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Special Considerations and Management of Bleeding Complications After IV t-PA

For acute stroke onset during or immediately after diagnostic angiography

May occur in the context of cardiac, neuro or peripheral interventional diagnostic angiography or treatment. If a femoral, radial or brachial arterial sheath is still in place, DO NOT REMOVE IT. The sheath should remain sutured in place while t-PA is given. Consider intra-arterial therapy if the sheath can be accessed and the Neuroendovascular staff agree that it is warranted. If not, consider giving t-PA IV at full dose 0.9 mg/kg. In all cases, leave the sheath in place and check STAT PTT. Observe the groin site closely and follow Hct and vital signs for evidence of acute blood loss. If a hematoma forms or there is evidence of blood loss, notify Vascular Surgery and apply pressure until hemostasis is achieved. If bleeding continues, see (see bleeding after t-PA). If no bleeding occurs, the sheath can be removed after 24 hours. If heparin cannot be held for sheath removal, Vascular Surgery will surgically close the vessel in the operating room.

For acute stroke onset days or weeks after transfemoral diagnostic angiography

If a femoral arterial sheath has been pulled within 2 weeks, carefully weigh the risk of bleeding against the anticipated benefit of t-PA therapy. If t-PA is given, notify Vascular Surgery prior to drug administration. Then observe the groin site closely and follow Hct and vital signs for evidence of acute blood loss. (Occult blood loss may occur into the retroperitoneum.) If any hematoma forms or there is evidence of acute blood loss, notify Vascular Surgery and apply direct pressure until hemostasis is achieved. If occult blood loss occurs, obtain an abdominal CT to look for retroperitoneal hematoma. If bleeding continues, t-PA can be reversed with FFP, cryoprecipitate, and platelets (see bleeding after t-PA).

Bleeding after t-PA

  • For suspected symptomatic hemorrhage after t-PA or other plasminogen activator has been given:
    • Hold administration of IV t-PA if still infusing until head CT or alternative imaging (if hemorrhage is suspected elsewhere) has been completed and shows no evidence of bleeding.
    • Exclude other possible causes of neurologic worsening or acute hemodynamic instability.
    • Check STAT labs: CBC, PT, PTT, platelets, fibrinogen and D-dimer.
    • Send blood bank sample for type and screen, cross-match and hold packed red cells appropriate to the hemorrhage volume, location, and associated symptoms
    • For uncontrolled, life-threatening bleeding, consider aminocaproic acid (Amicar) 10 g IV in 250 cc NS IV over 1 hr (note: there is a significant risk of pathologic thrombosis with Amicar).
    • For systemic hemorrhage, compress any compressible sites of bleeding, and consult appropriate additional services to consider mechanically occluding arterial or venous sources of medically uncontrollable bleeding.
  • For confirmed symptomatic hemorrhage on Head CT
    • Consult Neurosurgery for possible intervention.
    • Check STAT labs: CBC, PT, PTT, platelets, fibrinogen and D-dimer, if not already sent.
    • If hypofibrinogenemia present (< 100mg/dL) or likely to be present within 12 hours of t-PA administration, treat as follows:
    • Administer 10 units of cryoprecipitate
    • Administer 6-8 units of platelets
    • If patient is a Jehova‚Äôs Witness, call hematology to discuss use of tranexamic acid
  • If still bleeding at 1 hr (repeat head CT and re-draw labs):
    • If fibrinogen level still less than 100 mg/dL, repeat cryoprecipitate dose.
    • Consider anti-fibrinolytic: eg, aminocaproic acid (Amicar) 5gm bolus IV over 15-30 min
  • Institute frequent neurochecks and therapy of acutely elevated ICP, as needed.
  • Additional Options or considerations
    • If native platelet dysfunction is suspected due to concurrent uremia, give Desmopressin 0.3mcg/kg.
    • If heparin has been administered in the past 3 hours:
      • Discontinue the heparin infusion and order Protamine sulfate. Calculate total amount of heparin received over the preceding 3 hours.
      • If initiated within 30 minutes of last heparin dose: Give 1mg protamine per 100U heparin.
      • If initiated within 30-60 minutes: Give 0.5-0.75 mg protamine per 100U heparin.
      • If initiated within 60-120 minutes: Give 0.375-0.5mg protamine per 100U heparin.
      • If heparin stopped greater than 120 minutes ago: Give 0.25-0.375 mg protamine per 100U heparin.
      • Give by slow IV injection, not to exceed 5mg/min, with total dose not to exceed 50mg.
      • Monitor for signs of anaphylaxis; the risk is higher in diabetics who have received insulin.
      • Follow-up with STAT PTT q1 hour for the next 4 hours, then q4 hours through 12 hours of hospitalization.
    • Serious systemic hemorrhage should be treated in a similar manner. Manually compress and compressible sites of bleeding, and consult appropriate additional services to consider mechanically occluding arterial or venous sources of medically uncontrollable bleeding.
  • 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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