by 1–2 mg/hr infusion
• 5-mg bolus, followed
• 10-mg bolus, followed
See Chapter 13
THROMBOLYTIC CONSIDERATIONS WHEN USED WITH ANTICOAGULANTS 113
Ischemic stroke
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(continued)
to alteplase
0.1 mg/kg bolus
Or
0.25 mg/kg bolus
Both doses resulted in
improved reperfusion via
CT angiography compared
to 0.9 mg/kg alteplase
NA Phase 2 trial only compared
symptoms. The maximum
NA NA Within 3–4.5 hr of
Patient Group Urokinase Streptokinase Alteplase (rt-PA) Reteplase Tenecteplase (TNK)
TABLE 6-2: (Continued)
dose is 90 mg.
Patients ≥100 kg: Give
0.9 mg/kg (90 mg is the
maximum dose), for which
10% (9 mg) is given as a
0.9 mg/kg, for which 10%
(0.09 mg/kg) is given as
a bolus over 1 min. The
balance of the dose (0.81
bolus over 1 min and 90%
(81 mg) is then infused over
60 min.
Patients <100 kg: Give
mg/kg) is then infused over
60 min.
114 Anticoagulation Therapy
Catheter occlusion
Peripheral arterial
occlusion (intra-arterial)
administration)*
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NA NA
NA
29
One small case series of
15 patients used a dosing
regimen of 0.5–1.0 units/hr
for 12–32 hr
A larger case series of 26
patients used a dose of
0.5–2 units/hr (mean
0.9 units/hr) up to a total
(continued)
30
31
dose of 20 units (means
20.1 units ± 5.5)
A third case series in 81
patients used 0.5 units/hr
infusion for an average of
19.5 hr and a total dose of
10.3 units
catheter and retained for 30
min to 2 hr; may repeat in 2
NA 2 mg instilled into the
5,000 units/2 mL
in each IV catheter
lumen over 1–2 min;
Patient Group Urokinase Streptokinase Alteplase (rt-PA) Reteplase Tenecteplase (TNK)
TABLE 6-2: (Continued)
hr if catheter still occluded
dwell time 1–4 hr
then remove;
flush catheter with
0.9% NaCl prior
to reconnecting
tubing; may repeat
with 10,000 units if
catheter does not
clear
0.02–0.1 mg/kg/hr for up
to 36 hrOrNon weight-based infusion
ranging from 1–10 mg/
hr, with 2.5 and 5 mg/hr
most common doses used;
duration variable from 2–24
hr or until clot resolution
NA Weight based infusion—
240,000 units/
hr for 2 hr, then
120,000 units/
hr for 2 hr, then
60,000 units/hr for
20 hr or 120,000
units/hr IV for 2
hr, then 60,000
units/hr until clot is
dissolvedOr120,000 units/hr IV
for up to 48 hr
THROMBOLYTIC CONSIDERATIONS WHEN USED WITH ANTICOAGULANTS 115
Pleural effusion/empyema
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(continued)
NA NA
10 mg in 30 mL NS instilled
intrapleurally for 1 hr every
250,000 units/100 mL NS
instilled intrapleurally for
Patient Group Urokinase Streptokinase Alteplase (rt-PA) Reteplase Tenecteplase (TNK)
TABLE 6-2: (Continued)
12 hr for 3 days (6 doses
total). 5 mg of DNase can
be instilled intrapleurally for
1 hr either concurrently or 1
to 2 hr after the rt-PA.Or25 mg in 100 mL NS,
divided in two 60 mL-
syringes. Instill intrapleurally
2–4 hr
daily for 3 days. The chest
tube is clamped for the
first hour and suction was
applied for 2 hr
116 Anticoagulation Therapy
Prosthetic heart valve
Mechanical circulatory
support devices (see
Chapter 17 for additional
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NA NA
(continued)
10 mg IV bolus, then 90 mg
IV over 3–5 hr
150,000 units to 250,000
IIU loading dose IV over
4,400 units/kg IV
bolus over 30 min,
Patient Group Urokinase Streptokinase Alteplase (rt-PA) Reteplase Tenecteplase (TNK)
thrombosis
TABLE 6-2: (Continued)
TEG can be used to
assess the level of lysis.
An ultrasound can be
done to determine if the
clot has dissolved and
30 min, then 100,000
units/hr IVOr1.5 million units given IV
then 4,400 units/hr
over 3 hr
Or
1.5 million units
given IV over 3 hr
Various regimens exist; data
the TPA infusion can be
discontinued.
are limited to case series
(may depend on the device)
10 mg IV bolus, then 1 mg/
min for 20 min, then 1 mg/
hr for up to 24 hr
10−20 mg IV bolus, then
remaining dose (usually
#
information)
10–50 mg) over 2−4 hr
10–50 mg IV bolus
1 mg/min intraventricularly
(left ventricle cavity) over
20–50 min
THROMBOLYTIC CONSIDERATIONS WHEN USED WITH ANTICOAGULANTS 117
Ultrasound-facilitated,
catheter-directed, low-
dose thrombolytics
*Few randomized trials exist investigating the use of intra-arterial thrombolysis in the setting of peripheral arterial disease. As such, dosing strategies in this population are
highly variable as evidenced by the various dosing strategies provided for each agent. Clinicians may encounter dosing regimens that are not accounted for here.
Optimal use of thrombolytics in mechanical circulatory support devices requires further study. Data are limited to retrospective case reports or case series. Various regimens
and routes of therapy have been attempted. Choice of strategy should weigh the risks and benefits for each individual patient (see Chapter 17—Mechanical Circulatory
Support Devices).
Catheter-directed ultrasound-accelerated (e.g., EKOS catheter) thrombolysis dose and duration varies. Common doses are 0.5–1 mg/hr into each catheter. Doses may be
titrated up or down depending on patient response and laboratory values (e.g., fibrinogen). Common infusion durations are 8–24 hours in length.
DVT: deep vein thrombosis, hr: hour, IV: intravenous, PE: pulmonary embolism, TEG: thromboelastography, TPA: tissue plasminogen activator, units: International Units
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0.25–0.5 mg/hr intra-arterial
catheter administration
(dose divided by number
of limbs)
0.15–0.5 mg/hr intra-arterial
catheter administration
$
1 mg/hr for 24 hr with a
unilateral catheter
Patient Group Urokinase Streptokinase Alteplase (rt-PA) Reteplase Tenecteplase (TNK)
TABLE 6-2: (Continued)
Or
1 mg/hr/catheter for 12 hr
with bilateral catheters
catheter administration
Frostbite 1 mg/hr intra-arterial
#
$
118 Anticoagulation Therapy
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TABLE 6-3: Thrombolysis in Myocardial Infarction (TIMI)
Grade Flow—Grading of Coronary Blood Flow During
Coronary Angiography
TIMIGrade Description
TIMI 0 - no perfusion No antegrade flow beyond the point of occlusion
TIMI 1 - penetration without perfusion Faint antegrade coronary flow beyond the occlusion
TIMI 2 - partial perfusion Delayed or sluggish antegrade flow with complete
TIMI 3 - complete perfusion Normal flow with complete filling of the distal
Angiographic TIMI flow grade of the infarct artery is estimated before and after completion
of coronary balloon angioplasty according to four grades of flow (TIMI 0–3). PAMI (Primary
Angioplasty in Myocardial Infarction) investigators provided the description of TIMI 3 as
“opacification of the vessel within three cardiac cycles.”
with incomplete filling of the distal coronary bed
filling of the distal territory
territory
Monitoring Parameters in PE/DVT
•
General
Baseline aPTT, PT/INR, hematocrit, platelet count, fibrinogen
(streptokinase therapy)
Coagulation parameters during therapy: aPTT, PT/INR, fibrinogen
level (streptokinase)
Vital signs (BP, HR) at baseline and during therapy
Oxygen saturation and hemodynamic parameters
•
Therapeutic
Resolution of symptoms: shortness of breath (SOB), chest pain, leg
pain, improved hemodynamics
Resolution of ECG changes
Improved right ventricular function on echocardiogram
•
Toxic
Clinical evidence of bleeding (vascular access site, hematuria,
gastrointestinal [GI] bleeding, positive stool guaiac)
Intracranial bleeding: impaired cognitive, motor or sensory function
on neurologic exam
• In selected situations (e.g., arterial clots or clots
on heart valves) where common management
approaches are not feasible, alteplase doses (see
Table 6-2 for indication) can be considered with
assessment tools such as ultrasound, peripheral
pulses to assess the impact of the therapy. A
baseline thromboelastography (TEG) along with
THROMBOLYTIC CONSIDERATIONS WHEN USED WITH ANTICOAGULANTS 119
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a follow-up TEG (assessing the lytic portion
of the curves towards the end of the test) during
therapy can be used to assess the presence of
lysis and determine any adjustments in the
management regimen.
Monitoring Parameters in Stroke
•
General
Baseline aPTT, PT/INR, hematocrit, platelet count
Coagulation parameters during therapy: aPTT, PT/INR
Vital signs (BP, HR) at baseline and during therapy
•
Therapeutic
Resolution of symptoms: neurologic deficits at presentation
•
Toxic
Clinical evidence of bleeding (vascular access site, hematuria, GI
bleeding, positive stool guaiac)
Intracranial bleeding: impaired cognitive, motor, or sensory function
on neurologic exam
Monitoring Parameters in Catheter Occlusion
•
Therapeutic
Aspiration of blood or catheter contents
•
Toxic
Clinical evidence of bleeding (vascular access site, hematuria, GI
bleeding, positive stool guaiac)
Monitoring Parameters in Peripheral Arterial Occlusion
•
General
Baseline aPTT, PT/INR, hematocrit, platelet count, fibrinogen
(streptokinase therapy)
Coagulation parameters during therapy: aPTT, PT/INR, fibrinogen
level (streptokinase)
Vital signs (BP, HR) at baseline and during therapy
•
Therapeutic
Resolution of symptoms: leg pain, lower extremity ischemia,
restored perfusion
Angiographic evidence of improvement
•
Toxic
Clinical evidence of bleeding (vascular access site, hematuria, GI
bleeding, positive stool guaiac)
Intracranial bleeding: impaired cognitive, motor, or sensory function
on neurologic exam
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