LeftoversWhether alteplase (tPA) is given for ischemic stroke, pulmonary embolism, or STEMI, there is an important practical issue to be aware of during administration. Dr. Charles Bruen (@resusreview) published a great step-by-step pictorial tPA Mixing Tutorial. Once the tPA is mixed, it will invariably be infused via a smart pump through its corresponding tubing. At my institution we use Alaris® CareFusion smart pumps, through the principle applies irrespective of which brand pump is used.

The issue with tPA is that once the total volume from the bottle has been infused, the pump will automatically stop and produce a “no flow” alarm. When the alarm sounds there is still 12-15 cc’s of fluid remaining in the line. The concentration of the tPA solution is 1 mg/cc, meaning there is still 12-15 mg of drug that has not been infused.


Tubing 2-2

The Massachusetts General Hospital Stroke Service addresses this issue in their tPA Administration Guidelines. In order to complete the dose, they recommend the following:

  1. Un-spike the tPA bottle.
  2. Spike a bag of sodium chloride 0.9% using the same tubing set-up.
  3. Restart (continue) the smart pump to allow it to complete the original volume over the remaining time for the original infusion (1 hour for stroke, 2 hours for pulmonary embolism). This will allow all of the drug to be administered with none remaining in the tubing.

The same process can be utilized for any IV medication in which it is important to infuse every last drop.

Take Home Point: Be aware that there will be leftover medication in the tubing when the IV pump senses no more flow.

Image courtesy of Bryan Hayes

 I have no financial affiliations with the Alaris® company.

Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP

Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP

Leadership Team, ALiEM
Creator and Lead Editor, Capsules and EM Pharm Pearls Series
Attending Pharmacist, EM and Toxicology, MGH
Associate Professor of EM, Division of Medical Toxicology, Harvard Medical School
Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP


EM Pharmacist & Toxicologist @MassGeneralEM | Asst Prof @HarvardMed/@EMRES_MGHBWH | @ALiEMteam leadership | Capsules creator, ALiEMU | President, ABAT | #FOAMed