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Stroke Reperfusion Therapy: IV t-PA Administration

Comments in brackets denote activities specific to MGH, or additional commentary regarding national standards or guidelines. For example:

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tPA Mixing and Administration

APPLICABLE UNIT Emergency Department
ACTION Tissue plasminogen activator (tPA) for thrombolysis
INDICATION Treatment of acute ischemic stroke

Critical Elements

  • Usual Dosage Range and Route
    • 0.9 mg/kg to a maximum of 90 mg
      • First 10% of calculated dose GIVEN BY PHYSICIAN as intravenous bolus dose
      • Remaining 90% of calculated dose given in infusion over 1 hour
  • Verify that the Stroke Neurologist has reviewed the inclusion/exclusion criteria and discussed the plan with the patient and/or family if available
  • Verify that administration will start within three hours of symptom onset or time last known well
  • Document neurologic assessment findings at least hourly or more frequently if neurologic changes occur
  • If the patient's neurologic status declines during tPA infusion the following actions should be taken
    • Stop the infusion
    • Page the Stroke Neurologist
    • Draw and send PT/PTT, D-Dimer and fibrinogen
    • Prepare for emergent CT


  • 1 vial of t-PA (alteplase, or Activase 100 mg) or two vials of t-PA (alteplase, or Activase 50 mg each)
  • One 10 ml syringe
  • Two 20 -gauge needles
  • 10 mL Luer-lock syringe
  • 60 mL Luer-lock syringe
  • Two 10 mL Normal Saline Flushes
  • Standard pump tubing
  • MRI Tubing
  • Intravenous infusion pump
  • 100 mL bag of 0.9% NS
  • Alcohol wipes
  • Two red medication labels

Administration Protocol

It is appropriate to mix tPA prior to CT even if it is not used: See below procedure for returning tPA that is mixed but not administered.

  • Verify the bolus dose, infusion dose and discard dose with the Stroke Neurologist
  • Reconstitute the vial of t-PA with the supplied preservative-free water
    • Remove flip-caps from t-PA and sterile water vials
    • Swab both vial tops with alcohol prep pads
    • Insert transfer device into sterile water
    • Turn t-PA (lypophilized cake) vial upside down, position over the transfer device and push down
    • Invert the 2 vials allowing the sterile water to mix with the t-PA powder
    • Remove sterile water vial (with transfer device)
    • Gently swirl t-PA to dissolve powder (approximately 1 minute). DO NOT SHAKE.
    • Using 10 mL syringe, withdraw IV Bolus amount. (NOTE: Do not prime syringes with air.)
    • Apply label (“BOLUS DOSE”, t-PA, and dosage) to Bolus syringe. (MDs only administer bolus dose over 1 minute.)
    • Using 60 mL syringe, withdraw amount of drug to be wasted and discard
    • Attach vented spike adapter to t-PA vila using the same puncture site from the transfer device
    • Attach IV tubing to vented spike adapter (Note: some brands of IV tubing and the spike adapter are all one unit)
    • Attach IV tubing to MRI tubing if patient is going to have an MRI
    • Prime entire line
    • Place t-PA on infusion pump
    • Use BASIC MODE on pump to infuse over 1 hour
    • Infuse 100 mL Normal Saline after pump finishes (to administer all t-PA in tubing). (NOTE: Hang NS as soon as all the t-PA has entered into the drip chamber. Air cannot be withdrawn from the tubing as t-PA would be wasted.)
    • Final concentration is 1 mg/mL
  • Hand the bolus dose syringe to the Stroke Neurologist and verify again the bolus dose, infusion dose and rate and discard dose
  • Stroke Neurologist will administer bolus dose via intravenous push method over one minute
    • Stroke Neurologist will document administration of bolus dose on ED Medication Administration record including time, dose, route, initials and signature
  • Draw waste dose from bottle and verify waste amount by showing to the Stroke Neurologist and another nurse.
  • Fill out red medication label with all required information (patient name, medication, dosage, time, date, RN signature). Write "INFUSION DOSE" and affix label to Activase bottle
  • Connect alteplase bottle to IV pump tubing, carefully priming to avoid discarding any medication.
  • Verify patency of IV site and tubing connections
  • Attach noninvasive blood pressure cuff to other arm
  • Set infusion pump rate according to dosing sheet and start infusion with a total infusion time of 1 hour. Document infusion start time on medication record.
    • Infuse 100 mL Normal Saline after pump finishes (to administer all t-PA in tubing). (NOTE: Hang NS as soon as all the t-PA has entered into the drip chamber. Air cannot be withdrawn from the tubing as t-PA would be wasted.)
    • Document end time of infusion.

tPA Dosing Chart

Use the calculator for the optimal dose, and check the range by quickly estimating the dose from the table below

tPA Dose Calculator

Enter the Weight:

Estimated Weight (lbs) Conversion to Kilograms (Kg) Total iv t-PA Dose (mg) at 0.9 mg/kg t-PA Bolus (mg) *10% of total* t-PA Bolus (ml) Discard Dose t-PA (Not for infusion) Infusion Dose (mg) Infusion Rate (ml/hr)
220+ 100.0 90.0 9.0 9.0 10.0 81.0 81.0
210 95.5 85.9 8.6 8.6 14.1 77.3 77.3
200 90.9 81.8 8.2 8.2 18.2 73.6 73.6
190 86.4 77.7 7.8 7.8 22.3 70.0 70.0
180 81.8 73.6 7.4 7.4 26.4 66.3 66.3
170 77.3 69.5 7.0 7.0 30.5 62.6 62.6
160 72.7 65.5 6.5 6.5 34.5 58.9 58.9
150 68.2 61.4 6.1 6.1 38.6 55.2 55.2
140 63.6 57.3 5.7 5.7 42.7 51.5 51.5
130 59.1 53.2 5.3 5.3 46.8 47.9 47.9
120 54.5 49.1 4.9 4.9 50.9 44.2 44.2
110 50.0 45.0 4.5 4.5 55.0 40.5 40.5
100 45.5 40.9 4.1 4.1 59.1 36.8 36.8

EXAMPLE: Mrs. Jones weighs 150 lbs, which equals 68 Kg. Her total dose is (68 kg * 0.9 mg/kg) 61.4 mg which is equal to 61.4 ml of a 1mg/ml solution. You withdraw 6.1 ml from the 100 ml Actiavse bottle and hand to the Neurologist. Then you withdraw and discard (100 ml- 61 ml) = 39 ml as the waste. The volume of t-PA remaining in the Activase bottle is now (61.4 ml - 6.1 ml) 55.2 ml; you set the volume to infuse at a rate of 55.2 ml/hr and start the pump. As soon as the last drop of t-PA from the bottle enters the IV tubing drip chamber, remove the alteplase bottle and spike a 100 mL bag of Normal Saline with the same tubing set-up. Continue running the pump with the original 55.2 mL over 1 hour rate until all the Normal Saline is out of the bag.

Estimated Weight (lbs) 150
Conversion to Kilograms (Kg) 68.2
Total iv t-PA Dose (mg) at 0.9 mg/kg 61.4
t-PA Bolus (mg) *10% of total * 6.1
t-PA Bolus (ml) 6.1
Discard Dose t-PA (Not for infusion) 38.6
Infusion Dose (mg) 55.2
Infusion Rate (ml/hr) 55.2

Precautions and Side Effects

  • Hemorrhage (GI, GU, catheter puncture site, intracranial, retroperitoneal, pericardial, gingival, epistaxis)
  • New ischemic stroke
  • Bruising
  • Anaphylaxis
  • Laryngeal edema
  • Rash, urticaria

Protocol for Returning Unused Medication at MGH

When tPA is mixed but not administered or the packaging is damaged, the reconstituted and unused tPA should be returned for pharmacy credit

  • If t-PA is removed from Omnicell but not reconstituted and the packaging is intact, return to Omnicell under the patient's name
  • If t-PA packaging is not intact and the medication was not used, place a patient identification label on the box and page the pharmacist to pick it up.
  • If t-PA is reconstituted and not used, squirt any t-PA that was drawn up in syringes back into the t-PA vial. Place patient identification labels on the vials and box and page the pharmacist to pick it up. (NOTE: Be careful that no medicine can leak out of the vial due to the large spike that was initially placed during drug preparation.) Be sure this bottle is kept upright.
  • If t-PA is reconstituted or the packaging is not intact and the medication was not used, place a patient identification label on any container holding reconstituted drug _ t-PA bottle, syringe or IV bag. (Remove blunt canula or needles from syringes.) Place containers in a plastic bag if necessary to prevent spillage
  • Page ED RPh (pgr 34941) to facilitate returning med to pharmacy for patient credit a
  • IV administration equipment (tubing, syringes, etc.) is not returned to pharmacy
  • If medication was used at all (e.g. bolus administered, etc.) medication is NOT returned to pharmacy


  1. Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, McMullan PW Jr, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H; American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013 Mar;44(3):870-947. doi: 10.1161/STR.0b013e318284056a. Epub 2013 Jan 31.
  2. Albers GW, Amarenco P, Easton JD, Sacco RL, Teal P. Antithrombotic and thrombolytic therapy for ischemic stroke: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004 Sep;126(3 Suppl):483S-512S.American Heart Association. Guidelines for Cardiopulmonary Resuscitation Emergency Cardiovascular Care. Circulation. 2000, 102 (suppl I): I-1–I-384.
  3. National Institute of Neurological Disorders and Stroke Symposium. Improving the chain of recovery for acute stroke in your community: task force reports. Bethesda, MD: National Institutes of Health, Department of Health and Human Services; 2003.
  4. Marler JR, Jones PW, Emr M, eds. Setting New Directions for Stroke Care: Proceedings of a National Symposium on Rapid Identification and Treatment of Acute Stroke. Bethesda, MD: National Institute of Neurological Disorders and Stroke; 1997
  5. Bock BF. Proceedings of a National Symposium on Rapid Identification and Treatment of Acute Stroke: Response System for Patients Presenting With Acute Stroke. Accessed August 23, 2011.

Authoring Information

Reviewed/Approved by: Rost, Natalia, M.D., M.P.H. on behalf of ASQT

Last updated: 1/16/2015

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Still from the Stroke Evaluation simulation

This video simulation of an Emergency stroke evaluation illustrates the care of patients with acute stroke by the MGH Acute Stroke team.