Assessment

• Begin therapy as soon as possible after the onset of symptoms

» Monitor vital signs, including temperature, continuously for myocardial infarction. Do not use lower extremities to monitor blood pressure. Notify physician if systolic BP >180 mm Hg or diastolic BP >110 mm Hg. Thrombolytic therapy should not be given if hypertension is uncontrolled. Inform physician if hypotension occurs. Hypotension may result from the drug, hemorrhage, or cardiogenic shock

» Assess patient carefully for bleeding every 15 min during the 1st hr of therapy, every 15–30 min during the next 8 hr, and at least every 4 hr for the duration of therapy. Frank bleeding may occur from sites of invasive procedures or from body orifices. Internal bleeding may also occur (decreased neurologic status; abdominal pain with coffee-grounds emesis or black, tarry stools; hematuria; joint pain). If uncontrolled bleeding occurs, stop medication and notify physician immediately

» Inquire about previous reaction to anistreplase or streptokinase therapy. Assess patient for hypersensitivity reaction (rash, dyspnea, fever, changes in facial color, swelling around the eyes, wheezing). If these occur, inform physician promptly. Keep epinephrine, an antihistamine, and resuscitation equipment close by in the event of an anaphylactic reaction

» Inquire about recent streptococcal infection. Anistreplase and streptokinase may be less effective if administered between 5 days and 12 months of a streptococcal infection

» Assess neurologic status throughout therapy. Altered sensorium or neurologic changes may be indicative of intracranial bleeding

• Monitor ECG continuously. Notify physician if significant arrhythmias occur. IV lidocaine or procainamide (Pronestyl) may be ordered prophylactically. Monitor cardiac enzymes. Radionuclide myocardial scanning and/or coronary angiography may be ordered 7–10 days after therapy to monitor effectiveness of therapy

» Assess intensity, character, location, and radiation of chest pain. Note presence of associated symptoms (nausea, vomiting, diaphoresis). Administer analgesics as directed. Notify physician if chest pain is unrelieved or recurs

» Monitor heart sounds and breath sounds frequently. Inform physician if signs of CHF occur (rales/crackles, dyspnea, S₃ heart sound, jugular venous distention, relieved CVP)

• Hematocrit, hemoglobin, platelet count, fibrin/fibrin degradation product (FDP/fdp) titer, fibrinogen concentration, prothrombin time, thrombin time, and activated partial thromboplastin time may be evaluated before and frequently during therapy. Bleeding time may be assessed before therapy if patient has received platelet aggregation inhibitors

» Obtain type and crossmatch and have blood available at all times in case of hemorrhage

» Stools should be tested for occult blood loss and urine for hematuria periodically during therapy

• High Alert: If local bleeding occurs, apply pressure to site. If severe or internal bleeding occurs, discontinue infusion. Clotting factors and/or blood volume may be restored through infusions of whole blood, packed RBCs, fresh frozen plasma, or cryoprecipitate. Do not administer dextran; it has antiplatelet activity. Aminocaproic acid (Amicar) may be used as an antidote

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