Management of Tenecteplase Extravasation
Stop the infusion immediately, elevate the affected limb, and apply cold compresses to the extravasation site. Unlike chemotherapeutic vesicants, tenecteplase extravasation does not require specific antidotes and is managed conservatively with supportive measures.
Immediate Actions
- Discontinue the infusion immediately upon recognition of extravasation 1
- Leave the IV catheter in place initially to allow aspiration of any residual drug if possible (general extravasation management principle) 2
- Elevate the affected extremity to reduce local edema and promote venous drainage 1
- Apply cold compresses to the site for 15-20 minutes every 4-6 hours for the first 24-48 hours to reduce local inflammation and limit drug spread 3, 2
Key Clinical Distinction
Tenecteplase is NOT a vesicant or cytotoxic agent like chemotherapy drugs, so it does not cause the severe tissue necrosis seen with anthracyclines or nitrogen mustards 3. The primary concerns with tenecteplase extravasation are:
- Local bleeding and hematoma formation due to its anticoagulant effects 4, 5
- Mild local tissue irritation 6
- Potential for bruising at the site 7
No Specific Antidotes Required
Unlike chemotherapeutic extravasations that may require specific antidotes (hyaluronidase for vinca alkaloids, sodium thiosulfate for nitrogen mustard, dimethylsulfoxide for anthracyclines), tenecteplase extravasation does not have or require a specific reversal agent 3, 2. The fibrin-specific nature of tenecteplase limits systemic effects from small extravasated volumes 5, 6.
Monitoring and Documentation
- Assess the extravasation site for extent of swelling, discoloration, and any signs of hematoma formation 2
- Monitor neurovascular status of the affected limb (pulses, sensation, motor function) 2
- Document the estimated volume extravasated, time of recognition, and interventions performed 2
- Photograph the site if significant tissue changes are present for medicolegal documentation 2
Subsequent Dosing Considerations
Do NOT re-administer tenecteplase through the same IV line or in the same extremity 4. If the patient still requires thrombolytic therapy:
- Establish a new IV access in a different extremity with careful attention to proper technique 6
- Consider the weight-based single bolus dosing (30-50 mg based on patient weight) which minimizes the risk of administration errors 4
- Tenecteplase can be safely re-administered as it does not cause antibody formation, unlike streptokinase 4, 7
Prevention Strategies
The single-bolus administration of tenecteplase (given over 5 seconds) significantly reduces extravasation risk compared to prolonged infusions of alteplase 4, 6, 7. Key preventive measures include:
- Use of large-bore peripheral IV (18-20 gauge) or central venous access for administration 6
- Confirm IV patency with saline flush before and after tenecteplase bolus 2
- Avoid sites with compromised venous integrity (recent venipuncture, sclerosed veins, areas of edema) 2
When to Escalate Care
Surgical consultation is NOT typically required for tenecteplase extravasation, as tissue necrosis does not occur 3, 2. However, consider vascular surgery evaluation if:
- Large hematoma develops causing compartment syndrome symptoms (severe pain, paresthesias, pallor, pulselessness) 2
- Neurovascular compromise is present in the affected extremity 2
Critical Pitfall to Avoid
Do not confuse tenecteplase extravasation management with hypotension management during administration. Hypotension is NOT typically associated with tenecteplase (unlike streptokinase), and if it occurs, represents a separate complication requiring assessment for cardiogenic shock, bleeding, or allergic reaction—not extravasation 1, 4.