Reteplase

Reteplase (r-PA)

Class:
  • Fibrinolytic agent
Actions:
  • Binds to fibrin (in clot) and activates plasminogen to convert into plasmin (which degrades fibrin in clots)
  • Works on recent blood clots
Indications:
  • ST segment elevation myocardial infarction (STEMI) with onset of symptoms ≤ 12 hours
Pharmacokinetics:
  • Onset: 30 minutes
  • Peak: 30 – 90 minutes
  • Half-Life: 13 – 16 minutes
  • Duration: 48 hours
Adverse Effects:
  • Hemorrhage (intracranial, GI, intraocular, epistaxis, melena stools, other)
  • Anemia (2ndary to hemorrhage)
  • Reperfusion dysrhythmias (PVC's, sinus bradycardia, sinus arrest, heart block, ventricular tachycardia, ventricular fibrillation)
Contraindications: Patient must be screened for possible contraindications to prevent critical complications like cerebral hemorrhage!

 

 

  • Previous history of intracranial hemorrhage
  • Known structural cerebral vascular lesion (e.g., AV malformation)
  • Known malignant intracranial neoplasm (primary or metastatic)
  • Ischemic stroke within 3 months
  • Suspected aortic dissection
  • Active bleeding or bleeding tendency (except menses)
  • Significant closed head trauma or facial trauma within 3 months
  • Systolic BP ≥ 180 mm Hg
  • Diastolic BP ≥ 110 mm Hg
  • Recent trauma, surgery (including laser eye surgery), or GI/GU bleeding within 6 weeks
  • CPR > 10 minutes
  • Pregnant female
Dosages & Routes:
  • Intravenous: 10 units slow IV push over 2 minutes;  30 minutes later: repeat 10 units slow IV push over 2 minutes
Nursing Implications:
  • Drug Interactions:  Risk for bleeding may be higher with aspirin, glycoprotein IIb IIIa inhibitors, heparin, or dipyridamole.
  • Drug Incompatibilities:  Heparin
  • Screen patient carefully for possible contraindications prior to fibrinolytic therapy.
  • Flush IV line with 30 ml of normal saline prior to and after administering each IV push.
  • Be certain to give IV bolus slowly over 2 minutes.
  • Reperfusion dysrhythmias rarely require treatment, but appropriate resuscitation medications and equipment should be at the bedside.
  • Evidence of reperfusion include 1) relief of chest pain, 2) reperfusion dysrhythmias, 3) return of ST segments to baseline in affected leads, and 4) peaking of serum CK-MB
  • Continuously monitor patient during therapy for signs of hemorrhage (IV sites, puncture sites on skin, membranes, nasal cavity, stool, changes in mental status).
  • Watch for neurological alterations (like change in mental status, level of consciousness, seizures, hemiparesis/hemiplegia, changes in pupils, etc.) which may indicate cerebral hemorrhage.
  • Avoid ANY invasive procedures that might provoke hemorrhage.
  • Do not give any injections, draw blood specimens (especially not arterial), or perform any other form of venipuncture during fibrinolytic therapy.
  • Do not use noninvasive blood pressure monitoring on patient during fibrinolytic therapy.

 

References:

American Heart Association. (2006). Handbook of Emergency Cardiac Care (p. 52). Salem, MA: AHA.

Deglin, J.H., & Vallerand, A.H. (2009). Thrombolytic agents.  In Davis' drug guide for nurses (11th ed., pp. 1164-1169).  Philadelphia: F.A. Davis.

Dirks, J.L. (2010) Cardiovascular therapeutic management.  In L.D. Urden, K.M. Stacy, & M.E. Lough's (Eds.) Critical care nursing: Diagnosis and management (6th ed., pp. 510-515).  St. Louis: Mosby Elsevier.

Lehne, R.A. (2010). Pharmacology for nursing care (7th ed., pp. 612-618).  St. Louis: Saunders Elsevier.

Wilson, B.A., Shannon, M.T., Shields, K.M., & Stang, C.L. (2007).  Reteplase. In  Prentice Hall Nurse's Drug Guide 2007 (pp. 1422-1423).  Upper Saddle River, NJ: Pearson Prentice Hall.

 

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