Unique Plan Description: TPA_Activase (Alteplase) for Ischemic Stroke
Plan Selection Display: TPA_Activase (Alteplase) for Ischemic Stroke
PlanType: Medical                                 
Version: 2          
Begin Effective Date: 2023-07-25 15:29:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2024-04-02 15:05:32
Available at all facilities: Yes

TPA_Activase (Alteplase) for Ischemic Stroke
Vital Signs
	Vital Signs
		Blood pressure prior to administration should be SBP < 185 and DBP < 110mmHG  		Blood pressure should be maintained below SBP < 180 and DBP < 105mmHG during infusion and for the first 24 hours after TPA treatment.
		T;N, Q15min x2 hours, Q30min x 6 hours, then hourly until 24 hours after alteplase treatment.
Diet
	NPO
		T;N
IV Solutions
	niCARdipine 20mg/NS 200mL
		20 mg, EVERY BAG, 5 mg/hr
		200 mL, IV, Start: T;N, Duration: 1 Dose(s)/Time(s), Increment Increase: 2.5 mg/hr, Increment Decrease: 2.5 mg/hr, Increment Freq: 5 min(s), Max Dose: 15 mg/hr
			Comment: Begin to taper off nicardipine 1 hour after initiation of oral anti-hypertensive therapy. Reduce by 2.5mg/hr every 15 minutes.   If the dose has been titrated twice within the specified timeframe and goal parameter is not achieved, the titration dose can be doubled until the ordered parameter is achieved or maximum dose is reached. IV may be re-initiated after weaning within 12hours, re-initiate at the last dosing rate that maintained goal parameter SBP < 180 mmHG and DBP < 105 mmHG during and following administration (for 24 hours).Discontinue order after 12hr if patient does not require IV re-initiation.
	niCARdipine 25 mg/NS 250 mL
		250 mL, IV, Routine, Start: T;N+240, Increment Increase: 2.5 mg/hr, Increment Decrease: 2.5 mg/hr, Increment Freq: 5 min(s), Max Dose: 15 mg/hr
			Comment: Begin to taper off nicardipine 1 hour after initiation of oral anti-hypertensive therapy. Reduce by 2.5mg/hr every 15 minutes.   If the dose has been titrated twice within the specified timeframe and goal parameter is not achieved, the titration dose can be doubled until the ordered parameter is achieved or maximum dose is reached. IV may be re-initiated after weaning within 12hours, re-initiate at the last dosing rate that maintained goal parameter SBP < 180 mmHG and DBP < 105 mmHG during and following administration (for 24 hours).Discontinue order after 12hr if patient does not require IV re-initiation.
		25 mg, EVERY BAG, 5 mg/hr
	nicardipine 20mg/NS 200mL premix
		20 mg, EVERY BAG, 5 mg/hr
		200 mL, IV, Routine, Increment Increase: 2.5 mg/hr, Increment Decrease: 2.5 mg/hr, Increment Freq: 5 min(s), Max Dose: 15 mg/hr
			Comment: Begin to taper off nicardipine 1 hour after initiation of oral anti-hypertensive therapy. Reduce by 2.5mg/hr every 15 minutes.   If the dose has been titrated twice within the specified timeframe and goal parameter is not achieved, the titration dose can be doubled until the ordered parameter is achieved or maximum dose is reached. IV may be re-initiated after weaning within 12hours, re-initiate at the last dosing rate that maintained goal parameter SBP < 180 mmHG and DBP < 105 mmHG during and following administration (for 24 hours).Discontinue order after 12hr if patient does not require IV re-initiation.
Medications
		patient weight is > or =100kg use two orders below(NOTE)*
	Activase
		9 mg, Injection, IV Push, Once, STAT
			Comment: Pharmacy to send bolus.  Administer 10% of total TPA dose as an initial bolus over 1 minute: Do not administer if SBP > 185 or DBP > 110mmHG.
	Activase IVPB
		81 mg, Injection, IVPB, Once, STAT, 1 Dose(s)/Time(s)
			Comment: Comment: Dosing wt: _100kg_ (MAX dosing wt = 100kg)  NURSE:  After initial bolus then infuse this container to run 60 minutes. Stop infusion & notify provider if SBP > 180 or DBP> 105mmHG.
		patient weight is <100kg, use 2 orders below(NOTE)*
	Activase
		0.09 mg/kg, Injection, IV Push, Once, STAT
			Comment: Pharmacy to send bolus.  Administer 10% of total TPA dose as an initial bolus over 1 minute: Do not administer if SBP > 185 or DBP > 110mmHG.
	Activase IVPB
		0.81 mg/kg, INT, IVPB, Once, STAT, 1 hr
			Comment: Dosing wt: ______ (MAX dosing wt = 100kg)  NURSE:  After initial bolus then infuse this container to run 60 minutes. Stop infusion & notify provider if SBP > 180 or DBP> 105mmHG.
	Sodium Chloride 0.9%
		50 mL, IVPB, 1 Dose(s)/Time(s), 50 ml/hr
			Comment: Infuse at same rate as TPA infusion following the TPA infusion to clear tubing.
	labetalol  injection
		10 mg = 2 mL, Injection, IV PUSH, Q10MIN, PRN, see comment, Duration: 2 Dose(s)/Time(s)
			Comment: BP parameters/goals: SBP< 185mmHg or DBP < 110 mmHg. prior to administration tPA ; SBP < 180mmHg and DBP < 105mmHG during and following administration (for 24 hours) tPA. Notify MD if labetalol 10mg IV Q10min x 2 doses is not effective.
Patient Care
	Notify MD
		T;N, see comment
			Comment: If any of the following develop while administering or within the first 24 hours of receiving TPA: signs of bleeding, reports severe headache, SBP >180, DBP >105mmHG, nausea or vomiting, signs of neuro decline, signs of angioedema: includes swelling of mouth, lips, tongue, face or eyes, difficulty breathing. Stop TPA infusion, inquire about stat CT head w/o contrast.
	Peripheral Lock-Insert
		T;N, Insert 2 PIV's/obtain IV access x 2

Peripheral Lock - Access
Medications
	sodium chloride 0.9% flush injectable soln
		10 mL Syringe IV PUSH BID
		10 mL, Syringe, IV PUSH, Q5MIN, PRN, IV line flush
	lidocaine 1% injectable solution (MH/WH/FH)
		0.1 mL, IntraDermal, Q1H, PRN, see comment
			Comment: For IV start
	sodium chloride bacteriostatic 0.9% injectable soln
		0.1 mL, Injection, IntraDermal, Q1H, PRN, see comment
			Comment: For IV start, use if patient has lidocaine allergy.
	Sodium Chloride 0.9% IVPB Flush
		25 mL, IVPB, Q1H, PRN, IV line flush, 5 min(s)
			Comment: Use if medication not compatible with primary line or there is no primary line;  infuse 25mL.
Patient Care
	Peripheral Lock-Insert
		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