Team Work in Treatment of Acute Ischemic Stroke

Transcription

1 Diagnosis and Treatment in Acute Ischemic stroke July, 15 th Bach Mai Hospital Team Work in Treatment of Acute Ischemic Stroke Prof. Pham Minh Thong 1

2 Time is brain Ischemic stroke: big global burden Every second neurons die Every minute 1.9 million neurons die Every hour 120 million neurons die Completed stroke: loss of 1.2 billion neurons Blockage of one blood vessel will cause ischemia within 5 minutes -> Need of setting up the stroke center to manage and treat this problem probably 2

3 Time is brain! 3

4 Literature Review Alberts et al. (2000) reported Primary Stroke Centers improve care of patients with stroke (Level I, Grade A) Jauch et al. (2013) reported hospital should have an organized protocol for emergency evaluation of patient with suspected stroke Meta-analysis (Level I, Grade A) 4

5 Adams et al. (2007) reported ED physicians evaluation of acute stroke patients should be brief and thorough within 60 minutes of arrival in the ED Meta-Analysis (Level 1, Grade A) Jauch et al. (2013) reported healthcare institution should organize a multidisciplinary QI committee to review and monitor stroke care quality benchmarks, indicators, EBPs, and outcome Meta- Analysis (Level 1, Grade A) 5

6 -> All papers, even recently, always point out an important role of creating the Stroke Centers with high quality of multidisciplinary medical staff in examining, treating and managing for ischemic stroke Patients -> Reduces the rate of disability and social fee in taking care of ischemic patients -> Stroke center = good team (diagnosis & treatment) + good medical system (take care after treatment) 6

7 SYSTEM 7

8 Model in developed countries --Saver et al, Stroke Interventionalist

9 Goals of Stroke Care Time is Brain! Time Benchmark (AHA recommended timeframes) Door Door Door Door Door to to to to to Doctor CT CT Interpretation needle monitored bed minutes minutes minutes 60 minutes 3 hours 9

10 THE PROBLEM & SOLUTION FOR EACH STEP IN SYSTEMIC STROKE CARE 10

11 Community awareness - Example from Germany studies, 2012: The average time from symptom onset to the ED is hours. What percentage of people over 50 who do not recognize s/s of stroke? 42% What percentage of people over 50 can not name a single stroke symptom? 17 % Only 38% call Only 20-25% arrive within 3 hours --Saver et al, Stroke Interventionalist

12 Solution of Education Educate the people about: Good functional outcome starts from recognition of stroke at the onset -> realize the sign of stroke If pts arrive earlier, the rate of Fibrinolytic Tt can be ed (4.3% to 28.6%) and other procedures result also incresed -> important of time Education tools include : printout / AV program / Lectures / TV 12

13 F.A.S.T IMPACT FACE / ARM / SPEECH / TIME Before 2008 warning signs are taught FAST campaign was introduced during % of public could remember 3 of the signs after 3 months -> but how about US? 13

14 PRE-HOSPITAL TRANSPORTATION Avoiding delay time by: Call to Emergency Unit (911 / 108) Transport by Ambulance EMS system 14

15 Mobile Stroke Units for Pre-hospital Thrombolysis --Walter et al, PLOS One, 2010, Homburg --Audebert et al, JAMA 2014, Berlin 15

16 PRE-HOSPITAL STROKE MANAGEMENT Stroke patients are dispatched At highest level of care In shortest period of time Call to Team EMS response time Dispatch time On Scene time 90 sec < 8 minutes < 1 minute < 15 minutes --Saver et al, Stroke Interventionalist

17 RECOMMENDATION Educate stroke program for all staffs (physicians & EMS persons) All activation/ Priority dispatch/ reduces transport time Rapidly transport to closest certified Primary stroke center Notify the hospital about the potential of stroke patients 17

18 STROKE CENTER DESIGNATION 18

19 QUALITY IMPROVEMENT PROCESS Goals of stroke system Prevention/ Education/ Optimal use of EMS / Stroke care/ Rehabilitation/ Performance review Telemedicine may solve shortage of Neurologist and Radiologist A limited & essential diagnostic recommended to SAVE TIME Priority in decision of acute stroke treatment: tpa +/- Mechanical Thrombectomy +/- Other medical treatment 19

20 PRIMARY STROKE CENTER 20

21 Certification Main Eligibility standards include: A dedicated stroke-focused program Staffing by qualified medical professionals trained in stroke care Association/American Stroke Association or equivalent guidelines Equipment: CT non-contrast/msct Capable: Classify stroke patients/ NIHSS evaluation -> Make diagnosis (identify occluded vessel) -> treat with IV r-tpa in case of indication -> transfer to CSC 21

22 -> In Vietnam, we hope that this model can apply to even rural medical centers/ provincial hospital -> In Bach Mai now, we already have programs developed from 2012 in Emergency Dept to train doctors from satellite hospitals how to do in stroke cases - Diagnosis of AIS - Treat with IV r-tpa - Transfer in case of big occlusion AIS (NIHSS >10/ evidence in MSCT) -> Up to now, receive much more patients from other hospital but still Problem: difficult to train in intervention 22

23 COMPREHENSIVE STROKE CENTER This certification is provided through a partnership between the American Heart Association/American Stroke Association and The Joint Commission, the nation's largest independent healthcare evaluation body. 23

24 Certification Hospitals can treat the most complex stroke cases Eligibility standards include all components of a Primary Stroke Center PLUS: Availability of advanced imaging techniques, including MRI/MRA, CTA, DSA and TCD Availability of personnel trained in vascular neurology, neurosurgery and endovascular procedures 24/7 availability of personnel, imaging, operating room and endovascular facilities 24

25 ICU/neuroscience ICU facilities and capabilities Experience and expertise treating patients with large ischemic strokes, intracerebral hemorrhage and subarachnoid hemorrhage -> In Vietnam now, only some big hospitals in the central/ big cities can be qualified -> Target: Now training in some provincial hospitals to help them improving especially in the neuro intervention area in near future 25

26 Comparison of Stroke Center Primary Take care of most cases of ischemic types of stroke Not required for availability of interventional procedures No requirement for a separate intensive care for stroke patients Access to neurosurgery within 2 hours Send complex patients to a Comprehensive Stroke Center Comprehensive Care for all types of stroke patients (ischemic/hemorragic) 24/7 access to interventional procedures Dedicated neuroscience intensive care unit for patients On-site neurosurgical available 24/7 Receives patients from Primary Stroke Center 26

27 «Workflow workshop» 2 differents situations = When the patient presenting directly to your Stroke Center (2/3) -> Emergency/Neurology Dept -> Radiology Dept When the patient is referred from a distant Stroke center to your team (1/3) -> Directly to the Radiology Dept for further scan/ Intervention procedure 27

28 Key points for team setting Phone number for the 01 neurologist Phone number for the 01 Neuroradiologist 01 leader for one patient MSCT/MRI available 24/24 Call the anesthesiologist as soon as possible Teleradiology device for night call/ difficult case 28

29 Protocol changes 1) Treatment: IV + MT in the first 4.5 hours After 4.5 hours, mechanical thrombectomy only No later than 6 hours 2) Good patients selection: NIHSS: from 6 (to 25) Age 18 (to 80) ASPECTS 6 3) Big arterial Occlusion (M1, ICA)/ Good collateral 29

30 IV is still the first line recommended treatment for acute stroke. One Answer to IV limitation = Mechanical Recanalisation : Adjuvant Treatment = Large vessel occlusion stroke First LINE = IV contraindication Time window > 4.5 hrs 30

31 General < Local Anethesia (maintain blood pressure) Sheath 8F Balloon Occlusion Catheter: 8F inner diameter Intermediate catheter: for ASPIRATION first NO more IA r-tpa Thrombectomy Device (Solumbra): Trevo; Solitaire 31

32 Best treatment now + IV r-tpa (For < 4.5hrs but don t wait, do the Mechanical Thrombectomy right after transfusion) Mechanical Thrombectomy 32

33 INTENSIVE CARE UNIT FOR STROKE PATIENTS AFTER TREATMENT 33

34 ADMN TO THE HSPTL & TREATMENT AFTER HOSPITALISATION 25% of stroke patients may have neurological worsening during first hrs Dedicated stroke nursing care is very important 34

35 INPATIENT ACUTE STROKE CARE RECOMMENDATION Specialized stroke units are recommended (Unchanged) IA 92. Patients with suspected Pneumonia /UTI should be treated with appropriate antibiotics (Revised) IA 93. Heparin is recommended to prevent DVT (Unchanged) IA 94. Standardized stroke care order sets is recommended (Unchanged) IB 95. Assessment of swallowing before oral feeds / drugs is recommended (Unchanged) 96. NG/ND/PEG feedings to be given to maintain calorie needs in dysphagia (Revised) IB IB 35

36 INPATIENT ACUTE STROKE CARE RECOMMENDATION Early mobilization of minor strokes is recommended to prevent complications (Unchanged) IC 98. Early intervention to prevent recurrent stroke is recommended (Unchanged) 99. Aspirin for DVT prophylaxis, if the patient cannot receive OAC is IC reasonable (Revised) IIaA 100. NG tube may be preferred to PEG tube up to 2-3 weeks (Revised) IIaB 36

37 INPATIENT ACUTE STROKE CARE RECOMMENDATION Intermittent external compression devices can be used if anti-coagulant cannot be given (Revised) IIaB 102. Routine nutritional supplements are not beneficial (Revised) IIIB 103. Routine prophylatic antibiotics are not beneficial (Revised) IIIB 104. Routine bladder catheter is not recommended (Unchanged) IIIC 37

38 TREATMENT OF ACUTE NEUROLOGICAL COMPLICATION Multidisciplinary stroke care team is required to manage complex stroke patient 38

39 TREATMENT OF ACUTE NEU COMPLICATIONS RECOMMENDATION In major infarctions, with high risk of edema, transfer the patient to a hospital with Neurosurgical care (Revised) IA 106. Decompressive surgery for cerebellar infarction is preferred to prevent herniation and brain stem compression (Revised) IB 107. Decompression for malignant edema of the cerebrum is life saving (Revised) IB 108. Post stroke seizures should be treated with AED in similar way (Unchanged) IB 39

40 Tt OF ACUTE NEU COMPLICATIONS RECOMMENDATION EVD is useful for hydrocephalus secondary to stroke (Revised) IC 110. Malignant edema with large infarction may not be helped with aggressive medical measures (Revised) IIbC 111. Corticosteroids are not recommended for cerebral edema (lack of efficacy/increase in infarction) (Unchanged) IIIA 112. Prophylactic use of anticonvulsants is not recommended (Unchanged) IIIC 40

41 Protocol in BM Hospital Administered directly to Bach Mai Hospital First aid/ NIHSS/ Laboratory Test (1) Transferred from other hospitals/ already diagnosed - used r-tpa (2) Radiology Department IR room Imaging scanner (CT/MSCT MRI) Still have... Hemorrhage Evidence of big arterial occlusion Already Recanalized Medical treatment/ Other procedures Neuro intervention Thrombectomy 41

42 What we are looking for Emergency Department Neurology Department PATIENTS Cardiology Department Radiology Department Other hospitals 42

43 Conclusion Number of stroke patients admitting to Bach Mai hospital more and more increase each year Having a good designation of Stroke Center and standardizing ONE best Protocol is essential Need to team work between all departments to get more AIS patients benefit from treatment Always keep up to date with AHA/ASA guidelines in manage and treatment 43

44 THANK YOU FOR YOUR ATTENTION 44