Nephrology

312 Alteplase TPA Treatment For Peritonitis And Peritoneal Catheter Malfunction

  • Definitions/Considerations

    • Alteplase (tPA) treatment for Peritonitis and Peritoneal catheter  malfunction,
    • Alteplase (tPA) is a fibrinolytic agent.   It can be used as a thrombolytic agent to hydrolyse fibrin and fibrinogen.
    • Alteplase (tPA) lyses fibrin clots within the catheter lumen which may:

              - serve as a sanctuary sites for bacteria that may be responsible for recurrent peritonitis

              - block the catheter and obstruct flow

    • NOTE: This procedure must be in writing ordered by Medical staff with the consultant and Renal/Dialysis Nurse. Telephone orders will not be adequate
    • If treatment is not successful after twice administrating the medication The Haematology Unit Consultant - Paul Monagle  Pager no. 5827 will need to be consulted. Venography may be indicated
    • The treatment requires an admission to 7 West.

    Indications for TPA Therapy

    • Unable to use Central Venous Catheter- unable to aspirate blood/Heplock prior to Haemodialysis 
    • Unable to use Peritoneal Dialysis Tenckhoff catheter - poor PD outflow and unable to aspirate PD fluid/Fibrin clots in PD fluid.
    • To treat recurrent peritonitis with the same organism within 30 days after the completion of antibiotic treatment.

    Adverse Reactions

    • Bleeding from recent puncture or IV sites - this requires careful nursing attention.  Ecchymosis, epistaxis and gingivitis Have been observed in 1% or less.
    • Allergic Reaction - rare life-threatening (<0.02%) bronchospasm, hypotension, laryngeal oedema.
    • Mild reactions could include urticaria

    Accidental infusion 

    • Notify Nephrology consultant.   An attempt to wash the tPA away will usually be made

    Interactions

    • The risk of haemorrhage may be increased with the use of coumarin, heparin and other agents that influence haemostasis.

    Administration

    For recurrent peritonitis must use covering / prophylactic antibiotics as follows:

    • Administer 15mg/kg(max 500mg) IV Vancomycin and 20mg/kg IV Cephazolin
    • Instil patients normal bag of dialysate then follow as for catheter blockage

    For catheter blockage 

    1. Obtain from pharmacy 3 x 2mg/2ml FROZEN tPA syringes.  DO NOT use vial from ICU or 7W
    2. Allow syringes to thaw and bring to room temperature
    3. Make up to 12mls with Normal saline. Yielding a concentration  of  0.5mg/ml tPA
    4. Instil 10mls into PD Catheter
    5. Leave for 4 hours
    6. Withdraw (do not flush through) using sterile technique
    7. Proceed with  a CAPD exchange 
    8. Repeat 1 to 8

    (If not successful call Haematology - Paul Monagle pager 5827)

    • Send effluent for culture
    • Recommence dialysis regime and commence Keflex 10 -15/kg tds for 7 days and Nilstat 1-2mls orally tds if treating for peritonitis.