A few weekends ago during a very chaotic call, my ICU team ordered half-dose alteplase for a patient with a submassive PE without checking his INR. They had performed a thoughtful interview of the patient to look for contraindications to thrombolysis, but somehow this slipped through the cracks. On reviewing all the data together we recognized the mistake, almost had a stroke ourselves, and held the alteplase pending return of his INR. His INR was fine, he got the alteplase, and responded well.
Following this, I created an interactive contraindication checklist for my iphone (see below).This isn’t intended to replace deeper thoughts regarding the risks vs. benefits of thrombolysis, but rather as a last-minute survey to make sure that nothing obvious gets missed.It’s hazy what exactly is an “absolute contraindication” versus a “relative contraindication,” and this may shift depending on the situation (i.e. a “relative contraindication” may be OK if the patient is about to arrest from a massive PE, whereas it may not be OK for a stable patient with submassive PE).This is based primarily on the 2011 AHA/ACC guideline for massive PE.
For more thoughts on how to use thrombolytics for submassive PE, look here.