Monitoring Protocol After Tenecteplase (TNK) for Acute Ischemic Stroke
After tenecteplase administration for acute ischemic stroke, patients require intensive monitoring with neurological assessments and vital signs every 15 minutes for the first 2 hours, then every 30 minutes for 6 hours, and then hourly for 16 hours (total 24 hours of monitoring).
Immediate Post-TNK Monitoring Requirements
Vital Signs and Neurological Assessment
- First 2 hours: Every 15 minutes
- Next 6 hours: Every 30 minutes
- Following 16 hours: Every hour
- Total monitoring period: 24 hours
Blood Pressure Management
- Target: Maintain BP <180/105 mmHg for at least 24 hours after TNK administration
- Monitoring frequency: Same as vital sign schedule above
- Call physician if:
- Systolic BP >180 mmHg or <110 mmHg
- Diastolic BP >105 mmHg or <60 mmHg
- Pulse <50 or >110 beats/min
- Respirations >24/min
- Temperature >99.6°F
- Worsening of stroke symptoms or other neurological decline
Hypertension Management Options
If BP exceeds target:
- Labetalol: 10 mg IV followed by continuous IV infusion 2-8 mg/min; or
- Nicardipine: 5 mg/h IV, titrate up by 2.5 mg/h every 5-15 minutes, maximum 15 mg/h; or
- Clevidipine: 1-2 mg/h IV, titrate by doubling the dose every 2-5 min until desired BP reached; maximum 21 mg/h
- For severe hypertension unresponsive to above measures, consider IV sodium nitroprusside 1
Hemorrhagic Complication Monitoring
Signs of Intracranial Hemorrhage
- Change in level of consciousness
- New or worsening headache
- Nausea or vomiting
- Acute hypertension
- Deterioration in motor examination
Response to Suspected Hemorrhage
- Discontinue TNK infusion immediately if still running
- Notify physician immediately
- Obtain emergency CT scan
- Laboratory work:
- PT/INR
- aPTT
- Fibrinogen level
- CBC with platelets
- Type and cross-match
- Prepare to administer:
- 6-8 units of cryoprecipitate containing factor VIII
- 6-8 units of platelets 1
Additional Monitoring Parameters
Temperature
- Monitor every 4 hours or as required
- Treat temperatures >99.6°F with acetaminophen as ordered 1
Cardiac Monitoring
- Continuous cardiac monitoring for up to 72 hours 1
Fluid Balance
- Measure intake and output
- IV fluids: Normal saline at 75-100 mL/h 1
Activity Restrictions
- Bed rest initially
- Delay placement of nasogastric tubes, indwelling bladder catheters, or intra-arterial pressure catheters 1
Medication Restrictions
- No heparin, warfarin, aspirin, clopidogrel, or dipyridamole for 24 hours after TNK administration 1
Follow-up Imaging
- Obtain follow-up CT scan at 24 hours before starting anticoagulants or antiplatelet agents 1
Nurse-to-Patient Ratio
- 1:2 for the first 24 hours
- 1:4 after 24 hours if patient's condition is stable 1
Clinical Pearls and Pitfalls
Common Pitfalls
- Inadequate blood pressure control: Failure to maintain BP <180/105 mmHg increases risk of hemorrhagic transformation
- Delayed recognition of hemorrhagic transformation: Symptomatic ICH occurs in approximately 3.2% of patients receiving tenecteplase 2
- Premature administration of antithrombotics: Anticoagulants and antiplatelet agents should be delayed for 24 hours after TNK
Advantages of Tenecteplase over Alteplase
- Higher fibrin specificity
- Longer half-life
- Single-bolus administration (versus continuous infusion)
- Better safety profile with comparable efficacy
- Lower rates of symptomatic intracranial hemorrhage 3, 4
Special Considerations
- Tenecteplase is administered as a single IV bolus (0.25 mg/kg, maximum 25 mg) 3
- Recent evidence shows tenecteplase is associated with higher rates of spontaneous recanalization (10.4% vs. 1.4%) and lower rates of symptomatic intracranial hemorrhage (0.65% vs. 5%) compared to alteplase 4
- The monitoring protocol remains the same regardless of whether the patient received tenecteplase or alteplase 1
By following this comprehensive monitoring protocol, healthcare providers can optimize patient outcomes and minimize complications after tenecteplase administration for acute ischemic stroke.