Download t-PA Administration: Preventing Complications of Stroke

Administration of t-PA:
Preventing Complications
ACUTE ISCHEMIC STROKE
Carolyn Walker RN, BN
January 2011
QuickTime™ and a
None decompressor
are needed to see this picture.
t-PA Administration/ Preventing
Complications of Stroke
Learning Objectives:
Upon completion of this session, participants will be able to:

Describe the action of t-PA in relation to acute ischemic stroke

Identify criteria necessary for the administration of t-PA

Explain recommended preparation, administration,
assessment and on-going care of t-PA infusion

Identify possible adverse effects of t-PA administration

Identify signs and symptoms of 10 common stroke
complications

Describe the appropriate management of common stroke
complications
Thrombolysis in Acute Stroke
Rationale:
 Limit size of infarct by dissolving clot &
restoring blood flow to ischemic brain

Neuronal death & infarction evolve in a
time dependent manner

Prompt treatment with a thrombolytic
agent may promote reperfusion & improve
functional outcomes
t-PA (Activase) in Acute Ischemic Stroke
NINDS Study (1995) – Thrombolytic (t-PA)
given IV within 3 hours of stroke symptom onset
for treatment for acute ischemic stroke:

Approved in US in 1996

Approval in Canada in 1999
Diminishing Returns over Time
Favorable Outcome (mRS 0-1, BI 95-100, NIHH 0-1) at Day 90 Adjusted odds ratio with 95% confidence interval by stroke
onset to treatment time (OTT) ITT population (N=2776)
Courtesy Brott T et al
Pooled Analysis NINDS tPA, ATLANTIS, ECASS-I, ECASS-II
NNT 5
NNT 20
Canadian Stroke Strategy:
Best Practice Recommendations 2010

All patients with disabling acute ischemic
stroke who can be treated within 4.5 hours
after symptom onset should be evaluated
without delay to determine their eligibility for
treatment with t-PA.

All eligible patients should receive
intravenous alteplase (t-PA) within one hour
of hospital arrival

door-to-needle time < 60 minutes
Pre-Hospital Care: What’s New?

WHEN CAN YOU TREAT WITH T-PA?
The Art of t-PA Decision
Making
Treat Enthusiastically
Early
Young
Glucose, BP normal
On Protocol
Moderate-Severe Strokes
Good CT – higher
Treat nervously and
selectively (if at all)
Late
Old
↑↑Glucose, ↑↑BP
Off Protocol
Minor Stroke
Bad CT – ASPECTS < 3
ASPECTS
Dual antiplatelet therapy
Canadian Stroke Strategy:
Best Practice Recommendations 2010

There is limited clinical trial data to support use
of t-PA in the following circumstances:
 pediatric stroke
 stroke patients > 80 years old with diabetes
 adults who do not meet current criteria for tPA treatment
 intra-arterial thrombolysis.
Obtain emergency consultation with a
comprehensive stroke center
BRAIN ATTACK
TIME IS BRAIN!

Get drug in fast!

1.9 million neurons are
destroyed each minute
treatment is delayed

Goal - door to drug < 30 min
Pathophysiology and t-PA

Thrombus is formed during ischemic stroke.

Alteplase binds to fibrin in a thrombus:
 converts plasminogen to plasmin
 initiates local fibrinolysis with minimal
systemic effects.

Alteplase is cleared rapidly from circulating
plasma by the liver.
 >50% cleared within 5 min after infusion
 80% cleared within 10 min
Onset Time

Onset Time = Time when patient was last
seen well

Requires detective skills
Inclusion Criteria

Acute ischemic stroke with disabling
neurological deficits

Acute ischemic stroke presenting within
4.5 hours of stroke symptom onset.

No hemorrhage on CT scan
Exclusion Criteria:
Absolute Contraindications:

Intracranial hemorrhage

Active internal bleeding

Endocarditis or acute pericarditis
Exclusion Criteria:
Relative Contraindications:
Consult Stroke Specialist
Prior to Infusion of t-PA:




EMS / Bypass, ER protocols
Early arrival to ER
Rapid Assessment - ABC’s, LOC
Ensure Bloodwork is drawn:


Determine eligibility for t-PA based on the
inclusion/exclusion criteria.


CBC, lytes, Cr, urea, glucose, INR, PTT, TSH*,
fasting lipids, CK* and troponin
TIME of ONSET is CRITICAL!
STAT CT of head
Prior to Infusion of t-PA:

IV Access: start 2 IV’s

#1: used only for t-PA


#2: ‘life line’


Saline lock post infusion, and use for blood drawing only
for IV drug access/fluid administration
Patient / family education


Purpose of therapy
Potential side effects
Prior to Infusion of t-PA:

Blood pressure management
Maintain SBP < 185mmHg and DBP < 110mmHg
BP Treatment:

Labetalol 10-20mg IV push over 1-2 min,
repeat q10-20 min prn (max 300mg).
Do NOT use ß-blockers if HR < 60bpm

Hydralazine 10-20mg IV push over 1 min q20 min prn
IF PROBLEMS OCCUR
CONTACT STROKE SPECIALIST
COMPREHENSIVE STROKE CENTER!
Preparing t-PA: 100mg Vial

Holding Activase vial upside down, insert
other end of transfer device into center of
the stopper - Invert vials

Allow vials to sit undisturbed till foam subsides
(takes only seconds)
DO NOT SHAKE THE VIAL AS IT WILL
DENATURE THE PROTEIN STRANDS

TIME IS BRAIN!
Preparing t-PA (continued)

Infusion Chart: Look up patient’s weight to
determine bolus amount
 Withdraw bolus and give over 30-60 seconds
 Spike reconstituted vial of t-PA with infusion
tubing, and prime line
 Set infusion pump at rate listed for patient’s
weight
t-PA Must be given with an INFUSION PUMP!!

0.9 mg/kg (less 10% bolus) x 60 minutes
Precautions!!





Do not mix t-PA with any other medications.
Do not use IV tubing with infusion filters.
All patients must be on a cardiac monitor
When infusion is complete, saline lock IV and
flush with N/S
t-PA must be used within 8 hours of mixing when
stored at room temperature or within 24 hours if
refrigerated
Assessment during and after t-PA:
Vital Signs

Assess NVS, BP and Pulse


q15min x 2 hrs then q30 min x 6 hrs, q1hr x 16 hrs
and q4 hrs x 48 hrs
Assess NIHSS

Immediately after t-PA bolus, repeat at 30min, 60min,
3hr, 6hr and 24hr post t-PA initiation
If evidence of bleeding, neurological deterioration
(change of 2+ points on NIHSS), new headache
or nausea: - notify physician; arrange CT scan
Treat Blood Pressure:
If SBP > 180 mmHg and/or DBP >105 mmHg
Nursing Care during t-PA

Avoid taking BP in arm with IV’s or
venipunctures.
BP should be taken manually
 NIBP will cause petechiae


Avoid unnecessary handling of the patient.

Bed rest for 12 – 24 hours post t-PA
administration then reassess
Nursing Care during t-PA

No unnecessary venous or arterial punctures


Blood is drawn from IV saline lock if possible
Avoid invasive procedures

NG tubes, suction, or urinary catheterization

Apply pressure dressing to potential sources of
bleeding

Assess all secretions and excretions for blood
APSS Recommended t-PA
Protocol
Diet
 NPO for 6 hours post t-PA, pending swallow screen


Complete swallow screen prior to any oral intake
If fails, keep NPO then reassess
Glucose
 Monitor capillary glucose as follows:

If diabetic or lab glucose > 10 mmol/L


q4h x 24hr then reassess
If non-diabetic or lab glucose < 10 mmol/L

qid x 48 hr then reassess
Notify physician if glucose > 8 mmol/L
Recommend insulin by sliding scale (sc or IV)
APSS Recommended t-PA
Protocol
Antiplatelet/Anticoagulant Therapy
 No ASA, Clopidogrel, Aggrenox, Ticlopidine
or other antiplatelet agents for 24 hours from
start of t-PA
 No heparin, heparinoid or warfarin for 24
hours from start of t-PA
CT or MRI must be completed and reviewed by
physician to exclude intracranial hemorrhage prior to
above therapy
APSS Recommended t-PA
Protocol
Venous Thromboembolism Prophylaxis (DVT & PE)
 Assess patient daily for deep vein thrombosis

Intermittent pneumonic compression stockings while
on bed rest, then reassess

After 24h, if CT/MR is negative for hemorrhage,
consider the following when patient remains on bed
rest due to significant lower limb hemiparesis/plegia:


Unfractionated heparin sc 5000u q12 h OR
Enoxaparin 40mg sc q24h
APSS Recommended t-PA
Protocol
Bladder Management
 If possible, catheterize before t-PA admin




DO NOT DELAY t-PA for this
Avoid catheterization 5-7 hrs post t-PA
infusion
If unable to void - bladder scan and in/out
catheterization q4-6hrs
If voiding – do residuals daily until < 100 ml
CSS 2010 Recommendations:
Continence



Screen all stroke pts for urinary & fecal
incontinence and constipation
Use of portable ultrasound is recommended
Assess contributing factors




Meds, nutrition, diet, mobility, cognition,
environment and communication
Avoid indwelling catheters due to risk of
infection
Bladder training program
Bowel management program
Adverse Effects of t-PA
Bleeding

Superficial: due to lysis of fibrin in the
hemostatic plug


observe potential bleeding sites: venous &
arterial puncture, lacerations, etc.
Internal:

GI tract, GU tract, respiratory, retroperitoneal or
intracerebral
ACTIONS: If clinically significant bleeding or
deterioration of neuro status: STOP t-PA and
notify physician.
Adverse Effects of t-PA
Angioedema

Assess patient for signs of
Angioedema of the tongue:





Swelling of tongue/lips
notify Physician immediately
if swelling seen
1.3% of population
Assess at 30, 45, 60, 75 minutes after tPA bolus.
Once the t-PA infusion has finished the risk of
angioedema falls off
Patients on ACE inhibitors are at higher risk of
angioedema
Adverse Effects of t-PA
Nausea & Vomiting

25% of patients
Allergy/Anaphylaxis
<0.02% of patients
 Observe for skin eruptions, airway tightening
 Unexplained hypotension may occur as an
immune reaction

Follow-Up:

Repeat CT scan or
MRI scan at 18-30
hrs (approx 24 hrs)
post t-PA infusion

Daily neuro
assessments after
first 24 hours
Continue Care to
Prevent Complications
of
Stroke




Worsening speech problems
Decreased responsiveness
BP climbing
Change in respirations
What is happening?
Preventing Complications
Post Stroke Complications are related to:



Increased length of stay
Poor outcomes
Increased healthcare costs
60% stroke survivors experience
complications
Post Stroke Complications
Hemorrhagic transformation
 Hypertension
 Cerebral Edema
 Elevated Temperature
 Aspiration Pneumonia

- Dysphagia
- Depression
-Hyperglycemia
- UTI
- DVT
Hemorrhagic Transformation
Occurs in ~ 3% patients with ischemic stroke
~ 4% patients who received tPA
(within 36 hrs of infusion)
Cause:



Ischemic brain and damaged blood vessels
Injured blood vessels become “leaky”
Restored blood flow results in hemorrhage
Hemorrhagic Transformation
Occurrence influenced by:
 Size and location of infarct
 Degree collateral circulation
 Use of anticoagulants and interventions (ie. tPA)
Symptoms:



Neurological worsening
Increased BP
Respiratory changes
Hemorrhagic Transformation
Management




CT
Control BP
Avoid use of anticoagulants
Possible surgery
Hemorrhagic Transformation
Blood Pressure Control
Hold emergency HTN treatment unless:
SBP > 220mmHg or DBP > 120mmHg
Be aware…aggressive lowering of BP may cause neurological
worsening
Lower BP cautiously: 15-25% within first day
Maintain Blood Pressure Control - with t-PA
Hypertension During Acute Stroke
Occurrence:
 Systolic BP > 160mmHg is seen in over 60% stroke
patients (Robinson et al, Cerebrovasc Dis., 1997)

Often transient, lasting 24-72 hours and in most
patients does not require treatment.

BP declines within first hours after stroke without
medical treatment

Systolic BP has been noted to drop ˜ 28% during first
day, even without medications
Oliveira-Filho et al; 2003; Neurology; 61: 1047-1051
Why is Blood Pressure Increased?
Elevated blood pressure may be the result of:

Full bladder

Stress of cerebrovascular event
Nausea
Pain
Pre-existing hypertension
Physiological response to hypoxia
Increased intracranial pressure





Adams et al. Circulation; 2007; 115 : 478-534
Treatment of Hypertension
with Cerebrovascular Disease

Strongly consider blood pressure reduction
in all patients after the acute phase stroke

Expect to use combination therapy

ACE inhibitor, ARB, diuretic
Management of Hypertension

Target most patients still < 140/90



Home Measurement < 135/85
Diabetics < 130/80
Lifestyle Modification:

Sodium restriction, DASH diet, physical activity,
weight loss, alcohol restriction, smoking cessation
Cerebral Edema
Brain Tissue Shift: Clinical Worsening
Cerebral Edema
Incidence highest within 2-5 days of ischemic stroke
Symptoms:



Neurological worsening
Widening pulse pressure
bradycardia, resp changes
Management



Elevate HOB (prevent increasing ICP)
Frequent neuro assessment
Diuretics (ie. Mannitol)
Hyperglycemia
Patients with elevated blood sugars have a
poorer prognosis
Like hypertension, stress related hyperglycemia
will resolve naturally within 24 hours.
Hyperglycemia
Management





Check sugar initially on all patients
Continue monitoring if sugars > 8mmol/ L or diabetic
sliding scale insulin as necessary
Resume regular diabetic meds as soon as is possible
Administer fluids without glucose



Increased respirations
Increasing heart rate
Fever
What is happening?
Elevated Temperature
Patients with elevated temperature are more likely
to have a poor outcome
Can have elevated temperature without infection
Management


Treat temperature > 38.0 C with acetaminophen
Use cooling measures (fans, cooling blankets)


avoid shivering
Investigate cause of temperature
Dysphagia
Greek word meaning - “disordered eating”
Swallowing difficulties cause by damage to enervation of cranial
nerves IX, X, XI. Impaired coordination of swallowing
muscles or limited sensation in mouth/throat
Occurs in ~ 55% new onset strokes
~ 50% of these do not recover normal swallow by 6 months




Can cause airway obstruction and aspiration pneumonia
Can lead to dehydration, weight loss, malnutrition
Up to 70% dysphagic patients aspirate
up to 20% of those with stroke-related dysphagia die within first year
Dysphagia
Signs and Symptoms:







Choking, coughing during meals
Moist/ wet voice, nasal regurgitation
Drooling or loss of food from mouth, pocketing food in cheeks
Delay initiating swallow
Difficulty swallowing pills
Avoiding food or fluids
Dehydration, malnutrition
Dysphagia
Management:





NPO until swallow screen
Mouth care with minimal water - prevents colonization of
bacteria
Consult SLP, dietitian to recommend diet
Initiate enteral/parenteral feeds if unable to take PO fluids
within 48 hrs
Assist to eat: alert/calm environment
position upright
one spoonful at a time - slow, small bites
keep upright for 30 min post feeding
CSS 2010 Recommendations: Oral Care
Upon or soon after admission:

All Stroke patients should have



Oral/Dental assessment
Assessment to determine if neuromotor skills present
to safely wear full/partial dentures
Implement Oral care protocol (including use of dentures)


Consistent with Canadian Dental Assoc
Identify frequency, types of products, and
management with dysphasia
If concerns consult dentist, OT, SLP




Increased respirations
Increasing heart rate
Fever
Chest congestion
What is happening?
Aspiration Pneumonia
More occurrence with severe strokes
- immobile, poor cough, dysphagia,
May result from:
- vomiting, bed rest, seizures, mechanical
ventilation
Aspiration Pneumonia
Signs and Symptoms:







Tachypnea
Tachycardia
Fever
Wheezing
Rales
Chills
malaise
Aspiration Pneumonia
Prevention and Management:






Maintain NPO until swallow screen
Use minimal water with mouth care
Consult SLP
Protect airway and suction PRN
Prevent nausea and vomiting
Encourage deep breaths (prevent atelactasis)
Post Stroke Depression
Risk Factors:
 Female
 History of depression or psych illness
 Social isolation
 Functional impairment
 Cognitive impairment
Impact of PSD:
 Increased healthcare costs
 Poorer functional outcomes
 Slower stroke recovery
 Decreased quality of life
 Increased mortality
Post Stroke Depression
Symptoms: (often over looked)

sad, anxious, hopelessness, worthlessness,
helplessness, loss of interest in activities, decreased
energy, difficulty concentrating, insomnia,
oversleeping, thoughts of death/suicide, irritability

Reported prevalence

53% at 3 months

42% at 12 months
Post Stroke Depression
Management:

pharmacological
(Selective Serotonin Reuptake Inhibitors (SSRIs) and tricyclic antidepressants)





electroconvulsive therapy (ECT)
repetitive transcranial magnetic stimulation
(RTMS)
music therapy
speech therapy
cognitive Behavioural therapy
Urinary Tract Infection
usually following more severe stroke
Potential serious complication - sepsis
major cause is catheterization
avoid prolonged use of catheters
Symptoms:




Fever, chills, nausea, vomiting, malaise
Frequency, urgency, burning
Cloudy, pink or bloody urine
CONFUSION
Urinary Tract Infection
Management:




Maintain hydration and
nutrition
Administer antibiotics
Treat fever and pain
Monitor urine output
Deep Vein Thrombosis (DVT)
A blood clot in the veins of the lower limbs
Most DVT’s occur in first week after stroke
Highest risk if immobilized, elderly, severe stroke
Management:






Ambulate ASAP
Intermittent pneumonic compression stockings
Maintain hydration
Antithrombotic stockings
Anticoagulants as ordered
Monitor for possible PE
CSS 2010 Recommendations:
Mobilization

Mobilize all stroke patients as early and
frequently as possible - unless
contraindicated


Within 24 hours
Assess by rehab ASAP

Within 24-48 hours
CSS Best Practice Recommendations 2010
Prevent Complications:
Return to Action!