What are the implications of bleeding from a chest tube after administration of tissue plasminogen activator (tPA)?

From the Guidelines

If bleeding occurs from a chest tube after administering tissue plasminogen activator (tPA), immediate action is necessary to prevent significant morbidity and mortality, and the first step is to stop the tPA infusion immediately. The management of bleeding after tPA administration is crucial, and according to the most recent guidelines 1, it is essential to monitor vital signs closely, including blood pressure and heart rate, and assess the amount and rate of bleeding.

The following steps should be taken:

• Monitor vital signs closely, including blood pressure and heart rate
• Assess the amount and rate of bleeding
• Obtain urgent complete blood count, coagulation studies, and type and cross-match
• Administer intravenous fluids if there are signs of hypovolemia
• Consider transfusion of blood products if bleeding is significant
• Consult with the treating physician or thoracic surgeon for further management

To reverse the effects of tPA, consider:

• Administering cryoprecipitate (10 units) or fresh frozen plasma (2-4 units)
• Giving tranexamic acid 1g IV over 10 minutes, followed by 1g IV over 8 hours, as suggested by a recent case report 1

Bleeding after tPA administration is a known complication due to its fibrinolytic effects, and prompt recognition and management are crucial to prevent significant blood loss and associated complications, as highlighted in the guidelines for the early management of patients with acute ischemic stroke 1. The use of tPA increases the risk of serious hemorrhagic transformation, and it is essential to identify patients at higher risk of bleeding complications, such as those with an NIHSS score >20 or age >80 years, as noted in the comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient 1.

From the FDA Drug Label

The most frequent adverse reaction associated with all thrombolytics in all approved indications is bleeding Caution should be exercised with patients who have active internal bleeding or who have had any of the following within 48 hours: surgery, obstetrical delivery, percutaneous biopsy of viscera or deep tissues, or puncture of non‑compressible vessels Should serious bleeding in a critical location (e.g., intracranial, gastrointestinal, retroperitoneal, pericardial) occur, treatment with Cathflo Activase should be stopped and the drug should be withdrawn from the catheter

The implications of bleeding from a chest tube after administration of tissue plasminogen activator (tPA) are serious and may be life-threatening.

• Bleeding is the most frequent adverse reaction associated with tPA.
• Caution should be exercised in patients with active internal bleeding or recent invasive procedures.
• If serious bleeding occurs, treatment with tPA should be stopped immediately and the drug withdrawn from the catheter 2, 2.

From the Research

Implications of Bleeding from a Chest Tube after Administration of tPA

• The administration of tissue plasminogen activator (tPA) can lead to bleeding complications, including intracranial bleeding, gastrointestinal bleeding, and pulmonary hemorrhage 3.
• Intrapleural hemorrhage has been reported as a potential outcome after the administration of tPA and deoxyribonuclease therapy for complicated parapneumonic effusion 4.
• The risk of bleeding complications with tPA administration is a concern, and the use of tranexamic acid (TXA) has been explored as a potential treatment for tPA-induced pulmonary hemorrhage 3.
• The effectiveness of intrapleural tPA in improving drainage of loculated effusions has been demonstrated, but the risk of pleural hemorrhage is increased in patients receiving therapeutic anticoagulation 5.

Risk Factors for Bleeding Complications

• Therapeutic anticoagulation has been shown to increase the risk of pleural hemorrhage in patients receiving intrapleural tPA 5.
• The use of tPA in patients with severe frostbite injury has been associated with a low risk of severe bleeding complications 6.
• The risk of bleeding complications with tPA administration may be influenced by the dose and duration of treatment, as well as the presence of underlying coagulopathies or other risk factors 7.

Management of Bleeding Complications

• Tranexamic acid (TXA) has been used to treat tPA-induced pulmonary hemorrhage, with reported success in cessation of bleeding 3.
• The management of bleeding complications after tPA administration requires careful monitoring and prompt intervention to minimize the risk of adverse outcomes 4, 5.
• The use of low-dose tPA has been explored as a potential strategy to reduce the risk of bleeding complications while maintaining efficacy in the treatment of intermediate-high risk pulmonary embolism 7.