Thrombolytic Therapy (Lytics)—What is it????

·        The introduction of a catheter over a wire through a sheath into a targeted clot

·        For pulmonary embolism (PE), the access is through the R IJ or R femoral vein

·        A thrombolytic agent is then infused through the catheter at a designated rate to dissolve clot

·        IR will rotate weeks with Cardiology to intervene on patients with acute PE that meet criteria for IR intervention

·        IR MD will carry the virtual pager and will receive a page as will the CT surgery fellow, MICU attending, MICU fellow and Cardiology ICU fellow

Pre-procedure:

·        Bed placement:

o   Patient should either already in the CICU or MICU, or a transfer order must be in place to increase level of care. Confirm with your Charge Nurse that this process is in motion before the patient arrives for procedure! Seek help from House Supervisor when bed needs arise

·        CICU fellow is point person for the PE Response Team

·        Patient will be monitored by CICU or ICU transport

·        Consent/assessment/H & P with ASA and Airway assessment within one full day.

·        Review past medical history, allergies, NPO status

o   Allergy to contrast or heparin will need to be addressed/discussed with MD

o   Pt must meet NPO requirements for moderate sedation

Intra-Procedure:

·        Have heparin vial available (1000 units/mL) via PIV. The RN gives this medication if needed by MD.

·        If catheter directed lytics is done, there may be ONE or TWO infusion catheters through ONE venous sheath with ONE side port

o   Connect a standard pressure bag to the side port (line with clear tubing)

o   Number of infusion catheters depends on if PEs are uni- or bilateral

·        You may also be asked to draw up tPA. This is located in the PRU Pyxis refrigerator. It is to be given by the MD intra-procedure (typically 2 mg per infusion catheter). The RN will NOT be giving the tPA via PIV.

·        Patient should already be on heparin gtt, discuss this with physician to determine if drip will be stopped or continued at prescribed rate during procedure.

Infusion order:

·        Physician must enter the orders for the tPA infusion in EPIC. Communicate with the physician to ensure these orders are being placed PRIOR TO THE START OF THE CASE. Release signed and held orders so that the pharmacy can see the orders ASAP!!!!

·        Remind the MD to enter the order set for EKOS thrombolysis medicines:

·        Each infusion catheter will run tPA at 0.75 mg/hour in the following concentration:

o   10 mg in 250 mL bagàthe typical EKOS concentration even without use of the EKOS machine!!!!!!

·        Pharmacy will need to be called as soon as the tPA order is placed. tPA cannot be sent through the tube station and must be picked up from pharmacy. Page the pharmacist on call as well to expedite verification of the medication:

o   Open the hospital directory

o   Under On Call Schedule Search

§  Type “Pharmacist Day”

§  Click on “On Call Now”

§  Find the appropriate pharmacist depending on the patient’s service

o   After paging pharmacist, send message to pharmacy in the MAR to call 4-0440 when tPA is ready to be picked up

o   Communicate with your charge nurse to ensure communication with pharmacy on this medication and arrangement of pick-up

·        Frequent and clear communication with pharmacy can help expedite receipt of tPA

·        Heparin gtt will be managed in the ICU. We will not change the dose to the non-nomogram dose as we are used to doing for other thrombolytic cases. Do not adjust the dose unless you receive a MD order to do so and leave it running through a PIV

·        Have a transducer cable ready and available in the procedure room to measure PA pressures intra-procedure. Be familiar with how to zero on the monitor

Hooking up the Pump

·        Use the Baxter tubing (1C8109s no Y ports) with Hospira 30 inch extension set (12656-28) for tPA and heparin.

·        Label pumps and tubing with High Alert Medication labels (bright orange).

·     This is a small catheter going into an extremely tight space, so you may get a “distal occlusion” alarm. Must then increase the pump delivery pressure.

·        Hit “options” button (1).

·        Choose “Alarm settings” and click “OK” (2).

·        Click “OK” to scroll to “DS Pressure Limit” and use arrows to change limit to “HIGH” (3).

·        If pump still alarms “distal occlusion, check stopcocks and inform physician.

·        Do not force the sheath stop cock to the down position. These can break easily (leave it as is).

·        Add a conventional three way stopcock to the sheath side port (clear tubing) and turn it so the off is down.

·        Use white cap to cap off any ports not being used

·        Ensure you are dripping all infusions into the ports to ensure NO AIR enters the line.

·        Do not place a stop cock on the medication infusion line(s).

·        Mark the infusion catheter (with a marker) where it meets the sheath to monitor for dislodgement

Post-procedure:

·        Until tPA arrives from pharmacy, infuse normal saline at the treatment rate through the infusion catheter to prevent catheter from occluding.

·        tPA infusion must be running prior to sending patient to unit

·        VIR nurse must initiate the infusion prior to transfer. tPA and Heparin must be dual signed off on the MAR and an independent double check must be performed.

·        Patient must be going to an intermediate care or critical care bed.

·        All lytics patients must be transported by an RN and transfer handoff, vital signs, pulses, sheath site check documented.

·        Educate patient to call for help if feel warm or wet under affected area as this could indicate a bleed.  Ensure call bell is within reach.

·        The patient will not return to IR the following day for lytics f/u

·        After tPA runs for 13 hours, the PA pressure is measured on the floor and the sheath is removed

Lastly, treat these patients with the urgency that you would any emergent embo. These cases have the potential to go bad, so just be prepared for any outcome!