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.
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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.
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For more thoughts on how to use thrombolytics for submassive PE, look here.
Contraindications
for Thrombolysis in PE
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Tough situation. In general thrombolysis would be contraindicated in the immediate postoperative period. The therapeutic options in this situation would include interventional radiology approaches or surgical thrombectomy (which is being used more frequently in a few US centers). Unfortunately, both of these options are very operator-dependent and unavailable in many hospitals. If IR or surgical options are not available and the patient is extremely unstable in refractory shock, it might be reasonable to trial a very low dose of thrombolytic (i.e. 20mg alteplase). Discussion with the surgeon/OB may also help clarify how bloody the procedure was and how risky lysis… Read more »
Thanks.. I came across massive pe with refractory shock.. just immediately after cesarean section in recovery room.. echo based dx..
Would that be contraindicated?
Mnemonic: CTS-BASH (think of a bashful cardiothoracic surgeon – rare)
C = CNS (any neoplasm, hx of ICH, CVA 3 months, recent trauma)
T = Trauma (?relative/), non-compressive blood vessel puncture
S = Surgery (2-4 weeks)
B = bleeding (active, coagulopathic, thrombocytopenic , relative)
A = age (relative)
S = specific (relative = CPR, pregnancy)
H = HTN uncontrolled