What is the management for bleeding after Actilyse (Alteplase) fibrinolysis of a permanent catheter?

Management of Bleeding After Actilyse (Alteplase) Fibrinolysis of a Permanent Catheter

For bleeding after Actilyse (Alteplase) fibrinolysis of a permanent catheter, immediately stop the alteplase infusion, apply direct pressure to accessible bleeding sites, assess the severity of bleeding, and manage according to bleeding severity with appropriate blood products if needed. 1

Assessment and Initial Management

• Immediately discontinue the alteplase infusion when bleeding is detected 1
• Apply direct manual pressure to any accessible bleeding sites for at least 15-30 minutes 2
• Assess vital signs and hemodynamic stability to determine the severity of bleeding 2
• Obtain complete blood count (CBC), prothrombin time (PT), activated partial thromboplastin time (aPTT), and fibrinogen levels to guide management 1
• Type and cross-match blood if significant bleeding is present 1

Management Based on Bleeding Severity

For Minor Bleeding (e.g., oozing at catheter site):

• Apply direct pressure to the site 2
• Consider discontinuing any concurrent anticoagulants or antiplatelet agents 2
• Monitor for progression to more severe bleeding 1

For Major Bleeding (severe blood loss >5 mL/kg, requiring transfusion, or causing hypotension):

• Maintain airway, breathing, and circulation 1
• Administer volume replacement with crystalloids or colloids as needed 2
• Consider the following blood products based on laboratory results:
  • Cryoprecipitate: 10 units infused over 10-30 minutes (especially if fibrinogen <200 mg/dL) 1
  • Fresh frozen plasma: for correction of coagulation factors 2
  • Platelet transfusion: if platelet count is low or if patient is on antiplatelet therapy 2

Pharmacological Management

• Consider protamine sulfate if heparin was administered within 4 hours of bleeding onset 2
• For severe, uncontrolled bleeding, consider antifibrinolytic agents:
  • Tranexamic acid: 1000 mg IV infused over 10 minutes, or
  • ε-aminocaproic acid: 4-5 g over 1 hour, followed by 1 g IV until bleeding is controlled 3

Monitoring and Follow-up

• Perform frequent vital sign checks and hemodynamic monitoring until stabilized 1
• Repeat coagulation studies after blood product administration to guide further management 2
• Consider imaging studies if internal bleeding is suspected 2
• Reassess the need for the catheter - determine if it should be removed or replaced once bleeding is controlled 4

Special Considerations

• The risk of bleeding is higher with concurrent use of anticoagulants or antiplatelet agents 2
• Patients with pre-existing thrombocytopenia are at increased risk of bleeding complications 1
• Very early catheterization (within 2-3 hours) after fibrinolytic therapy carries an increased bleeding risk and should be avoided unless necessary for failed fibrinolysis 3
• Bleeding risk is higher in elderly patients and those with renal impairment 3

Prevention Strategies for Future Procedures

• Use the minimum effective dose of alteplase for catheter clearance 1
• Consider radial artery access rather than femoral access for subsequent procedures to reduce bleeding risk 3
• Avoid unnecessary invasive procedures during and immediately after fibrinolytic therapy 2
• Consider patient-specific risk factors for bleeding before administering fibrinolytics 3