Pre-Procedure:

• Obtain informed consent

• Review the patient's medical history, NPO status, allergies, and H & P:

  • • If the patient has IV contrast allergy, premedication will be needed per the MD order

• Ensure transfer order for Intermediate (Stepdown) or ICU care is entered by MD in EPIC if the patient is not currently on one of those units

• Communicate bed needs with the House Supervisor and confirm bed availability BEFORE the case starts

• Have 2 infusion pumps available:

  • • One pump is for the Heparin drip, one pump is for the tPA (Alteplase) infusion

    • If you do not have 2 pumps in your room, contact Service Response (4-5611) to bring additional pumps

• For Arterial access procedures:

  • • Locate and assess the patient's pre-procedure pedal pulses

    • Document in EPIC

Intra-Procedure:

• • When the MD confirms that thrombolytic therapy will be initiated, prime the LYTICS TUBING without Y-SITES (located in the Elevator Store Room and labeled Lytics Tubing) as follows:

    • • One set primed with Heparin

      • One set primed with Normal Saline, which will be replaced by tPA once available from pharmacy

  • Set up your infusion pumps at the MD prescribed rate and then set to "Hold"

    • • Typical Heparin dose is 500 units/hour (Bag concentration is 25,000 units per 250 mL)

      • Typical tPA dose is 0.5 mg/hour = 50 mL/hour 

  • CHECK YOUR ORDERS:

    • • Label the tubing with High Alert medication stickers

      • Label the tubing with Time and Date

      • Label pumps with High Alert medication stickers

  • Ensure the MD entered orders for the tPA and Heparin in EPIC

    • • Release and acknowledge these orders

  • Send text page to On-Call Pharmacist covering the service (Radiology or Vascular Surgery) to verify the order

  • Call the pharmacy at 4-8761 to notify that tPA has been ordered. Provide pharmacy with call back number to call when tPA is ready to be picked up

  • Communicate to your Charge nurse when tPA needs to be picked up from pharmacy:

    • • It cannot be tubed

      • If lytics occurring after hours, communicate with Imaging or PRU nurse to obtain the tPA from the Pharmacy

  • Prime and inflate arterial pressure bag with Normal Saline

Post-Procedure:

• Place PICC Stat Lock (4-5 Fr depending on size of infusion catheter) on the infusion catheter located on the nursing cart

• Secure stat lock with Arrow catheter clamp with a fastener (4-5 Fr depending on the size of infusion catheter)

• Connect saline-primed tubing to the infusion catheter and start the pump:

  • • Once tPA is up from pharmacy, replace the fluid bag with the tPA

    • tPA requires an independent double-check and dual sign-off on the MAR in EPIC

• Verify the Heparin dose & location of the Heparin drip (through the Sheath versus PIV): Connect the Heparin-primed tubing to the Sheath Side-Port or PIV and start the infusion pump at the ordered rate:


  • • Heparin requires an independent double-check and dual sign-off on the MAR in EPIC

• Connect the pressure bag to the sheath side port

• Secure line with gauze and several large Tegaderms

• Call report to Intermediate/ICU floor:

  • • If the bed is not available, the patient can recover in the PRU until the bed is ready

• Remind the patient to keep the extremity still and straight. Do Not elevate HOB above 15 degrees

• Transport patient to unit:

  • • If you need assistance, you can request transport to assist to the unit, but the RN MUST be present throughout the transport

    • Document hand-off vital signs, sheath site, and pulses

Documentation in EPIC:

• Time of initiation of Heparin and tPA drips on the MAR

  • • Requires dual sign-off and independent double check

• Concentration and Drip Rate should populate on the MAR from the MD order

• All pumps and IV lytic tubing are clearly labeled:

  • • With high alert stickers

    • With date and time stickers

• Time report is given, and the name of the nurse receiving a report

Sarah DeRycke, RN

Michael Yellin, RM