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Administration of t-PA: Preventing Complications

Administration of t-PA: Preventing Complications . ACUTE ISCHEMIC STROKE. Carolyn Walker RN, BN January 2011. t-PA Administration/ Preventing Complications of Stroke. Learning Objectives : Upon completion of this session, participants will be able to:

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Administration of t-PA: Preventing Complications

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  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 (N=2776) Pooled Analysis NINDS tPA, ATLANTIS, ECASS-I, ECASS-II Courtesy Brott T et al NNT 5 NNT 20

  6. 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

  7. Pre-Hospital Care: What’s 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 < 3 Dual antiplatelet therapy

  9. 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 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 < 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. • >50% 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. Prior to Infusion of t-PA: • EMS / Bypass, ER protocols • Early arrival to ER • Rapid Assessment - ABC’s, 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

  17. Prior to Infusion of t-PA: • IV Access: start 2 IV’s • #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

  18. 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!

  19. 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!

  20. 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

  21. 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

  22. 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

  23. 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

  24. 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

  25. 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)

  26. 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

  27. 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

  28. 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

  29. 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

  30. 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: STOPt-PA and notify physician.

  31. 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

  32. 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

  33. 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

  34. Continue Care toPrevent Complicationsof Stroke

  35. Worsening speech problems • Decreased responsiveness • BP climbing • Change in respirations What is happening?

  36. Post Stroke Complications are related to: Increased length of stay Poor outcomes Increased healthcare costs Preventing Complications • 60% stroke survivors experience complications

  37. Hemorrhagic transformation - Dysphagia Hypertension - Depression Cerebral Edema -Hyperglycemia Elevated Temperature - UTI Aspiration Pneumonia - DVT Post Stroke Complications

  38. 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

  39. 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

  40. Management CT Control BP Avoid use of anticoagulants Possible surgery Hemorrhagic Transformation

  41. 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 HemorrhagicTransformation

  42. 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

  43. 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

  44. Treatment of HypertensionwithCerebrovascular Disease • Strongly consider blood pressure reduction in all patientsafter the acute phase stroke • Expect to use combination therapy • ACE inhibitor, ARB, diuretic

  45. 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

  46. Cerebral Edema Brain Tissue Shift: Clinical Worsening

  47. 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) Cerebral Edema

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