Physician=s Order

							             Clinician’s Order Form




                              Tissue-Plasminogen Activator (t-PA)
        Order for Thrombolysis
         in Pediatric Patients
                 Page 1 of 1


Absolute Contraindications:                                                      Weight: _____________ kg
-- active hemorrhage
-- fibrinogen < 100 mg/dl
Relative Contraindications:
-- recent surgery
-- receiving antiplatelet medication [aspirin, clopidogrel (Plavix®)]

1. Admit the patient to an ICU:            PICU            PCICU                   NNICU
    Thrombolytic t-PA infusions are prohibited in an unmonitored patient care area.
2. Baseline type and cross, Hgb, Hct, platelet count, and fibrinogen before t-PA administration and q4-6h while
    receiving t-PA.
3. Vital signs at baseline and every 30 minutes.
4. Strict bed rest (no activity; patient may NOT be held by parent/caregiver).
5. NPO.
6. Strict intake and output q1h.
7. Insure secure intravenous access.
8. 0.9% NaCl 1000 ml at the bedside.
9. Maintenance IV fluids: ___________________________________ IV at ____________ ml/hour
10. Monitor for bleeding and quantify the amount of blood loss by accurately weighing all gauze.
11. Notify house officer STAT if the patient has any degree of bleeding.
12. If the patient has significant bleeding (> 5 mL/kg), or systolic blood pressure below _____ mmHg or diastolic
    blood pressure below _____ mmHg:
    A.) Discontinue t-PA infusion.
    B.) Notify house officer STAT.
    C.) Call for blood STAT.
    D.) Send CBC and fibrinogen STAT.
    E.) Apply direct pressure to site of bleeding for 30 minutes (NOTE: sandbags and elastoplastin tape are
                  not acceptable).
13. Avoid arterial punctures, intramuscular injections, placement of foley catheters, feeding tubes, and rectal
    probes, administration of rectal suppositories, deep endotracheal suctioning, and chest percussive therapy
    while t-PA is infusing.
14. t-PA ________mg in _______ ml 0.9% NaCl IV at _______ ml/hour for ______ hours ( _______ mg/kg/hour),
    OR until clinical improvement, resolution of thrombus, or bleeding occurs.
    NOTES:        Usual dose is 0.1 to 0.5 mg/kg/hour.
                  Maximum concentration is 1 mg/ml.
                  Do not exceed 0.5 mg/kg/hour without attending physician approval.
15. Hold heparin infusion while t-PA is infusing.
16.  Initiate heparin 20,000 units in 500 ml D5W IV at ______ units/kg/hr = ______ ml/hr after t-PA is infused.
     Resume heparin infusion at ________ units/kg/hour = ________ ml/hour after t-PA is infused.
17. Perform other monitoring tests ( ECHO VQ scan angiography) after t-PA infusion completed.



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Physicians signature                                         Pager ID            Date/Time
(Final Draft 4/3/03)