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Administration of t-PA:

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Administration of t-PA: Preventing Complications ACUTE ISCHEMIC STROKE Carolyn Walker RN, BN January 2011 * Unnecessary handling of patient may cause bruising. – PowerPoint PPT presentation

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Title: Administration of t-PA:


1
Administration of t-PA Preventing Complications
 

ACUTE ISCHEMIC STROKE
Carolyn Walker RN, BN January 2011
2
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

3
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

4
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

5
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 (N2776) Pooled Analysis NINDS tPA,
ATLANTIS, ECASS-I, ECASS-II
Courtesy Brott T et al
NNT 5
NNT 20
6
Canadian Stroke StrategyBest 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 lt 60 minutes

7
Pre-Hospital Care Whats New?
  • WHEN CAN YOU TREAT WITH T-PA?

8
The Art of t-PA Decision Making
  • Treat Enthusiastically
  • Early
  • Young
  • Glucose, BP normal
  • On Protocol
  • Moderate-Severe Strokes
  • Good CT higher ASPECTS
  • Treat nervously and selectively (if at all)
  • Late
  • Old
  • ??Glucose, ??BP
  • Off Protocol
  • Minor Stroke
  • Bad CT ASPECTS lt 3
  • Dual antiplatelet therapy

9
Canadian Stroke StrategyBest Practice
Recommendations 2010
  • There is limited clinical trial data to support
    use of t-PA in the following circumstances
  • pediatric stroke
  • stroke patients gt 80 years old with diabetes
  • adults who do not meet current criteria for t-PA
    treatment
  • intra-arterial thrombolysis.
  • Obtain emergency consultation with a
    comprehensive stroke center

10
BRAIN ATTACKTIME IS BRAIN!
  • Get drug in fast!
  • 1.9 million neurons are destroyed each minute
    treatment is delayed
  • Goal - door to drug lt 30 min

11
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.
  • gt50 cleared within 5 min after infusion
  • 80 cleared within 10 min

12
Onset Time
  • Onset Time Time when patient was last seen well
  • Requires detective skills

13
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

14
Exclusion Criteria
  • Absolute Contraindications
  • Intracranial hemorrhage
  • Active internal bleeding
  • Endocarditis or acute pericarditis

15
Exclusion Criteria
  • Relative Contraindications
  • Consult Stroke Specialist

16
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17
Prior to Infusion of t-PA
  • EMS / Bypass, ER protocols
  • Early arrival to ER
  • Rapid Assessment - ABCs, LOC
  • Ensure Bloodwork is drawn
  • CBC, lytes, Cr, urea, glucose, INR, PTT, TSH,
    fasting lipids, CK and troponin
  • Determine eligibility for t-PA based on the
    inclusion/exclusion criteria.
  • TIME of ONSET is CRITICAL!
  • STAT CT of head

18
Prior to Infusion of t-PA
  • IV Access start 2 IVs
  • 1 used only for t-PA
  • Saline lock post infusion, and use for blood
    drawing only
  • 2 life line
  • for IV drug access/fluid administration
  • Patient / family education
  • Purpose of therapy
  • Potential side effects

19
Prior to Infusion of t-PA
  • Blood pressure management
  • Maintain SBP lt 185mmHg and DBP lt 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 lt 60bpm
  • Hydralazine 10-20mg IV push over 1 min q20 min
    prn
  • IF PROBLEMS OCCUR
  • CONTACT STROKE SPECIALIST
  • COMPREHENSIVE STROKE CENTER!

20
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21
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!

22
Preparing t-PA (continued)
  • Infusion Chart Look up patients 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 patients
    weight
  • t-PA Must be given with an INFUSION PUMP!!
  • 0.9 mg/kg (less 10 bolus) x 60 minutes

23
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

24
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 gt 180 mmHg and/or DBP gt105 mmHg

25
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26
Nursing Care during t-PA
  • Avoid taking BP in arm with IVs 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

27
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

28
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 gt 10 mmol/L
  • q4h x 24hr then reassess
  • If non-diabetic or lab glucose lt 10 mmol/L
  • qid x 48 hr then reassess
  • Notify physician if glucose gt 8 mmol/L
  • Recommend insulin by sliding scale (sc or IV)

29
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

30
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

31
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 lt 100 ml

32
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

33
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.

34
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

35
Adverse Effects of t-PA
  • Nausea Vomiting
  • 25 of patients
  • Allergy/Anaphylaxis
  • lt0.02 of patients
  • Observe for skin eruptions, airway tightening
  • Unexplained hypotension may occur as an immune
    reaction

36
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

37
Continue Care toPrevent Complications of Stroke
38
  • Worsening speech problems
  • Decreased responsiveness
  • BP climbing
  • Change in respirations
  • What is happening?

39
Preventing Complications
  • Post Stroke Complications are related to
  • Increased length of stay
  • Poor outcomes
  • Increased healthcare costs

60 stroke survivors experience complications
40
Post Stroke Complications
  • Hemorrhagic transformation - Dysphagia
  • Hypertension - Depression
  • Cerebral Edema -Hyperglycemia
  • Elevated Temperature - UTI
  • Aspiration Pneumonia - DVT

41
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

42
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

43
Hemorrhagic Transformation
  • Management
  • CT
  • Control BP
  • Avoid use of anticoagulants
  • Possible surgery

44
Hemorrhagic Transformation
  • Blood Pressure Control
  • Hold emergency HTN treatment unless
  • SBP gt 220mmHg or DBP gt 120mmHg
  • Be awareaggressive lowering of BP may cause
    neurological worsening
  • Lower BP cautiously 15-25 within first day
  • Maintain Blood Pressure Control - with t-PA

45
Hypertension During Acute Stroke
  • Occurrence
  • Systolic BP gt 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
46
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

47
Treatment of Hypertensionwith Cerebrovascular
Disease
  • Strongly consider blood pressure reduction
  • in all patients after the acute phase stroke
  • Expect to use combination therapy
  • ACE inhibitor, ARB, diuretic

48
Management of Hypertension
  • Target most patients still lt 140/90
  • Home Measurement lt 135/85
  • Diabetics lt 130/80
  • Lifestyle Modification
  • Sodium restriction, DASH diet, physical activity,
    weight loss, alcohol restriction, smoking
    cessation

49
Cerebral Edema
Brain Tissue Shift Clinical Worsening
50
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)

51
Hyperglycemia
  • Patients with elevated blood sugars have a poorer
    prognosis
  • Like hypertension, stress related hyperglycemia
    will resolve naturally within 24 hours.

52
Hyperglycemia
  • Management
  • Check sugar initially on all patients
  • Continue monitoring if sugars gt 8mmol/ L or
    diabetic
  • sliding scale insulin as necessary
  • Resume regular diabetic meds as soon as is
    possible
  • Administer fluids without glucose

53
  • Increased respirations
  • Increasing heart rate
  • Fever
  • What is happening?

54
Elevated Temperature
  • Patients with elevated temperature are more
    likely to have a poor outcome
  • Can have elevated temperature without infection
  • Management
  • Treat temperature gt 38.0 C with acetaminophen
  • Use cooling measures (fans, cooling blankets)
  • avoid shivering
  • Investigate cause of temperature

55
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

56
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

57
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

58
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

59
  • Increased respirations
  • Increasing heart rate
  • Fever
  • Chest congestion
  • What is happening?

60
Aspiration Pneumonia
  • More occurrence with severe strokes
  • - immobile, poor cough, dysphagia,
  • May result from
  • - vomiting, bed rest, seizures, mechanical
    ventilation

61
Aspiration Pneumonia
  • Signs and Symptoms
  • Tachypnea
  • Tachycardia
  • Fever
  • Wheezing
  • Rales
  • Chills
  • malaise

62
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)

63
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

64
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

65
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

66
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

67
Urinary Tract Infection
  • Management
  • Maintain hydration and
  • nutrition
  • Administer antibiotics
  • Treat fever and pain
  • Monitor urine output

68
Deep Vein Thrombosis (DVT)
  • A blood clot in the veins of the lower limbs
  • Most DVTs 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

69
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
70
Prevent ComplicationsReturn to Action!
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