Stroke Reperfusion Therapy: IV t-pa Treatment Phase

Transcription

1 Strke Reperfusin Therapy: IV t-pa Treatment Phase IV tpa Administratin fr Adult Patients Arriving Within 3 Hurs. Cnsent Frm Indicatins fr IV tpa Cntraindicatins Warnings t-pa Dsing Treatment Phase ED Nurse Repnsibilities Neurlgist Respnsibilities Pst Treatment Phase ED Nurse Repnsibilities Neurlgist Respnsibilities tpa patient inf sheet References Authring InfrmatinCmments in brackets dente activities specific t MGH, r additinal cmmentary regarding natinal standards r guidelines. Fr example: Prir t making any medical decisins, please view ur disclaimer. Cnsent Frm IV Cnsent Frm Indicatins fr IV tpa Age greater than r equal t 18 yrs A significant neurlgic deficit expected t result in lng term disability Nn-cntrast CT scan shwing n hemrrhage r well-established new infarct Acute ischemic strke symptms with nset r last knwn well, clearly defined, less than 3 hurs befre t-pa will be given (nte additinal warnings fr the hur time perid belw) Cntraindicatins These are based n FDA apprved labeling f alteplase. Cntraindicatins include any f the fllwing: SBP greater than 185 r DBP greater than 110 mmhg (see BP Managment) [despite medical interventin t lwer it] Recent intracranial r spinal surgery, head trauma, r strke (less than 3 mnths) Histry f intracranial hemrrhage r brain aneurysm r vascular malfrmatin r brain tumr

2 [may cnsider iv tpa in patients with CNS lesins that have a very lw likelihd f bleeding such as small unruptured aneurysms r benign tumrs with lw vascularity] Active internal bleeding (within prir 21 days) Platelets less than 100,000, PTT greater than 40 sec after heparin use, r PT greater than 15 r INR greater than 1.7, r knwn bleeding diathesis [see prtcl fr starting tpa while awaiting results f PT/PTT] Current use f nvel ral anticagulants [NOACs] (direct thrmbin inhibitrs r factr Xa inhibitrs) within 48 hurs f evaluatin r with abnrmal labs if >48hrs (aptt, INR, platelet cunt, r ECT, TT, r factr Xa essays) Suspicin f subarachnid hemrrhage [by imaging r clinical presentatin] Arterial puncture at nn-cmpressible site within prir 7 days CT findings (ICH, SAH, r majr acute infarct signs) [e.g. hypdensity greater than 1/3 cerebral hemisphere] Warnings These cnditins may increase the risk f unfavrable utcmes but are nt necessarily a cntraindicatin t treatment: Seizure at nset [if residual deficits are thught t be due t the pstictal state rather than t ischemia] Majr surgery/trauma (less than 15 days) Recent GI r urinary tract bleeding (within 21 days) Strke severity - t severe (e.g., NIHSS greater than 22) [At MGH, we typically d nt exclude patients based n an increased NIHSS alne.] Glucse less than 50 r greater than 400 mg/dl [if residual deficits are due t the altered metablic state rather than t ischemia. If rapid diagnsis f vascular cclusin can be made, treatment may be given.] Recent MI (within 3 mnths) and/r Left heart thrmbus dcumented Increased risk f bleeding due t any f the fllwing: Acute pericarditis Subacute bacterial endcarditis (SBE) Pregnancy Hemstatic defects including thse secndary t severe hepatic r renal disease Diabetic hemrrhagic retinpathy, r ther hemrrhagic phthalmic cnditins Septic thrmbphlebitis r ccluded AV cannula at seriusly infected site Patients currently receiving ral anticagulants, e.g., Warfarin sdium [and INR greater than 1.7] Advanced age Rapid imprvement Strke severity t mild [e.g. anticipate ability t discharge t hme] Life expectancy less than 1 year r severe c-mrbid illness r CMO n admissin *Fr extended windw IV thrmblysis ( hurs frm last seen well), additinal relative exclusin criteria exist t-pa Dsing Calculate the exact dse f t-pa using the t-pa Dsing Calculatr if patient's weight is knwn r measured. If estimating weight t 10 lb intervals, the Dsing Sheet belw may be used. Estimated Weight (lbs) Cnversin t Kilgrams (Kg) Ttal iv t-pa Dse (mg) at 0.9 mg/kg t-pa Blus (mg) *10% f ttal* t-pa Blus (ml) Discard Dse t-pa (Nt fr infusin) Infusin Dse (mg) Infusin Rate (ml/hr)

3 Treatment Phase ED Nurse Respnsibilities: Mix and draw up tpa per prtcl: Prvide physician with the 10% blus dse, either in CT area r ED bay Prepare the infusin If tpa is mixed but patient des nt receive drug, ntify pharmacist t return mixed t-pa and initiate rebate Once infusin begins mnitr vital signs as fllws: Every 15 min fr 2 hurs, then: Every 30 minutes fr 6 hurs, then: Every 60 minutes fr 16 hurs Ntify physician immediately if SBP/DBP greater than 175/100 D nt insert Fley catheter r nasgastric tube unless rdered Dcument hurly neurlgic reassessment (mre frequently if patient's cnditin changes) ED Physician Respnsibilities: Stand-by fr emergent management f ptential knwn side effects f IV t-pa: Bleeding cmplicatins Angiedema Neurlgist Respnsibilities (includes Resident, Fellw r Attending): Calculate IV tpa dse based n weight estimate and tpa dsing table: Dcument estimated weight Review with nursing staff t ensure accuracy Cnfirm BP within safe limits Write rder fr tpa ttal dse as a blus plus infusin Administer the 10% blus ver 1 minute and dcument time n ED medicatin rder sheet Repeat NIHSS evaluatin if patient exam has changed significantly Facilitate IAT fr patients that are eligible Strict cntrl f bld pressure fr 24 hurs per prtcl Request an Acute Strke admissin bed t the CMF/ICU Service. The patient remains under the care f the Acute Strke Team until fficially transferred t the CMF/ICU Attending. Patients eligible fr the Acute Strke Care Unit (ASCU) admissin n Lunder 7 pst-iv t-pa must be strictly cnsidered fllwing the ACSU prtcl. Crdinate the pst tpa care with the ED attending t ensure cntinuity until the patient can be transferred ut f the ED Management f bld pressure (see BP Management)

4 Pst Treatment Phase ED Nurse Respnsibilities Dcument neurlgic assessment hurly r mre frequently if changes ccur Vital sign mnitring as described abve under Treatment Phase Verify the patency f IV and cmpletin f the tpa dse Prvide nursing reprt t the accepting nurse Prvide family/patient with apprpriate resurce materials abut strke Neurlgist Respnsibilities (includes Resident, Fellw r Attending) ICU/Acute Strke Care Unit admissin fr mnitring during first 24 hurs Use the standard pst- t-pa rder set and mdify, as indicated Order rutine nn-cntrast head CT at 24 hurs pst treatment (r STAT with any wrsening in neurlgical status) Vital signs every 15 minutes fr 2 hurs, then every 30 minutes fr 6 hurs, then every 1 hur fr 16 hurs Strict cntrl f bld pressure fr 24 hurs per prtcl Restrict patient intake t strict NPO including meds until swallwing screen perfrmed and passed Cntinuus pulse ximetry mnitring, rder xygen by nasal cannula r mask t maintain O2 sat greater than 95% Tylenl 650 mg p(pr if still NPO) every 4 hurs PRN T greater than 99.4; cnsider cling fr T greater than 102 N antiplatelet agents r anticagulants (including heparins fr DVT prphylaxis) in first 24 hurs N Fley catheter, nasgastric tube, arterial catheter r central venus catheter fr 24 hr, unless abslutely necessary Fr any acute wrsening f neurlgic cnditin: Fr suspected symptmatic hemrrhage after t-pa r ther plasmingen activatr has been given: Hld administratin f IV t-pa if still infusing until head CT r alternative imaging (if hemrrhage is suspected elsewhere) has been cmpleted and shws n evidence f bleeding. Exclude ther pssible causes f neurlgic wrsening r acute hemdynamic instability. Check STAT labs: CBC, PT, PTT, platelets, fibringen and D-dimer. Send bld bank sample fr type and screen, crss-match and hld packed red cells apprpriate t the hemrrhage vlume, lcatin, and assciated symptms Fr uncntrlled, life-threatening bleeding, cnsider amincapric acid (Amicar) 10 g IV in 250 cc NS IV ver 1 hr (nte: there is a significant risk f pathlgic thrmbsis with Amicar). Fr systemic hemrrhage, cmpress any cmpressible sites f bleeding, and cnsult apprpriate additinal services t cnsider mechanically ccluding arterial r venus surces f medically uncntrllable bleeding. Fr Allergic reactins Fr cnfirmed symptmatic hemrrhage n Head CT Check STAT labs: CBC, PT, PTT, platelets, fibringen and D-dimer. If hypfibringenemia present, treat with anitfibrinlytic r crypreciptate (r bth) as fllws: Give anti-fibrinlytic: eg, amicar 5 gram blus i.v. ver min If fibringen less than 100 mg/dl, then give cryprecipitate 10 units. If still bleeding at 1 hr and fibringen level still less than 100 mg/dl, repeat cryprecipitate dse. Institute frequent neurchecks and therapy f acutely elevated ICP, as needed. Additinal Optins r cnsideratins If mild, eg rash, itching: Immediately stp the t-pa infusin 1. If patient has a knwn platelet disrder, give 6 units platelets. 2. Fr uncntrlled, life-threatening bleeding, cnsider amincapric acid (Amicar) 10 grams IV in 250 cc NS IV ver 1 hr as a last resrt. Nte there is a significant risk f pathlgic thrmbsis with Amicar. 3. Serius systemic hemrrhage shuld be treated in a similar manner. Manually cmpress and cmpressible sites f bleeding, and cnsult apprpriate additinal services t cnsider mechanically ccluding arterial r venus surces f medically uncntrllable bleeding Administer diphenhydramine (Bendaryl) 25-50mg IV x 1.

5 PO) Cnsider sterid, i.e., hydrcrtisne 100mg IV x 1 (r methylprednislne dsepack (Medrl Pak) dse pack, if patient can take Nebulizatin if brnchspasm (uncmmn) If mderate r severe, eg facial r lingual swelling, anaphylaxis, etc: Immediately stp the t-pa infusin, alert the ED team Administer epinephrine (Epipen(R) 0.3mg in 0.3ml) IM (r if severe Epinephrine IV) Blus 1-2L NS rapidly Supplement xygen. The patient may require intubatin. Facilitate respiratry evaluatin and securing the airway Crdinate care with accepting CMF team resident References 1. Jauch EC, Saver JL, Adams HP Jr, Brun A, Cnnrs JJ, Demaerschalk BM, Khatri P, McMullan PW Jr, Qureshi AI, Rsenfield K, Sctt PA, Summers DR, Wang DZ, Wintermark M, Ynas H; American Heart Assciatin Strke Cuncil; Cuncil n Cardivascular Nursing; Cuncil n Peripheral Vascular Disease; Cuncil n Clinical Cardilgy. Guidelines fr the early management f patients with acute ischemic strke: a guideline fr healthcare prfessinals frm the American Heart Assciatin/American Strke Assciatin. Strke Mar;44(3): di: /STR.0b013e a. Epub 2013 Jan Albers GW, Amarenc P, Eastn JD, Sacc RL, Teal P. Antithrmbtic and thrmblytic therapy fr ischemic strke: the Seventh ACCP Cnference n Antithrmbtic and Thrmblytic Therapy. Chest Sep;126(3 Suppl):483S-512S.American Heart Assciatin. Guidelines fr Cardipulmnary Resuscitatin Emergency Cardivascular Care. Circulatin. 2000, 102 (suppl I): I-1 I Natinal Institute f Neurlgical Disrders and Strke Sympsium. Imprving the chain f recvery fr acute strke in yur cmmunity: task frce reprts. Bethesda, MD: Natinal Institutes f Health, Department f Health and Human Services; Marler JR, Jnes PW, Emr M, eds. Setting New Directins fr Strke Care: Prceedings f a Natinal Sympsium n Rapid Identificatin and Treatment f Acute Strke. Bethesda, MD: Natinal Institute f Neurlgical Disrders and Strke; Bck BF. Prceedings f a Natinal Sympsium n Rapid Identificatin and Treatment f Acute Strke: Respnse System fr Patients Presenting With Acute Strke. August 23, Authring Infrmatin Reviewed/Apprved by: Rst, Natalia, M.D., M.P.H. n behalf f ASQT Last updated: 1/16/2015