From the Guidelines
Managing Bleeding after tPA Administration
The protocol for managing bleeding after tissue plasminogen activator (tPA) administration involves close monitoring of the patient, immediate discontinuation of the infusion if severe symptoms occur, and emergency CT scan to assess for intracranial hemorrhage 1.
- The patient should be admitted to an intensive care or stroke unit for monitoring, with neurological assessments every 15 minutes during the infusion and every 30 minutes thereafter for the next 6 hours, then hourly until 24 hours after treatment.
- Blood pressure should be measured every 15 minutes for the first 2 hours and subsequently every 30 minutes for the next 6 hours, then hourly until 24 hours after treatment, with antihypertensive medications administered to maintain blood pressure at or below systolic 180 mm Hg or diastolic 105 mm Hg.
- A follow-up CT scan should be obtained at 24 hours before starting anticoagulants or antiplatelet agents.
- The risk of symptomatic intracranial hemorrhage is a significant concern, with a reported risk of 6% in the original NINDS trials, although recent community-based studies and registries report lower rates of hemorrhage 1.
- Careful selection of patients and scrupulous ancillary care are crucial in preventing bleeding complications, with factors affecting decisions about administration of tPA outlined in guidelines 1.
- The use of anticoagulants and antiplatelet agents should be delayed for 24 hours after treatment with tPA 1.
From the Research
Protocol for Managing Bleeding after tPA Administration
The management of bleeding after tissue plasminogen activator (tPA) administration is crucial to prevent further complications. The following points outline the protocol for managing bleeding after tPA administration:
- Monitoring for adverse events: Close monitoring during the first 12 hours after IV tPA treatment is essential, as 92.9% of adverse events occur within this time frame 2.
- Use of tranexamic acid (TXA): TXA may be a viable option in the setting of tPA-induced pulmonary hemorrhage, as it has been shown to cease bleeding in a patient with post-tPA pulmonary hemorrhage 3.
- Reversal of thrombolytic therapy: TXA has been used to reverse thrombolytic therapy with tPA in a patient with symptomatic intracranial hemorrhage (ICH) who was unwilling to receive blood products 4.
- Low-dose tPA policy: A policy of low-dose tPA (0.5-4 mg) for intraoperative pulmonary thromboembolism during liver transplantation has been shown to improve patient outcomes 5.
- Safety of antiplatelet agents and heparin: The use of antiplatelet agents and heparin for stroke interventions following IV tPA appears to be safe without significant increased risk of hemorrhagic complications 6.
Bleeding Complications
Bleeding complications after tPA administration can be life-threatening, and it is essential to be aware of the potential risks:
- Intracranial bleeding: Approximately 5% of patients may have significant intracranial bleeding, increasing mortality to 45% 3.
- Gastrointestinal bleeding: Use of tPA can also cause gastrointestinal bleeding, which can be life-threatening 3.
- Pulmonary hemorrhage: Post-tPA pulmonary hemorrhage is a rare but potentially life-threatening complication 3.