Thrombolysis administration
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1 Thrombolysis administration Liz Mackey Stroke Nurse Practitioner Western Health Sunshine & Footscray Hospital, Melbourne
2 Thanks ASNEN committee members Skye Coote, Acute Stroke Nurse, Eastern Health (slide 5) Lizzie Dodd, Clinical Practice Consultant, Acute Stroke Unit Coordinator, The Queen Elizabeth Hospital, SA Health (slide 21) 2
3 Outline Pharmacology Inclusion / Exclusion criteria Administration 3
4 Fibrin and the clot Fibrin, the protein that forms the meshwork of the clot 4
5 What is tpa? Tissue plasminogen activator Fibrinolytic agent i.e. Clot Buster Activates plasminogen to form plasmin Plasmin lyses fibrin 5
6 Inclusion criteria Onset symptoms within hours at the time of treatment initiation Clinical diagnosis of ischaemic stroke causing measurable neurological deficits (impaired language, motor function, cognition and / or gaze, vision, or neglect). Patient able to undergo a CT (+/- perfusion) before t-pa administration CT scan findings compatible with ischaemic stroke Age > 18 years. 6
7 Exclusion criteria Absolute contraindications Patient should not receive thrombolysis: the risk of bleeding / complications is too great Relative contraindications Consider the overall picture and risk versus benefit Discuss with stroke / neurology consultant May need to discuss with other specialist consultant(s) 7
8 Exclusion criteria Thrombolysis should not be given if: Likely aetiology other than brain ischaemia. Evidence of acute or chronic intracranial haemorrhage on CT. Clinical presentation of subarachnoid haemorrhage even if the initial CT is normal. Coma or severe obtundation with fixed eye deviation and complete hemiplegia. Hypertension (systolic >185mmHg or diastolic > 110 mmhg) on repeated measures prior to administration of tpa without response to medication. Presumed septic embolus. Blood Glucose < 2.8 or > 22 mmol/l. Pre-existing neurological illness resulting in a Modified Rankin Scale Score of 3 or higher Other serious, advanced, or terminal illness that would impose a significant hazard to the patient if the intravenous tpa were initiated. 8
9 Exclusion criteria * Relative contraindications: Discuss with the on-call neurologist. Known hereditary or acquired haemorrhagic diathesis (Platelet count < /mm³, Activated Partial Thromboplastin Time (APTT) or Prothrombin Time (PT) greater than normal), or oral anticoagulant therapy with an International Normalised Ratio (INR) of >1.7. * Intracranial neoplasm that is terminal or would increase the risk of intracranial bleeding after the administration of thrombolytic therapy, or may confound neurological assessment. * History of stroke / serious head trauma / intracranial or intraspinal surgery within previous 90 days. * Past history of intracranial haemorrhage, subarachnoid haemorrhage, arteriovenous malformation or aneurysm.* 9
10 Exclusion criteria * Relative contraindications: Discuss with the on-call neurologist. Early infarct signs greater than 1/3 of the middle cerebral artery territory.* Seizure on presentation. * Myocardial Infarction (within 90 days) * Major surgery (within 14 days) or arterial puncture at non-compressible site (within 7 days). * Recent trauma (within 30 days) with internal injuries or ulcerative wounds. * Gastrointestinal or urinary tract haemorrhage (within 21 days). * Pregnancy or parturition within the previous 30 days. * 10
11 Administration dose Dose = weight based on mg / kg 0.9 mg/kg IV 10% = bolus, injected over 1-minute WITHIN one-minute start infusion Remaining 90% infused over 1 hour 100 kg: Administer 10% of total dose as initial bolus over 1 minute; THEN 0.81 mg/kg as continuous infusion over 60 min; not to exceed total dose of 90 mg >100 kg: total dose = 90mg Administer 9 mg (10% of 90 mg) as IV bolus over 1 min; THEN 81 mg as a continuous infusion over 60 min 11
12 Patient Weight (kg) Total 0.9mg/kg (mg) Vol. of 1mg/ml Alteplase Patient Weight (kg) Total 0.9mg/kg (mg) Vol. of 1mg/ml Alteplase 10% Bolus (ml) 90% Infusion (ml) 10% Bolus (ml) 90% Infusion ml) kg & over
13 Administration infusion options 1. Syringe driver Image 13
14 Administration infusion options 2. Pump 14
15 Image medimart.com Western Health protocol 15
16 Western Health infusion pump program 16
17 Cost of alteplase at Western Health 50mg = $ mg = $ image 17
18 18
19 19
20 Administration drawing up the tpa 20
21 Reactions Anaphylactoid reactions Rash Urticaria Bronchospasm Hypotension Shock Angioedema Angioedema: Rare (1-2%) but potentially life-threatening Angioedema assessment: Check tongue size at beginning of infusion. Repeat every 15 minutes until 30 mins after tpa infusion Look for signs of bilateral or unilateral tongue enlargement Look for other signs of allergy 21
22 Administration guidelines for first 24-hrs Time Line 0 hrs THROMBOLYSIS ADMINISTRATION GUIDELINES First 24 Hours 10% bolus given over 1 minute Remaining 90% given as an infusion over 1 hour Monitor BP & GCS every 15 min - BP should be < 185/110 mmhg to be eligible for Alteplase treatment If SBP > 185 mmhg or DBP > 110 mmhg follow protocol for hypertensive management 22
23 Administration guidelines for first 24-hrs 0 2hr 15 minutely Neuro/Vital signs including temp for 2 hours to commence infusion. Report SBP<100mmHg or >185mmHg and DBP > 110mmHg (ongoing) Manual BP cuffs should be used instead of automatic BP machines to avoid over-inflation and bruising as a result of this Internal and external bleeding assessment (ongoing) Strict FBC (ongoing) Risk Assessment falls prevention (ongoing) Avoid any invasive therapies during Alteplase administration. If stable, organise transfer to Acute Stroke Unit 23
24 Administration guidelines for first 24-hrs 2 6 hrs 6 hrs 6 10 hrs ½ hourly GCS & vital signs & 1/24 temps for 4 hours. All urine & faeces to be screened for blood Internal and external bleeding assessment ongoing Avoid cannulation, IDC/NGT insertion for six hours post tpa Risk Assessment falls prevention (ongoing) NO anti-coagulation / anti-platelet therapy for 24-hours Bloods: (CK, Troponin, clotting, FBE) 1 hourly GCS & vital signs for 4 hours Internal and external bleeding assessment ongoing Risk Assessment falls prevention (ongoing) 24
25 Administration guidelines for first 24-hrs hrs 2 hourly GCS & vital signs for 12 hours GIT assessment including Speech Pathology Assessment Nasogastric tube can now be inserted if required All urine to be screened for blood 12hrs Pathology (FBE, clotting profile) 22hrs + 4 hourly GCS & vital signs until review 25
26 26
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