1 / 70

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:

lirit
Télécharger la présentation

Administration of t-PA: Preventing Complications

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  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

More Related