Description:
Streptokinase is a thrombolytic agent i.e. it dissolves vascular thrombi. This potent agent is derived from the beta hemolytic streptococci and is consequently associated with the risk of anaphylaxis. The risk is dependent upon the level of the patients circulating anti-streptokinase antibodies. Streptokinase acts by stimulating the conversion of plasminogen to plasmin. Is a proteolytic enzyme which is able to disrupt fibrin stability and production? The half life of streptokinase in 6 hours.

Clinical pharmacology:

Standards:
Streptokinase may only be prepared. Administered and monitored by nursing staff who work in the Accident & Emergency Department and ICU/CCU.

Indications:
► Early in myocardial infarction. Evidence of acute anterior myocardial infarction within 6 hours of onset of episode of pain that
    lead to admission.
► Use of streptokinase for inferior infarcts to be discussed with cardiologist/physician.
► Acute pulmonary and systemic arterial thrombi.
► Suspected myocardial infarction marked by an ECG with left bundle branch block.
► Absence of contraindications to streptokinase and Aspirin.

PT Selection Criteria:
Onset of cardiac like chest pain which is >30 minutes in duration and within six hours of assessment.
Chest pain for up to twenty four hours which is continuing.

Contraindications:
► Age over 70 years.
► Bacterial endocarditis
► Bleeding tendency
► Pericarditis.
► Recent surgery or trauma, head injury or CPR.
► Previous IV Streptokinase re last 6 months.
► Ulcer or gastrointestinal hemorrhage or ulcerative reflux, esophagitis or ulcer symptoms
► Proliferative diabetic, retinopathy.
► Recent or planned arterial puncture previous or next 24 hours.
► Oral anticoagulants.
► Any history of CVA, Cerebral AV malformation and cerebral aneurysm
► Bleeding diathesis
► Surgery including dental extractions in past 14 days.
► Major trauma or head trauma in past 14 days.
► Uncontrolled hypertension diastolic >110 or greater
► Pregnancy.
► Severe renal, liver disease, acute pancreatitis.

Relative contraindication:
► Ventilation.
► Left heart thrombus.
► Prolonged (more than 15 minutes) and possibly traumatic CPR.
► Uncontrolled hypertension diastolic BP .120mmHg and systolic BP >300mmHg.
► Invasive procedure e.g. subclavian puncture in the last 10 days, inclusive of temporary pacemaker insertion.
► Bacterial endocarditis.
► GIT bleeds within 6 months.

Outcomes:
Signs of repreinfusion:
► Relief of pain.
► Return of ST segments to normal.
► Reperfusion arrhythmias usually a dioventricular rhythm.
► Early CPK peak.

Special considerations:
► Any of the contraindications.
► Avoid invasive procedures as far as possible.
► Beware of drugs causing effects on the clotting system or platelets and possible interaction with therapy.

Equipment:
► ECG machine
► Continuous ECG monitoring
► IV canola access
► Streptokinase 1.5 million u/s given in 100mls normal saline over 45-60 minutes.
► Blood pressure monitoring

Procedure:
Administration:
► ECG and diagnosis.
► Bloods for FBC, U/E/C's, Coags, and Cardiac Enzymes group and hold.
► Soluble aspirin 150mgs orally then daily for at least 1 month.
► Give 1.5 million u/s streptokinase in 100mls normal saline or 5% dextrose over 45mins to 1 hour.

Nursing Considerations:
► Continuous monitoring of HR and rhythm throughout thrombolytic administration.
NB: Successful lysis of the clot may be evidenced by reperfusion arrhythmias. These may be of various forms; may be mild or catastrophic. In effects emergency equipment (cardiac arrest trolley and a defibrillator) close at hand throughout infusion and post 24 hours. Reperfusion rhythms are only treated when they are sustained and or producing symptoms.

► Vital observations:
Record 15 minutely for at least 1 hour from onset of infusion until stable. _ hourly for a further hour then hourly for 24 hours.

► Hypotension:
Can occur in up to 20% of patient treated.

Management:
► Placing patient in supine position
► Reduce rate of infusion
► Stop infusion and restart when BP recovers

The risk of external and internal hemorrhage is maximal in the first 24 hours.

Observation for and prevention include:
► Minimal duration of cuff inflation when recording BP.
► Daily urinalysis for haematuria whilst anti-coagulation therapy continues.
► Assessment reporting and documentation of abdominal pain and/or distension, faecal blood, neurological deficits and
    cannula site bleeds.
► A least 5 minutes of compression for Venipunctures sites during thrombolytic therapy.
► At least 2 minutes of compression for Venipunctures sites during possible heparin therapy.

Allergic reactions may include fever increased liver enzymes, reduced renal function, polyarthralgia, polyarthritis and rash. Should any of these reactions occur the nurse is to notify the RMO immediately.

Presentation:
► Record ECG 2 hours post infusion twice daily for 48 hours and PRN.
► Monitor CPK at 6 and 12 hours, then daily.
► Monitor APTT at 16-20 hours then daily till an acceptable level.
► Test urine for blood.
► Assess need for heparin therapy as per cardiology or physicians decision.

References:
ET et al , Cardiovascular Drug Guidelines, 1995/96 2nd Edition; RNSH/Coronary Care Policies/Procedures, 1993, Lismore Base Hospital Streptokinase policy ICU & Emergency Dept.