What medication and dose should be ordered for a patient with ischemic stroke undergoing thrombolysis, specifically tissue plasminogen activator (tPA)?

Thrombolysis Orders for Acute Ischemic Stroke

Order intravenous alteplase (tPA) at 0.9 mg/kg (maximum 90 mg total dose), with 10% given as an IV bolus over 1 minute, followed by the remaining 90% infused over 60 minutes. 1

Pre-Administration Requirements

Before initiating tPA, you must ensure the following:

• Blood pressure control: Reduce blood pressure to <185/110 mm Hg before starting tPA, using labetalol or nicardipine as needed 1
• If blood pressure cannot be controlled below these thresholds, tPA is absolutely contraindicated 1
• Imaging: Obtain non-contrast head CT to exclude intracranial hemorrhage 2
• Time verification: Document exact time of symptom onset to confirm eligibility 3

Dosing Calculation and Administration

Calculate the dose as follows:

• Total dose = patient weight in kg × 0.9 mg/kg 1
• Maximum weight for calculation: 100 kg (even if patient weighs more) 1
• Maximum total dose: 90 mg regardless of actual weight 1
• Bolus dose: 10% of total calculated dose given IV over 1 minute 1
• Infusion dose: Remaining 90% infused over 60 minutes 1

Time Window Considerations

Your treatment decision depends critically on time from symptom onset:

• 0-3 hours: Strong recommendation to administer tPA (Grade 1A) 2
• 3-4.5 hours: Conditional recommendation to administer tPA (Grade 2C) 2
• Beyond 4.5 hours: Strong recommendation AGAINST tPA (Grade 1B) 2, 3

Post-Administration Monitoring Protocol

Blood pressure monitoring is critical and must follow this schedule:

• Every 15 minutes during the infusion 1
• Every 15 minutes for 2 hours after infusion 1
• Every 30 minutes for the next 6 hours 1
• Hourly for the following 16 hours 1
• Target blood pressure: Maintain <180/105 mm Hg throughout this period 1

Critical Medication Restrictions

Do NOT administer the following for 24 hours after tPA:

• Any anticoagulants 1
• Any antiplatelet agents (including aspirin) 1

After 24 hours, initiate aspirin 160-325 mg once daily 2

Additional Orders for Stroke Management

Beyond tPA administration, order:

• DVT prophylaxis: Prophylactic-dose subcutaneous heparin (UFH or LMWH) or intermittent pneumatic compression devices for patients with restricted mobility 2
• Avoid elastic compression stockings (Grade 2B recommendation against) 2

Expected Complications and Monitoring

Be prepared for symptomatic intracranial hemorrhage, which occurs in 6.4% of tPA-treated patients versus 0.6% of placebo patients 1. Monitor neurological status closely during and after infusion.

Special Population Considerations

Do NOT give tPA to patients on direct oral anticoagulants (DOACs) like apixaban due to substantially elevated bleeding risk 1

For patients on antiplatelet therapy prior to stroke, use the same 0.9 mg/kg dose, though there is a 3% absolute increased risk of symptomatic intracranial hemorrhage compared to those not on antiplatelet therapy 1

Common Pitfalls to Avoid

• Do not use lower doses: Standard 0.9 mg/kg dosing produces better functional outcomes than lower doses (0.5-0.7 mg/kg) without increasing hemorrhage risk 4
• Do not exceed the maximum 90 mg total dose even in patients weighing >100 kg 1
• Do not delay for "perfect" blood pressure control if BP is <185/110 mm Hg—time is brain 1
• Do not give aspirin or other antiplatelets within 24 hours of tPA 1