Unique Plan Description: Thrombolytic for Pulmonary Embolism
Plan Selection Display: Thrombolytic for Pulmonary Embolism
PlanType: Medical                                 
Version: 2          
Begin Effective Date: 2014-02-28 10:25:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2025-12-23 08:16:28
Available at all facilities: Yes

Initiation
Vital Signs
	BP and Pulse
		T;N, Q15MIN, 8, Dose(s)/Time(s)
		T;N+120, Q30MIN, 12, Dose(s)/Time(s)
		T;N+480, Q1H, 24, hr
Activity
	Bedrest
		T;N
Laboratory
	CBC with Diff
		Stat, spec type = Blood
			Comment: Baseline, prior to start of TPA, do not delay TPA therapy for these results
	Fibrinogen Level - MH/WH/JE
		Stat, spec type = Blood
			Comment: Baseline, prior to start of TPA, do not delay TPA therapy for these results.
	Fibrinogen Level - FH
		Stat, spec type = Blood
			Comment: Baseline, prior to start of TPA, do not delay TPA therapy for these results.
	PTT - MH/WH/JE
		Stat, spec type = Blood
			Comment: Baseline, prior to start of TPA, do not delay TPA therapy for these results.
	Partial Thromboplastin Time (PTT) - FH
		Stat, spec type = Diagnostic Blood
			Comment: Baseline, prior to start of TPA, do not delay TPA therapy for these results.
IV Solutions
		For submassive PE, if anticipating starting TPA therapy while patient is already on heparin, stop heparin and allow PTT to return to <2 times patient's baseline PTT.  If patient has received enoxaparin dose, stop enoxaparin and allow LMWH Xa level to retu(NOTE)*
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	Activase
		100 mg, INT, IVPB, Once, STAT, infuse over 2 hr
			Comment: 100 mg over 2 hours (50mL/hr).
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		50 mg, INT, IVPB, Once, STAT, infuse over 2 hr
			Comment: 50 mg over 2 hours (25mL/hr).
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		50 mg, Injection, IV Push, Q15MIN, STAT, 2 Dose(s)/Time(s)
			Comment: Give 50 mg IV bolus over 2 minutes followed by 50 mg bolus given 15 minutes later over 2 minutes. Use the same alteplase 100mg vial to prepare both 50mg doses.
Patient Care
	Neurological Assessment-Focused
		T;N, Q15MIN, 8, Dose(s)/Time(s)
		T;N+120, Q30MIN, 12, Dose(s)/Time(s)
		T;N+480, Q1H, 24, hr
	Notify MD
		T;N, if any new abnormal neurological assessment.
		T;N, if any of the following develop within the first 24 hours of receiving tpa: signs and symptoms of bleeding, c/o headache, SBP >/= 150mmHg, or DBP >/= 90mmHg, or nausea/vomiting. Inquire about stat CT of head without contrast.
	Notify MD of Lab results
		T;N, any PTT level >136
		T;N, any fibrinogen level <100
	Foley Catheter
		T;N, Do NOT insert foley during TPA infusion, or for 24 hours post TPA infusion.
	No Venipunctures
		Avoid any unnecessary peripheral venous punctures for 24 hours post tpa infusion.
	Do Not
		No insertion of any IV, NG, central lines or arterial lines during tpa infusion and for 24 hours post tpa infusion.

Post Thrombolytic
Laboratory
	Fibrinogen Level - MH/WH/JE
		Stat, spec type = Blood
	PTT - MH/WH/JE
		T;N+360, Routine, Q6H, 4 Dose(s)/Time(s), spec type = Blood
	CBC with Diff
		T;N+360, Routine, Q6H, 4 Dose(s)/Time(s), spec type = Blood
	Fibrinogen Level - MH/WH/JE
		T;N+360, Routine, Q6H, 4 Dose(s)/Time(s), spec type = Blood
	Fibrinogen Level - FH
		T;N, Stat, spec type = Blood
	Partial Thromboplastin Time (PTT) - FH
		T;N+360, Q6H, 4, Dose(s)/Time(s), Routine, spec type = Diagnostic Blood
	Fibrinogen Level - FH
		T;N+360, Routine, Q6H, 4, Dose(s)/Time(s), spec type = Blood
Medications
Anticoagulants
Patient Care

	Notify MD of Lab results
		T;N, POST TPA: results of stat lab, and start heparin as ordered when PTT is < 2 times patient's baseline.  If PTT is >2 times the patient's baseline, repeat PTT Q1H until PTT is <2 times the patient's baseline before starting the heparin infusion.

Hparin DVT/PE (High Dose) PTT No Bolus
Laboratory
	INR - MH/WH/JE
		Stat, spec type = Blood
	PTT - MH/WH/JE
		Stat, spec type = Blood
		T;N+1440, Routine, Q6H, spec type = Blood
IV Solutions
	HEParin 25,000 units/premixed diluent 250 mL
		250 mL, IV, STAT
			Comment: conc: 100 units/mL. Titrate according to High Dose Weight Based Heparin Protocol.  Maximum weight for dosing 110kg.1) PTT < 52 seconds, bolus 70 units/kg & increase rate by 4 units/kg/hr.2) PTT = 52-64 seconds, bolus 35 units/kg & increase rate by 2 units/kg/hr.3) PTT = 65-110 seconds, (therapeutic range) Do not give bolus & do not change rate.4) PTT = 111-135 seconds, do not bolus. Decrease rate by 2 units/kg/hr.5) PTT = 136 seconds or more, do not give bolus. Stop infusion for 60 mins & decrease rate by 3 units/kg/hr.Upper hard limits for weight based and non-weight based infusions are as follows: 40 units/kg/hour and 3000 units/hour, respectively; if patient needs require exceeding these limits, contact pharmacy and prescriber
		25,000 units, EVERY BAG, 18 unit/kg/hr
Medications
	HEParin 1000 units/mL injectable solution (MH/WH)
		70 units/kg, Injection, IV Push, Q6H, PRN for see comment, T;N+360
			Comment: Dose = 70 units/kg Bolus.  PTT < 52 seconds, Patient on High Dose heparin Protocol.  Pharmacy to calculate dose.  (MAXIMUM bolus = 7700 units)
		35 units/kg, Injection, IV Push, Q6H, PRN for see comment, T;N+360
			Comment: Dose = 35 units/kg Bolus.  PTT level between 52-64 seconds.  Patient on High Dose Heparin Protocol.  Pharmacy to calculate dose.  (MAXIMUM bolus = 3800 units)
Patient Care
	Notify MD
		T;N, if PTT is not in therapeutic range within 24 hours
		T;N, if 2 consecutive 70 unit/kg boluses of heparin given and the PTT is not in therapeutic range within 12 hours
		T;N, For any critical PTT >135 AND with any 2 consecutive PTTs >135
		T;N, If baseline PTT is >42 seconds (5 seconds above upper normal limit of 22-37 seconds).
	Order Lab
		T;N+1440, Change PTT order to daily after 2 consecutive therapeutic PTT's or back to Q6H if any dose change.
	Avoid IM Injections if possible while on anticoagulants
		T;N

Heparin DVT/PE (High Dose) PTT Monitoring (MH/WH/J
Admit/Discharge/Transfer
		This plan is to be used for patients with diagnoses of deep vein thrombosis or pulmonary embolism(NOTE)*
Laboratory
	INR - MH/WH/JE
		Stat, spec type = Blood
	PTT - MH/WH/JE
		Stat, spec type = Blood
		T;N+360, Timed, Q6H, spec type = Blood
IV Solutions
	HEParin 25,000 units/premixed diluent 250 mL
		250 mL, IV, STAT, T;N
			Comment: conc: 100 units/mL. Titrate according to High Dose Weight Based Heparin Protocol.  Maximum weight for dosing 110kg.1) PTT < 52 seconds, bolus 70 units/kg & increase rate by 4 units/kg/hr.2) PTT = 52-64 seconds, bolus 35 units/kg & increase rate by 2 units/kg/hr.3) PTT = 65-110 seconds, (therapeutic range) Do not give bolus & do not change rate.4) PTT = 111-135 seconds, do not bolus. Decrease rate by 2 units/kg/hr.5) PTT = 136 seconds or more, do not give bolus. Stop infusion for 60 mins & decrease rate by 3 units/kg/hr.Upper hard limits for weight based and non-weight based infusions are as follows: 40 units/kg/hour and 3000 units/hour, respectively; if patient needs require exceeding these limits, contact pharmacy and prescriber
		25,000 units, EVERY BAG, 18 unit/kg/hr
Medications
	HEParin 1000 units/mL injectable soln
		70 units/kg, Injection, IV Push, Once, STAT
			Comment: Dose = 70 units/kg Bolus. Patient on High Dose Heparin Protocol.  Pharmacy to calculate dose.  Begin heparin bolus and infusion immediately after initial stat labs are drawn. (MAXIMUM bolus = 7700 units)
		70 units/kg, Injection, IV Push, Q6H, PRN for see comment, T;N+360
			Comment: Dose = 70 units/kg Bolus.  PTT < 52 seconds, Patient on High Dose heparin Protocol.  Pharmacy to calculate dose. (MAXIMUM bolus = 7700 units)
		35 units/kg, Injection, IV Push, Q6H, PRN for see comment, T;N+360
			Comment: Dose = 35 units/kg Bolus.  PTT level between 52-64 seconds.  Patient on High Dose Heparin Protocol.  Pharmacy to calculate dose. (MAXIMUM bolus = 3800 units)
Patient Care
	Notify MD
		T;N, For surgical patients, contact surgeon for approval to start heparin protocol if ordered post surgery
		T;N, if PTT is not in therapeutic range within 24 hours
		T;N, if 2 consecutive 70 unit/kg boluses of heparin given and the PTT is not in therapeutic range within 12 hours
		T;N, For any critical PTT >135 AND with any 2 consecutive PTTs >135
		T;N, If baseline PTT is >42 seconds (5 seconds above upper normal limit of 22-37 seconds).
	Order Lab
		T;N, Enter orders for PTT Q6Hr timed after initiation of therapy or any dosage change until 2 consecutive PTT in therapeutic range, then q24h in am.
	Avoid IM Injections if possible while on anticoagulants
		T;N

Hparin Non DVT/PE (Low Dose) PTT No Bolus
Laboratory
	INR - MH/WH/JE
		Stat, spec type = Blood
	PTT - MH/WH/JE
		Stat, spec type = Blood
		T;N+1440, Routine, Q6H, spec type = Blood
IV Solutions
	HEParin 25,000 units/premixed diluent 250 mL
		250 mL, IV
			Comment: conc: 100 units/mL. Titrate according to Low Dose Weight Based Heparin Protocol.  Maximum weight for dosing 110kg.  MAXIMUM INITIAL rate is 1000 units per hr.1)  PTT < 52 seconds, bolus 60 units/kg & increase rate by 4 units/kg/hr.2)  PTT = 52-64 seconds, bolus 30 units/kg & increase rate by 2 units/kg/hr.3)  PTT = 65-110 seconds, (therapeutic range) Do not give bolus & do not change rate.4)  PTT = 111-135 seconds, do not bolus. Decrease rate by 2 units/kg/hr.5)  PTT = 136 seconds or more, do not give bolus. Stop infusion for 60 mins & decrease rate by 3 units/kg/hr.Upper hard limits for weight based and non-weight based infusions are as follows: 40 units/kg/hour and 3000 units/hour, respectively; if patient needs require exceeding these limits, contact pharmacy and prescriber
		25,000 units, EVERY BAG, 12 unit/kg/hr
Medications
	HEParin 1000 units/mL injectable solution (MH/WH)
		60 units/kg, Injection, IV Push, Q6H, PRN for see comment, T;N+360
			Comment: Dose = 60 units/kg Bolus.  PTT level < 52 seconds, Patient on Low Dose heparin Protocol.  Pharmacy to calculate dose. (MAXIMUM bolus = 6600 units)
		30 units/kg, Injection, IV Push, Q6H, PRN for see comment, T;N+360
			Comment: Dose = 30 units/kg Bolus.  PTT level between 52-64 seconds.  Patient on Low Dose Heparin Protocol.  Pharmacy to calculate dose. (MAXIMUM bolus = 3300 units)
Patient Care
	Notify MD
		T;N, if PTT is not in therapeutic range within 24 hours
		T;N, if 2 consecutive 60 unit boluses of heparin given and the resulting PTT value is not in therapeutic range within 12 hours
		T;N, For any critical PTT >135 AND with any 2 consecutive PTTs >135
		T;N, If baseline PTT is >42 seconds (5 seconds above upper normal
	Order Lab
		T;N+1440, Change PTT order to daily after 2 consecutive therapeutic PTT's or back to Q6H if any dose change.
	Avoid IM Injections if possible while on anticoagulants
		T;N

Hparin Non DVT/PE (Low Dose) PTT No Bolus (MJE)
Laboratory
	INR - MH/WH/JE
		Stat, spec type = Blood
	PTT - MH/WH/JE
		Stat, spec type = Blood
		T;N+1440, Routine, Q6H, spec type = Blood
IV Solutions
	HEParin 25,000 units/premixed diluent 250 mL
		25,000 units, EVERY BAG, 12 unit/kg/hr
		250 mL, IV
			Comment: conc: 100 units/mL. Titrate according to Low Dose Weight Based Heparin Protocol.  Maximum weight for dosing 110kg.  MAXIMUM INITIAL rate is 1000 units per hr.1)  PTT <  64 seconds, bolus 60 units/kg & increase rate by 4 units/kg/hr.2)  PTT =  64-81 seconds, bolus 30 units/kg & increase rate by 2 units/kg/hr.3)  PTT =  81-135 seconds, (therapeutic range) Do not give bolus & do not change rate.4)  PTT =  136-162 seconds, do not bolus. Decrease rate by 2 units/kg/hr.5)  PTT =  163 seconds or more, do not give bolus. Stop infusion for 60 mins & decrease rate by 3 units/kg/hr.Upper hard limits for weight based and non-weight based infusions are as follows: 40 units/kg/hour and 3000 units/hour, respectively; if patient needs require exceeding these limits, contact pharmacy and prescriber
Medications
	HEParin 1000 units/mL injectable solution (JE)
		60 units/kg, Injection, IV Push, Q6H, PRN for see comment, T;N+360
			Comment: Dose = 60 units/kg Bolus. PTT level < 64 seconds, Patient on Low Dose heparin Protocol.  Pharmacy to calculate dose. (MAXIMUM bolus = 6600units)
		30 units/kg, Injection, IV Push, Q6H, PRN for see comment, T;N+360
			Comment: Dose = 30 units/kg Bolus. PTT level between  64-81 seconds.  Patient on Low Dose Heparin Protocol.  Pharmacy to calculate dose. (MAXIMUM bolus = 3300units)
Patient Care
	Notify MD
		T;N, For surgical patients, contact surgeon for approval to start heparin protocol if ordered post surgery
		T;N, if PTT is not in therapeutic range within 24 hours
		T;N, if 2 consecutive 60 unit boluses of heparin given and the resulting PTT value is not in therapeutic range within 12 hours
		T;N, if 2 consecutive PTT values are greater or equal to 163 seconds
		T;N, If baseline PTT is >40 seconds (5 seconds above upper normal limit of 22-35 seconds)
	Order Lab
		T;N, Enter orders for PTT Q6Hr timed after initiation of therapy or any dosage change until 2 consecutive PTT in therapeutic range, then q24h in am.
	Avoid IM Injections if possible while on anticoagulants
		T;N

Hparin DVT/PE (High Dose) PTT No Bolus (MJE)
Laboratory
	INR - MH/WH/JE
		Stat, spec type = Blood
	PTT - MH/WH/JE
		Stat, spec type = Blood
		T;N+1440, Routine, Q6H, spec type = Blood
IV Solutions
	HEParin 25,000 units/premixed diluent 250 mL
		25,000 units, EVERY BAG, 18 unit/kg/hr
		250 mL, IV, STAT
			Comment: conc: 100 units/mL. Titrate according to High Dose Weight Based Heparin Protocol.  Maximum weight for dosing 110kg.1) PTT < 64 seconds, bolus 70 units/kg & increase rate by 4 units/kg/hr.2) PTT = 64-81 seconds, bolus 35 units/kg & increase rate by 2 units/kg/hr.3) PTT = 81-135 seconds, (therapeutic range) Do not give bolus & do not change rate.4) PTT = 136-162 seconds, do not bolus. Decrease rate by 2 units/kg/hr.5) PTT = 163 seconds or more, do not give bolus. Stop infusion for 60 mins & decrease rate by 3 units/kg/hr.Upper hard limits for weight based and non-weight based infusions are as follows: 40 units/kg/hour and 3000 units/hour, respectively; if patient needs require exceeding these limits, contact pharmacy and prescriber
Medications
	HEParin 1000 units/mL injectable solution (JE)
		70 units/kg, Injection, IV Push, Q6H, PRN for see comment, T;N+360
			Comment: Dose = 70 units/kg Bolus.  PTT < 64 seconds, Patient on High Dose heparin Protocol.  Pharmacy to calculate dose. (MAXIMUM bolus = 7700units)
		35 units/kg, Injection, IV Push, Q6H, PRN for see comment, T;N+360
			Comment: Dose = 35 units/kg Bolus.  PTT level between  64-81 seconds.  Patient on High Dose Heparin Protocol.  Pharmacy to calculate dose. (MAXIMUM bolus = 3800units)
Patient Care
	Notify MD
		T;N, For surgical patients, contact surgeon for approval to start heparin protocol if ordered post surgery
		T;N, if PTT is not in therapeutic range within 24 hours
		T;N, if 2 consecutive 70 unit/kg boluses of heparin given and the PTT is not in therapeutic range within 12 hours
		T;N, if 2 consecutive PTT results are greater or equal to 163 seconds
		T;N, If baseline PTT is >40 seconds (5 seconds above upper normal limit of 22-35 seconds)
	Order Lab
		T;N, Enter orders for PTT Q6Hr timed after initiation of therapy or any dosage change until 2 consecutive PTT in therapeutic range, then q24h in am.
	Avoid IM Injections if possible while on anticoagulants
		T;N

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase