Pharmacologic class: Tissue plasminogen activator
Therapeutic class: Thrombolytic enzyme
Pregnancy risk category C
Binds to fibrin and converts plasminogen to plasmin, which breaks down fibrin clots and lyses thrombi and emboli. Causes systemic fibrinolysis.
Powder for injection: 50 mg/vial with 10-ml syringe and TwinPak Dual Cannula Device and 10-ml vial of sterile water for injection
⊘Indications and dosages
➣ To reduce mortality associated with acute myocardial infarction
Adults weighing 90 kg (198 lb) or more: 50 mg I.V. bolus given over 5 seconds
Adults weighing 80 kg to 89 kg (176 to 197 lb): 45 mg I.V. bolus given over 5 seconds
Adults weighing 70 kg to 79 kg (154 to 175 lb): 40 mg I.V. bolus given over 5 seconds
Adults weighing 60 to 69 kg (132 to 153 lb): 35 mg I.V. bolus given over 5 seconds
Adults weighing less than 60 kg (132 lb): 30 mg I.V. bolus given over 5 seconds
• Hypersensitivity to drug or other tissue plasminogen activators
• Active internal bleeding
• Bleeding diathesis
• Recent intracranial or intraspinal surgery or trauma
• Severe uncontrolled hypertension
• Intracranial neoplasm
• Arteriovenous malformation or aneurysm
• History of cerebrovascular accident (CVA)
Use cautiously in:
• previous puncture of noncompressible vessels, organ biopsy, hypertension, acute pericarditis, high risk of left ventricular thrombosis, subacute bacterial endocarditis, hemostatic defects, diabetic hemorrhagic retinopathy, septic thrombophlebitis, obstetric delivery
• patients taking warfarin concurrently
• patients older than age 75
• pregnant or breastfeeding patients.
• Reconstitute by mixing contents of prefilled syringe with 10 ml of sterile water for injection. Swirl gently; don't shake. Draw up prescribed dosage from vial, then discard remainder. Give I.V. over 5 seconds through designated line.
Don't deliver in same I.V. line with dextrose solutions. Flush I.V. line with normal saline solution before giving drug if patient has been receiving dextrose.
Give with heparin if ordered, but not through same I.V. line.
CNS: intracranial hemorrhage, CVA
CV: hypotension, arrhythmia, myocardial rupture, myocardial reinfarction, cardiogenic shock, atrioventricular block, cardiac arrest, cardiac tamponade, heart failure, pericarditis, pericardial effusion, mitral regurgitation, thrombosis, embolism, hemorrhage
EENT: epistaxis, minor pharyngeal bleeding
GI: nausea, vomiting, hemorrhage
Hematologic: anemia, bleeding tendency
Respiratory: respiratory depression, pulmonary edema, apnea
Skin: bleeding at puncture sites, hematoma
Drug-drug. Anticoagulants, aspirin, dipyridamole, indomethacin, phenylbutazone: increased bleeding risk
Drug-diagnostic tests. Coagulation tests: fibrinogen degradation in blood sample
Monitor ECG. Stay alert for reperfusion arrhythmias.
Monitor vital signs carefully. Watch for signs and symptoms of respiratory depression and reinfarction.
Evaluate all body systems closely for signs and symptoms of bleeding. If bleeding occurs, stop drug and give antiplatelet agents, as ordered.
• Monitor CBC and coagulation studies. However, know that drug may skew coagulation results.
Inform patient that drug increases risk of bleeding. Advise him to immediately report signs and symptoms of bleeding.
• Teach patient safety measures to avoid bruising and bleeding.
• Tell patient he'll undergo regular blood tests during therapy.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs and tests mentioned above.
Pharmacologic: plasminogen activators
Time/action profile (fibrinolysis)
Adverse Reactions/Side EffectsAdverse reactions are frequently sequelae of underlying disease
- arrthythmias (life-threatening)
- cardiogenic shock (life-threatening)
- cardiac tamponade
- embolism (life-threatening)
- heart failure (life-threatening)
- myocardial infarction (life-threatening)
- myocardial rupture (life-threatening)
- pericarditis (life-threatening)
- pericardial effusion (life-threatening)
- pulmonary edema (life-threatening)
- recurrent myocardial ischemia (life-threatening)
- thrombosis (life-threatening)
- bleeding (life-threatening)
- allergic reactions including anaphylaxis
Drug-Drug interactionAspirin, NSAIDs, warfarin, heparin and heparin-like agents, abciximab, eptifibatide, tirofiban, clopidogrel, ticlopidine, or dipyridamole —concurrent use may increase the risk of bleeding, although these agents are frequently used together or in sequence.Risk of bleeding may be increased by concurrent use of cefotetan, cefoperazone, or valproic acid.
- Begin therapy as soon as possible after the onset of symptoms.
- Assess patients for bleeding every 15 min during the 1st hr, every 15–30 min during the next 8 hr and at least every 4 hr for the duration of therapy. Frank bleeding may occur from invasive sites or body orifices. Internal bleeding may also occur (decreased neurologic status, abdominal pain with coffee-ground emesis or black tarry stools, joint pain). If uncontrolled bleeding occurs, stop tenecteplase immediately.
- Monitor vital signs, including temperature, every 4 hr during course of therapy. Do not use lower extremities to measure BP. Notify health care professional if systolic BP >180 mmHg or diastolic BP >110 mmHg. Tenecteplase should not be given if hypertension is uncontrolled. Inform health care professional if hypotension occurs. Hypotension may result from the drug, hemorrhage, or cardiogenic shock.
- Assess neurologic status throughout therapy. Altered sensorium or mental changes may be indicative of intracranial bleeding.
- Coronary Thrombosis:: Monitor ECG continuously in patients with coronary thrombosis for significant arrhythmias. Antiarrhythmics may be ordered prior to or during alteplase therapy to prevent reperfusion arrhythmias. Cardiac enzymes should be monitored. Coronary angiography or radionuclide myocardial scanning may be used to assess effectiveness of therapy.
- Assess intensity, character, location, and radiation of chest pain. Note presence of associated symptoms (nausea, vomiting, diaphoresis). Administer analgesics as ordered by physician. Notify health care professional if chest pain is unrelieved or recurs.
- Monitor heart and breath sounds frequently. Inform health care professional of signs of HF (rales/crackles, dyspnea, S3 heart sound, jugular venous distention, elevated CVP).
- Lab Test Considerations: Monitor hematocrit, hemoglobin, platelet count, prothrombin time, thrombin time, activated partial thromboplastin time, and fibrinolytic activity prior to and frequently throughout therapy. Bleeding time may be assessed prior to therapy if patient has received platelet aggregation inhibitors.
- Obtain type and crossmatch of blood and have blood available at all times in case of hemorrhage.
If local bleeding occurs, apply pressure to site. If severe internal bleeding occurs, discontinue infusion. Clotting factors and/or blood volume may be restored through infusions of whole blood, packed RBCs, fresh frozen plasma, or cryoprecipitate. Do not administer dextran, as it has antiplatelet activity. Aminocaproic acid (Amicar) may be used as an antidote.
- Stools should be tested for occult blood loss and urine tested for hematuria periodically during therapy.
Potential Nursing DiagnosesAcute pain
Ineffective tissue perfusion (Indications)
Risk for injury, high risk for (Adverse Reactions)
- high alert: Overdosage and under-dosage of thrombolytic medications have resulted in patient harm and/or death. Have second practitioner independently check original order, dosage calculations, and infusion pump settings. Do not confuse the abbreviation t-PA for alteplase (Activase) with the abbreviation TNK t-PA for tenecteplase (TNKase). Clarify orders that contain either of these abbreviations.
- Tenecteplase should be used only in settings where hematologic function and clinical response can be adequately monitored. Avoid IM injections and unnecessary venipunctures. Apply pressure to all arterial and venous punctures for at least 30 min. Avoid venipunctures at noncompressible sites (e.g., jugular and subclavian sites).
- Avoid invasive procedures, such as IM injections or arterial punctures, with this therapy. If such procedures must be performed, apply pressure to all arterial and venous puncture sites for at least 30 min. Avoid venipunctures at noncompressible sites (jugular vein, subclavian site).
- Systemic anticoagulation with heparin is usually begun several hours after the completion of thrombolytic therapy.
- Acetaminophen may be ordered to control fever.
- pH: 7.3.
- Intravenous: Prior to therapy start two IV lines: one for tenecteplase, the other for any additional IV infusions.
- Intermittent Infusion: Diluent: Vials are packaged with sterile water for injection (without preservatives) to be used as diluent. Do not use bacteriostatic water for injection. Do not discard shield assembly. To reconstitute aseptically withdraw 10 mL of diluent and inject into the tenectplase vial, directing the stream into the powder. Slight foaming may occur; large bubbles will dissipate if left standing undisturbed for several minutes. Swirl gently until contents are completely dissolved; do not shake. Solution containing 5 mg/mL is clear and colorless to pale yellow. Withdraw dose from reconstituted vial with the syringe and discard unused portion. Once dose is in syringe, stand the shield vertically on a flat surface (with green side down) and passively recap the red hub cannula. Remove the entire shield assembly, including the red hub cannula, by twisting counter clockwise. Shield assembly also contains the clear-ended blunt plastic cannula; retain for split septum IV access. Reconstitute immediately before use. May be refrigerated and administered within 8 hrs.
- Rate: Administer as a single IV bolus over 5 seconds.
- Y-Site Incompatibility: Precipitate forms in line when administered with dextrose-containing solutions. Flush line with saline-containing solution prior to and following administration of tenecteplase.
- Additive Incompatibility: Do not admix.
- Explain to patient and family the purpose of tenecteplase and the need for close monitoring.
- Advise patient to remain on bed rest and to avoid unnecessary procedures such as shaving and vigorous toothbrushing for 24 hr.
- Instruct patient to report signs of hypersensitivity and bleeding promptly.
- Restoration of coronary perfusion resulting in limitation of infarct size and decrease in complications, such as mortality.