Download Thrombolysis in Acute Stroke- Westmead Hospital PP08

PROCEDURE
Thrombolysis for acute ischaemic stroke with intravenous alteplase at Westmead Hospital
Purpose
The purpose of this procedure document is to provide clear guidance on the safe and evidencebased administration of alteplase for the thrombolysis of patients presenting with acute ischaemic
stroke either to Westmead Emergency Department or on the wards of Westmead Hospital.
Intended Audience
Medical, nursing and radiological personnel involved in the acute assessment of patients presenting
with stroke symptoms within Westmead Hospital. The majority of these will work within Neurology,
Geriatrics, Acute Stroke Unit, Emergency & Radiology Departments. However, as all inpatients could
potentially develop an acute stroke, the audience may potentially include all inpatient teams and
nursing staff.
Expected Outcomes
Patients presenting within time-windows for thrombolysis and fulfilling eligibility criteria will be
assessed by specifically-trained medical staff , be investigated appropriately and receive timely
treatment with alteplase according to evidence-based procedure. This would be expected to
increase the proportion of patients regaining full independence. Patients will be monitored and
complications of treatment will be recognised and treated appropriately. Patient outcomes will be
regularly reviewed and submitted to International Registries.
Risk Level
High. Adverse outcomes including the risk of death and severe permanent disability may result from
both inappropriately administered and inappropriately omitted treatment with alteplase.
PROCEDURE STATEMENT
Adult patients presenting within 4.5 hours of stroke onset will be identified as potentially eligible for
treatment with intravenous alteplase. They will be assessed rapidly by the Thrombolysis Registrar
and/or the Stroke Consultant in person. If they satisfy defined clinical and radiological inclusion and
exclusion criteria, and the Stroke Consultant authorises treatment, they will be offered intravenous
alteplase .Alteplase will be appropriately dosed and administered. Patients will be monitored closely
for complications according to defined protocols. Patient outcome will be recorded and submitted
to registries
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Education Notes
Acute Ischaemic Stroke is a common and serious medical emergency with high mortality, morbidity
and financial cost.
The pathophysiology of AIS is of occlusion of an intra- or extracranial blood vessel with resulting
ischaemia. If the vessel remains occluded the ischaemic brain tissue progresses to irreversible
infarction. Intravenous alteplase is a fibrinolytic agent which causes breakdown of occluding blood
clot, so restoring blood flow to the ischaemic brain, potentially reducing the volume of infarction and
hence decreasing patient disability and dependency.
The fibrinolytic activity of alteplase increases the risk of intracranial and systemic bleeding which can
offset the benefit of the treatment. A number of clinical and radiological exclusion criteria exist to
reduce this risk. Intracranial haemorrhage must be excluded with neuroimaging prior to treatment
with alteplase. The benefits of treatment diminish and the risks of treatment increase with time
from stroke onset
Meta-analysis of trials of thrombolytics (including alteplase) have shown benefit of treatment in
selected patients treated within 3 hours of the onset of stroke symptoms. The largest individual
randomised controlled trial study of alteplase within 3 hours (n=620) showed that 11-13% more
patients were independent with treatment than with placebo (Number Needed to Treat =10) with
no increase in mortality, despite a 6.4% increase in intracranial bleeding.
In 2003 an Australian TGA license was granted for the use of alteplase (Actilyse®) in AIS patients
fulfilling selection criteria presenting within 3 hours of stroke onset.
International registries were established to monitor the safety of alteplase usage in practice. The
largest of these is the SITS registry with over x000 patients.
In 2009 a further study of treatment of selected AIS patients in the 3-4.5 hour time-window,
demonstrated superiority of alteplase over placebo. In 821 patients, 66.5% were independent with
treatment vs. 61.5% (OR 1.31 (CI 1.10-1.56) NNT=20) without. There was no increase in mortality
and a low (2.7%) incidence of symptomatic intracranial haemorrhage. It was emphasised that the
earlier treatment could be given the better and that widening the time-window should not delay
treatment.
The 2010 National Stroke Foundation Clinical Guidelines (endorsed by the RACP, ACEM and
ANZSGM) supported treatment with alteplase up to 4.5 hours after stroke symptom onset if:
a) they satisfied specific inclusion and exclusion criteria
b) the alteplase was given under the authority of a physician trained and experienced in
stroke management
c) in a hospital setting with access to a stroke multidisciplinary care team, appropriate
pathways and protocols, and rapid access to neuroimaging
2
In October 2010 the TGA license for alteplase (Actilyse®) was expanded to include stroke patients
presenting within 4.5 hours of stroke onset.
Stroke incidence increases with age, as does stroke mortality and poor outcome. Patients over 80
years have an increased risk of intracranial bleeding with alteplase and advanced age has been a
relative contraindication to treatment. Registry studies have suggested that alteplase can be given
with benefit in selected patients in this age group.
Westmead Hospital has offered treatment with alteplase to AIS patients since 2004. There is a 24
hour/ 365 day per year on-call thrombolysis phone/pager carried by a doctor of Registrar or
Advanced Trainee level with appropriate in-house training. Treatment with alteplase is authorised
by either the Consultant Neurologist or Consultant Geriatrician after reviewing standardised
eligibility criteria.
Definitions
Acute Ischaemic Stroke (AIS)
Acute focal (or global) neurological deficit with no apparent cause
other than vascular. In very early presentations this definition
may of necessity include 'stroke mimics'
Thrombolysis
Treatment with a fibrinolytic agent in an attempt to restore
perfusion to an occluded extra- or intracranial artery
NIHSS scale
A standardised scale for assessing the severity of stroke. Higher
scores indicate more severe symptoms
Stroke Onset
The time when the patient was last definitely normal. For those
patients that wake with symptoms, the time will be assumed to
be when they last went to sleep and known to be normal
Stroke Consultant
A Consultant Neurologist or Geriatrician participating in the acute
on-call roster with appropriate training in acute stroke
management. A Geriatrician will usually be responsible for
patients over 70 years and a Neurologist for those under 70
Thrombolysis Registrar
A Registrar, Fellow or Advanced Trainee who has received
departmental training in thrombolysis and participating in the
stroke thrombolysis roster
3
PROCEDURE
1. Identification of patients
a) ED
Patients presenting to Westmead Emergency Department with acute neurological symptoms
suggestive of stroke will be identified at Triage. The time of onset of symptoms will be sought.
Unless there is a clear history that the onset was over 4.5 hours prior, the patient should be triaged
as Category 2, allocated a monitored bed and brought to the attention of ED Medical Staff for rapid
assessment. Where the onset time is initially unknown, urgent attempts should be made to establish
the onset time from additional collateral history.
b) Wards
Inpatients presenting with acute neurological symptoms on the ward will be identified by ward
nursing staff. The Nursing Team Leader will be consulted and the Registrar for the inpatient team
(or if out-of-hours the on-call Medical Registrar) paged.
2. Initial Monitoring of Patients
Patients should have Temperature, Pulse, Blood Pressure, Oxygen Saturations, Neurological
Observations and a BSL performed. Pulse and BP should be monitored every 15 minutes.
3. Initial Medical Assessment
A rapid history and examination should be performed. This should include confirmation of the stroke
onset time. It should include general neurological examination including visual fields, and speech
but not detailed sensory examination or an NIHSS. Contraindications to thrombolysis should be
sought using the proforma (Appendix 1).
4. Urgent Referral
The patient should be discussed with the Thrombolysis Registrar without delay at this stage (or
earlier). This referral should NOT be delayed to arrange investigations. Patients with
contraindications should still usually be discussed as they may be eligible for other acute stroke
treatments, further neuroimaging or clinical trials
In the unlikely event that the TR cannot be contacted the appropriate Stroke Consultant should be
contacted directly.
5. Urgent Investigations
An urgent non-contrast CT brain should be requested. (In some circumstances, a contrast
examination or MRI will be the appropriate investigation but this will be on the advice of the
Thrombolysis Registrar or Stroke Consultant). An urgent report should be requested.
Venous blood samples should be sent urgently for Full Blood Count, Electrolytes Urea & Creatinine,
Glucose and Clotting studies
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6. Thrombolysis Registrar
Based on the details provided in the referral the TR will make a decision to either:
a) attend the patient if the patient seems eligible for treatment or requires further
in-person assessment
b) give advice to the referring doctor
They may seek further advice and/or inform the Stroke Consultant at this stage
7. Assessment by Thrombolysis Registrar (and/or Stroke Consultant)
The TR when they attend the patient will:
a) clarify the history particularly the onset time
b) perform and document an NIHSS examination
c) review the CT scan (or other neuroimaging) and its report if available
d) review the blood tests if available (thrombolysis should not be delayed to wait for blood
tests if they are not reasonably expected to be abnormal)
e) review the indications and contraindications
e) explain the rationale for thrombolysis as a preliminary to consent
8. Decision to Thrombolyse
The decision and responsibility to thrombolyse will be taken by the Stroke Consultant responsible for
the patient after either:
a) reviewing the patient and investigations in person
or
b) if unable to attend without causing a delay in thrombolysis
and discussing the history, examination and investigations with the TR
and is satisfied that thrombolysis can be delivered according to procedure
9. Consent
Consent will be sought from capacitous patients for treatment with alteplase.
Where capacitous patients cannot sign, witnessed verbal consent will be used.
Where a patient is of Non-English Speaking Background, appropriate translation services will be
used.
5
Consent will be sought from the appropriate responsible person where the patient lacks capacity.
Where there are no relatives or responsible persons available, patients who lack capacity but
fulfilling the TGA-approved licensed indication may be treated with alteplase without consent as an
emergency treatment.
10. Calculation of alteplase dose (see appendix 2)
The treatment dose of alteplase (Actilyse®) is 0.9mg/kg with a maximum dose of 100mg. This should
be calculated using an actual patient weight if possible or an reported/estimated weight if
impractical to weigh.
10% of the total dose is given as a bolus. The remaining 90%of the dose is infused over 1 hour. Both
doses should be prescribed on the treatment chart by the treating doctor. A nomogram is provided
in Appendix 2.
11. Reconstitution of alteplase (see appendix 3)
The usual preparation of alteplase is as actilyse® 50mg. (Patients who weigh more than 55kg will
therefore need two packages). Each package contains a vial containing the active ingredient as a
powder, a vial containing sterile water as diluent and a transfer cannula. When reconstituting the
powder, it should be gently inverted and not shaken. The resulting mixture is at a concentration of
1mg/mL and should not be diluted further or mixed with other drugs.
11. Administration of alteplase (see appendix 3)
The bolus dose should be drawn up from one of the vials with a syringe and administered as a bolus
over 1-2 minutes by the treating doctor. The infusion should be administered into a dedicated
intravenous cannula via an infusion pump over 1 hour.
12. Nursing care of patients who have been treated with alteplase (appendix 4)
a) monitor vital signs and GCS every 15 minutes for first 2 hours
then every 30 minutes for the next 6 hours
then hourly until 24 hours after treatment
b) avoid insertion or removal of indwelling catheters, removal of intravenous cannulae, IM
injections, shaving or other invasive procedures during the first 24 hours after
treatment. Venepuncture should be performed carefully and only as required
c) assess skin and oral integrity before, during and after alteplase treatment. If peripheral
bleeding occurs, apply pressure until the bleeding stops to prevent haematoma formation
d) Avoid toothbrushes, mouth wash or soft sponge to prevent oral trauma within the first 24
hours
e) Ensure patient safety is maintained to avoid potential trauma or falls
6
f) explain the reasons for monitoring and treatment to patient and family members as well
as the usual information about stroke
13. Blood pressure treatment after treatment with alteplase
Increased BP following treatment with alteplase increases the risk of intracranial bleeding. If a
patient develops SBP>180mmHg or DBP>110mmHg, the medical officer should be informed and
blood pressure lowering treatment prescribed. (eg clonidine, hydralazine as per stroke proforma).
Patients receiving parenteral antihypertensive treatment should have BP recorded every 15 minutes.
14. Interactions with alteplase
Antiplatelet agents (e.g. aspirin, dipyridamole and clopidogrel) and anticoagulants (heparins, lowmolecular weight heparins and warfarin) are likely to increase bleeding risk with alteplase and
should be avoided for the first 24 hours
14. Complications of alteplase
a) orolingual angioedema
occurs in approx 1.3% of cases. Alteplase should be ceased and consideration given to
treatment with antihistamines (e.g. chlorpheniramine 16mg IV), steroids (e.g.
hydrocortisone 200mg IV), adrenaline nebulisers. Intubation is indicated if airways
compromised
b) intracranial bleeding
may be heralded by headache , rising blood pressure or falling GCS. The alteplase infusion
should be stopped, the patient reassessed and a CT scan of the brain arranged. The Stroke
Consultant should be informed and asked for further management advice
c) systemic bleeding
may be suspected by visible blood, tachycardia, falling blood pressure, abdominal distension
or falling haemoglobin/haematocrit. If bleeding in a critical site (e.g. gastrointestinal tract,
retroperitoneum, pericardium) is suspected, the alteplase infusion should be
stopped, venous blood should be taken for cross-match, and clotting studies. Fluid
resuscitation should be commenced as necessary, and appropriate diagnostic investigations
considered. The Stroke Consultant should be informed and asked for management advice
15. Transfer of patients
a) In Emergency
A bed on the Acute Stroke Unit (D4B) should be requested. The patient can be
transferred after the alteplase infusion has finished if the patient is stable. Unstable
patients should be considered for HDU or ICU as per usual indications
b) On wards
7
Where possible the patient should be transferred to the Acute Stroke Unit (D4B)
prior to treatment with alteplase if this can be done without causing significant
delay. If a patient has to be given treatment with alteplase outside the Emergency
Department or Acute Stroke Unit, the Thrombolysis Registrar and/or the Stroke
Consultant should remain with the patient for the duration of the infusion and
transfer to D4B arranged as soon as possible
16. Follow-up management
Patients will have usual Stroke Unit multidisciplinary assessments while on the Stroke Unit. Followup neuroimaging will be performed at 24 hours, NIHSS scores will be performed at 24 hours and 1
week (or discharge if sooner).
17. Governance
All Thrombolysis Registrars will receive formal specific training. Thrombolysis cases will be reviewed
in the weekly Neurovascular Radiology Meeting. Data and outcomes will be presented at the
monthly Stroke Unit Management Meeting and be subject to audit. Adverse events (which may
include inappropriately omitted thrombolysis) will be discussed at Neurology or Geriatric Morbidity
& Mortality Meetings and reported to IIMS as appropriate. Data will be submitted to the
international SITS registry. Protocols and procedures will be reviewed regularly and revised in the
light of changes in evidence.
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Appendix 1: Indications and Contraindications to Treatment with IV Alteplase
Inclusion Criteria All boxes should be ýes'
Y N
□
□
□
□
□
□ Age 18 or greater
□ Onset of stroke symptoms defined and treatment can be started within 4.5 hours of onset
□ Disabling neurological deficit (usually measurable on the NIHSS)
□ Neuroimaging has excluded intracranial bleeding
□ Consent has been obtained. Patients who lack capacity but satisfying criteria may be given
thrombolysis as an emergency treatment if no responsible person contactable
Exclusion Criteria All boxes should be 'No'. If any 'Ýes' discuss with thrombolysis registrar as may be
eligible for alternative treatment or neuroimaging
Y N
□
□
□
□
□ History of previous stroke or serious head trauma in last 3 months
□ Clinical presentation suggestive of subarachnoid haemorrhage even if CT is normal
□ Seizure at stroke onset
□ History of suspected intracranial haemorrhage, aneurysm, arteriovenous malformation,
intracranial neoplasm or history of intracranial or spinal surgery
□ □
□ □
History of significant bleeding disorder within last 6 months
□
□
□
□
□
□
Administration of heparin within 48 hours preceding stroke onset with elevated aPTT
Known haemorrhagic diathesis, severe hepatic disease or patient receiving oral
anticoagulation with INR>1.3
□
□
□
□
□
□
Administration of low molecular weight heparin within 48 hours of stroke onset
Presumed septic embolus, diagnosis of bacterial endocarditis or pericarditis
Documented ulcerative gastrointestinal disease over the last 3 months
Major surgery or significant trauma (e.g. CABG or head trauma) within past 3 months
Recent (within 10 days) obstetric delivery, organ biopsy, puncture of a non-compressible
blood vessel or traumatic (>2 minute) cardiopulmonary resuscitation
□ □
□ □
□ □
Pregnancy or lactation
Known thrombocytopaenia (<100 x 109/L)
Finger prick BSL <2.8 mmol/L or > 22.0 mmol/L
Relative Exclusion Criteria
Y N
□ □ Uncontrolled baseline hypertension SBP> 185mmHg or DBP>110mmHg or aggressive
treatment required to achieve these
□ □ Menstruation (may need transfusion support)
□ □ Proliferative diabetic retinopathy
□ □ Age greater than 80 years (particularly with a history of hypertension)
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□ □ Patients with established radiological changes of infarction in>1/3 of the MCA territory have
increased bleeding risk
Appendix 2: Calculation of Alteplase Dose
The dose of intravenous alteplase (Actilyse®) for treatment of Acute Ischaemic Stroke is 0.9 mg/kg
(maximum of 90mg). 10% of the dose is given as a bolus over 1-2 minutes and the remainder as an
infusion over 1 hour.
1. Weigh Patient
Kg
Patient's Weight Measured
Kg
Patient's Weight Estimated
2. Calculate Total Dose Required
Total Dose =0.9 x Weight
Or use nomogram
mg
3. Calculate Bolus Dose Required
mg 1-2 minutes
over
Bolus dose=0.1 x Total Dose
Or use nomogram
4. Calculate Infusion dose Required
Infusion Dose = Total Dose- Bolus Dose
mg
over 1 hour
Or use nomogram
Nomogram
Body Weight in Kg
45
50
55
60
65
70
75
80
85
90
95
≥100
Total Dose (mg)
0.9mg/kg
40.5
45
49.5
54
58.5
63
67.5
72
76.5
81
85.5
90
Bolus Dose (mg)
10% of total
4.0
4.5
4.9
5.4
5.8
6.3
6.7
7.2
7.6
8.1
8.5
9.0
Infusion Dose (mg)
Total dose - Bolus Dose
36.5
40.5
44.6
48.6
52.7
56.7
60.8
64.8
68.9
72.9
77.0
81.0
10
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Appendix 3: Mixing & Administration of Alteplase (Actilyse®)
Equipment
Sufficient Actilyse vials for Total Dose (Each package containing drug in vial as powder, diluent in vial
and mixing cannula)
2x 50mL Syringes
2x 10mL syringes
One Syringe Driver pump (Alaris IVAC P6000) and tubing
Intravenous Medication Labels
100mL 0.9% saline solution for priming lines and flushes
2x 14G (green) needles
Antiseptic wipes
Mixing the Actilyse
1. Check the dose and expiry dates of the drug and diluent
2. Pierce the diluent bottle with the mixing cannula
3. Pierce the vial containing drug as powder with the other end of
the mixing cannula and direct the diluent onto the powder
4. When all the diluent has entered the powder vial remove the
mixing cannula and dissolve the powder by swirling or gently inverting. Do not shake.
5. Repeat for other packages of Actilyse® until sufficient drug for the total dose has been prepared
6. Leave the solution to stand to clear large bubbles
7. The final solution is at a concentration of 1mg/mL
Preparing and administering the Bolus Dose
1. The bolus dose should be prescribed on the Once-only section of the drug chart by the
Thrombolysis Registrar (TR) or Stroke Consultant (SC)
2. Using a 10mL syringe and green needle, withdraw the calculated bolus dose
3. Sterilise the port of the cannula using an antiseptic wipe
4. Confirm the patency of the intravenous cannula with a 0.9% saline flush
5. The bolus dose should be administered over 1-2 minutes by the TR or SC
6. The drug chart prescription should be signed by the TR or SC with the time of bolus administration
Preparing and Administering the Infusion Dose
1. The infusion dose should be prescribed on the patient's infusion chart by the TR or SC
2. Using 50mL syringes and green needles draw up the total infusion dose (most patients will require
two syringes)
3. Label the syringes according to WSAHS policy
4. Insert the first 50mL syringe into the syringe driver and prime the tubing
5. Set at a rate in mL/hour equal to the total infusion dose (eg if the total infsuion dose is 64.8mg,
the rate should be 64.8 mL/hour)
6. Sign and time the prescription on the infusion chart
6 If a second 50mL syringe is needed, replace the first syringe with the second at the end of the first
infusion
7. At the end of the total infusion, flush the tubing with normal saline
12
Appendix 4: Nursing Care of Patients Treated with Alteplase
Observations and Monitoring
Initial assessment
Temperature, Pulse, BP, Respiratory rate SaO2, Neurological Observations, BSL
Stroke patients should have continuous cardiac monitoring for first 24 hours
Prethrombolyis
Pulse, BP, Neurological observations every 15 minutes
Oral and skin integrity
During thrombolysis
Continuous cardiac monitoring
Pulse, BP & Neurological observations every 15 minutes
Observe for signs of bleeding
Post thrombolysis
Pulse, BP & Neurological Observations
every 15 minutes for first 2 hours,
then every 30 minutes for the next 6 hours,
then hourly until 24 hours after treatment
Observe for signs of bleeding
Additional Nursing Requirements for Thrombolysis patients
1. Avoid insertion or removal of indwelling catheters, removal of intravenous cannulae, IM
injections, shaving or other invasive procedures during the first 24 hours after treatment.
Venepuncture should be performed carefully and only as required
2. If peripheral bleeding occurs, apply pressure until the bleeding stops to prevent haematoma
formation
3. Avoid toothbrushes, mouth wash or soft sponge to prevent oral trauma within the first 24
hours
4. Ensure patient safety is maintained to avoid potential trauma or falls
5. Explain the reasons for monitoring and treatment to patient and family members as well as the
usual information about stroke
6. Patients with elevated BP (SBP>180mmHg or DBP> 110mmHg) are at increased risk of bleeding.
Patients who exceed these BP thresholds will need to have medical review for consideration of
antihypertensive therapy.
7. The commonest complications of thrombolysis are hypersensitivity reactions (such as
angioedema) and intracranial or systemic bleeding. Nurses should be aware of these and act
according to the thrombolysis procedure if they occur
13
Appendix 5: Actilyse ® (Alteplase) Product Characteristics
USE / DESCRIPTION
Alteplase, is recombinant tissue plasminogen activator (rtPA). It is used in the treatment of acute
ischaemic stroke, acute myocardial infarction and acute pulmonary embolus
Alteplase is a serine protease that has the property of fibrin enhanced conversion of plasminogen to
plasmin. Alteplase produces minimal conversion of plasminogen in the absence of fibrin; and when
introduced into the systemic circulation, Alteplase binds to fibrin in a thrombus and converts the
entrapped plasminogen to plasmin. This initiates local fibrinolysis with minimal systemic effects.
Alteplase is produced by recombinant DNA technique using a Chinese hamster ovary cell-line.
The pH of the reconstituted solution is 7.3 +/- 0.5 (1).
PREPARATION/ PRESENTATION:
ACTILYSE® (Injection) Alteplase (recombinant tissue plasminogen activator (rtPA)); white;
lyophilised
powder
for
reconstitution
with
water
for
inj;
Dose: IV admin in hospital only; see full product information
Pack: 10 mg (+ 10 mL solv.) [1]
Pack: 50 mg (+ 50 mL solv.) [1]
Pack: 50 mg (+ 50 mL solv.) [1] x2
The reconstituted solution should then be administered intravenously. It may be diluted further with
sterile physiological saline solution (0.9 %) up to a minimal concentration of 0.2 mg/ml. The
reconstituted solution may be diluted further with sterile physiological saline solution (0.9 %) up to
1:5 . Avoid excessive agitation during dilution; mix by gently swirling and/ or slow inversion
It may not, however, be diluted further with water for injections or carbohydrate infusion solutions,
e. g. dextrose
Alteplase must not be mixed with other drugs, neither in the same infusion-vial nor via the same
catheter
LOADED BY:
MO/ RN or Pharmacy
STORAGE:
Shelf life is 36 months
Chemical and physical in-use stability of the reconstituted solution has been demonstrated for 24
hours at 2 - 8°C and 8 hours at 25°C. From a microbiological point of view, the product should be
used immediately
Special precautions for storage
Do not store above 25°C.
14
Protect from light. Store in the original package
STROKE THROMBOLYSIS PROCEDURE SUMMARY SHEET
(EMERGENCY DEPARTMENT)
Step
If still eligible for treatment arrange
urgent CT brain, CBC, EUC, Clotting ,
Glucose
□
□
□
□
□
Patient assessed by Thrombolysis
Registrar. NIHSS performed, history,
examination and results reviewed
□
Patient Identified as Possible Stroke
Within 4.5 hours of symptom Onset
Patient Transferred to Monitored Bed
and Observations Performed
(Appendix 4)
Patient Assessed. Diagnosis of stroke
established. Contraindications
reviewed (Appendix 1)
Thrombolysis Registrar Contacted
Decision to offer thrombolysis
Consent obtained
Alteplase dose calculated
(Appendix 2)
Alteplase prepared (Appendix 3)
Bolus dose administered
Infusion commenced
□
□
□
□
□
□
Person Responsible
Procedure
Point
Triage Nurse
1
ED Nurse
2
ED Doctor
3
ED Doctor
4
ED Doctor
5
Thrombolysis Registrar
(and/or Stroke Consultant)
7
Stroke Consultant
8
Thrombolysis Registrar
(and/or Stroke Consultant)
9
Thrombolysis Registrar
(and/or Stroke Consultant)
10
ED Nurse
11
Thrombolysis Registrar
(and/or Stroke Consultant)
11
ED Nurse
11
15
□
Monitoring of patient (Appendix 4)
ED & Stroke Unit Nurses
12, 13, 14
REFERENCES
Adams et al. Guidelines for the early management of patients with ischemic stroke. Stroke
2007;38:1655-1711
Braimah et al. Nursing care of Acute Stroke Patients After Receiving rt-TPA therapy. Journal of
Neuroscience Nursing 1997:373-383
del Zoppo et al. Expansion of the Time Window for Treatment of Acute Ischaemic Stroke with
Intravenous Tissue Plasminogen Activator. Stroke 2009;40:2945
Ford et al. Intravenous Alteplase for Stroke In Those Older than 80 Years Old. Stroke 2010;41:2568
Hacke et al. Thrombolysis with Alteplase 3-4.5 hours after Ischaemic Stroke. NEJM 2008; 359:131729
National Stroke Foundation. Clinical Guidelines for Stroke Management 2010. Melbourne Australia
NiNDS rt-PA Study Group. Tissue Plasminogen activator in Acute Ischemic Stroke NEJM
1995;333:1581-1587
Summary of Product Characteristics: Actilyse® Boeringer-Ingelheim.
http://www.medicines.org.uk/emc/medicine/308/SPC/Actilyse/
The Brain Attack Coalition. TPA Stroke Study Guidelines.
www.stroke-site.org/guidelines/tpa_guidelines.html
Wardlaw et al. Thrombolysis for Acute Ischaemic Stroke (Cochrane Review). In: The Cochrane
Library. Issue 4, 2003. Oxford, UK: Update Software, Cochrane Library, John Wiley & Sons
VERSION HISTORY
Date of Issue
23 March 2009
8 November 2010
Document Version
Thrombolysis in Acute StrokeWestmead Hospital PP08/638
Procedure 1.0
Change Details
Author
Policy revision of original
policy February 2004
Mr Nazih Beydoun,
NUM
Stroke
Unit
Westmead Hospital
Reformatted as procedure.
Expansion of time-window.
Revision of authorisation of
thrombolysis practice.
Dr Andrew Evans, Staff
Specialist, Westmead
Hospital
16
Clarification of alteplase
administration practices.
17