Thrombolysis Nursing

Competencies
Objectives
 Nursing Care of a Thrombolysed patient
What informed the Stroke Strategy

 RCP Sentinel Audits (2002-2006)

 NAO Report (Nov 2005)

 Stroke strategy framework 2007
 Nice
 “There is a massive and regular
failure to respond to the
emergency of stroke” (NAO 2005)
 Low public awareness of symptoms,
prevention & management
 Slow admission to hospital, Difficult access
to imaging, Insufficient specialist
resources
 Less than 1% of pts thrombolysed
compared to 9% in Australia
 Stroke is a Medical Emergency
’Time is Brain’
 Speedy diagnosis
 Rapid access to imaging
 Thrombolysis
 Rapid access to supportive therapy
(HASU)
 Rapid secondary prevention
 Rapid surgical/ radiological intervention in
arterial disease (carotid / vertebral)
80% of Strokes = Ischaemic

 80% of Ischaemic stroke caused by

embolism from
 Heart
 Aortic arch
 Extracranial arteries to the brain
 Thrombolysis

 Thrombus= clot
 Lysis = destruction of cells
 Thrombolysis is achieved by using
rt-PA (alteplase)
 rt-PA reverses underperfusion, allowing
ischaemic penumbra to recover
 Thrombolysis

 rt-PA= recombinant tissue plasminogen

activator
 Plasmin is the enzyme that degrades
fibrin, the protein which is the main
constituent of blood clots
 rt-PA activates the release of plasmin as
plasminogen
Rational for giving Thrombolysis

Reduces the size of Ischaemic damage

( infarct) by restoring blood flow

Cells in the brain ie. Neurons die over time

.Prompt treatment with a thrombolytic
agent ( rTPa –Alteplase) may promote
reperfusion & improve functional outcomes
 Thrombolysis

 Must be given within 4.5 hours of stroke

 Strict inclusion criteria
 Licensed for IV use in under 80’s
 Consultant decision: intra-arterial, 80+
 Dramatic increase in post-stroke
quality of life
Cerebral infarct - onset

Onset

Infarct
Ischaemic
penumbra
Cerebral infarct – 6 hours

6 Hours

Infarct
Ischaemic
penumbra
Cerebral infarct – 24 hours

24 Hours

Infarct
Ischaemic
penumbra
 Without thrombolysis

2hrs
 Thrombolysis - The Evidence

 NINDS trial 1995 (National Institute of

Neurological Diseases & Stroke)
 ECASS 1 and ECASS 2 (European Co-
operative Stroke Study) up to 3 hours
 ECASS 3 showed benefit up to 4.5 hours
 2009 American stroke association widens
use of rTPa to 4.5 hours
 RCP Audit 2006 - Thrombolysis

 Only 10% admitted directly to unit with

acute facilities

 18% of hospitals do thrombolysis

 30 hospitals thrombolysed 218 patients
ratios (with 95% CIs) of an unfavourable outcome with

tPA given within 3 hrs of onset of stroke

Odds ratios (with 95% CIs) of an unfavourable outcome with tPA given within 3 hrs of
onset of stroke
Odds ratios (with 95% CIs) of an unfavourable outcome

with tPA given within 3 hrs of onset of stroke

 Thrombolysis - The Evidence

 Fewer complications
 Frequently, dramatic lack of disability
 Quicker recovery
 Reduction in LOS
‘Time is Brain’ - Stroke Pathway

 Triage, FAST test

 Speedy call to Stroke Team (whatever
severity)
 Rapid admission to ASU
 CAPACITY
 The Mental Capacity Act 2005, which came fully into force in October 2007, provides the legal
framework for acting and making decisions on behalf of individuals who lack the capacity to make
specific decisions for themselves in relation to personal welfare, healthcare and financial
matters. It applies to persons age 16 and over.
 The Mental Capacity Act (MCA) applies to England and Wales.

 Principles of the Act

 The Act sets out five principles which guide the legislation. These are:

 · ‘A person must be assumed to have capacity unless it is established that he lacks

capacity.
 · (3) A person is not to be treated as unable to make a decision unless all practicable steps
to help him to do so have been taken without success.
 · (4) A person is not to be treated as unable to make a decision merely because he makes
an unwise decision.
 · (5) An act done, or decision made, under this Act for or on behalf of a person who lacks
capacity must be done, or made, in his best interests.
 · (6) Before the act is done, or the decision is made, regard must be had to whether the
purpose for which it is needed can be as effectively achieved in a way that is less restrictive of
the person’s rights and freedom of action
 Testing Capacity
 The Functional Test
 The person must be able to:

 understand the information relevant to the decision,


 retain that information,

 weigh that information as a part of the process of making a decision,


 communicate his/her decision (whether by talking, using sign language or
any other means)
 .
 This test must be complete and recorded; the documentation must
demonstrate the above process
 ABC

 Airway

 Breathing

 Circulation
 After ABC
 GCS

 ECG

 Blood glucose

 Fluid access

 Hydration

 Bloods

 Nil by Mouth

 Transfer to CT-continue ABC

 Time is brain

 1.9 million neurons are lost

each minute after a stroke

 Protect ischaemic penumbra

Stroke 2006
 CT
 Known time of
symptoms <4 hours
 NIHSS score
 No haemorrhage
 No contraindications
 Consent
 Age
 Thrombolysis
Alteplase rTPA
0.9mg /Kg

10% of total dose –Bolus 2-3

mins

90% of total dose –Infuse over 60

mins
 rTPA Alteplase
 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 flush with
Normal saline
 t-PA must be used within 8 hours of mixing
when stored at room temperature or within 24
hours if refrigerated
 Complications of Thrombolysis

 Intra -cerebral haemorrhage-1.7%

 (1 in 77 patients) 0.28% fatal
 SITS MOST 2007

 Bleeding-minor bleeding is common

(IV site)

 Anaphylaxis- 1%
Ace inhibitors Frontal & insular lesions

 Angiodoema 1.3% Canadian study

1,135 pts
 Major Heamorrhage 0.4%
Angioedema
 Patient Story
 Mr X 88 years of age

 Jet pilot in the war & last flew

in 1986

 Collapsed right sided weakness

 Unable to talk . Couldn’t think

clearly.
 999 ambulance to A%E

 “Clock work military precision

like gun team at Earls court”
 First 24 hours

30% of all stroke patients will deteriorate in

the first 24hours

Stroke 2009
 Monitor GCS

 Ability to engage with

immediate surroundings

 Standardised stimuli
E1-E4
V1-V5
M1-M6
 Best and Worst Score
 GCS 15- E4 V5 M6
Awake, alert and fully
responsive

 GCS 3-E1 V1 M1
No cerebrally mediated
response to stimulus
 NIHSS - A Research Tool

Fifteen item impairment

scale

 Neurological outcome

 Degree of recovery
 Physiological Monitoring
1. Hypoxia
Respirations
Saturations <92%
Associated with neurological
deterioration

2. Temperature
>38C must be treated.
-associated with infarct volume

3. Arrhythmias
Continuous ECG
Early detection and treatment of AF
Right hemisphere /insular lesions
 Physiological Monitoring contd
4.Blood pressure

Non thrombolysed patients

BP Not treated unless:

Systolic >220mmHg or
Diastolic >120mmHg with 2
consecutive readings

Thrombolysed patients
BP is treated if:
Systolic >185mmHg or
Diastolic >110mmHg with 2
consecutive readings

Abrupt fall in BP may affect cerebral

perfusion pressure
 Physiological Monitoring contd
5.Blood Sugar

 Hyperglycaemia BM>10 treat &

monitor

 Hypoglycaemia –immediate
treatment with glucose

Hyperglycaemia is associated with

poor clinical outcome
 Physiological Monitoring Contd
7. Anuria
6. Hydration Polyuria
Glucose

Circulatory failure
Cerebral perfusion
 Complications of Stroke

 Aspiration Pneumonia
 Urinary infection
 DVT
 Pulmonary Embolus
 Shoulder subluxation
 Depression
 Malnourishment
 Pressure sores
 Falls
 Seizures
 Swallow Complications
(Dysphagia)

Chest Infection

Aspiration Pneumonias
50% are silent

 Swallow screen
 Nil by mouth first 24hours
 Guided eating & drinking regime
 Encourage to cough
 Sitting out of bed
 Mobilisation
 Mouth Care
Increased risk of infection
Pain and discomfort
Effects swallow

 Gentle mouth care

 Adequate hydration
 Gentle tooth brushing
 Head Position
Controversial

 Head in a neutral position

 Flat if tolerated.

 Or 30 –40 degrees

 Aids venous drainage &

improves cerebral perfusion
 Bladder &Bowels
Urinary incontinence
Urinary infection

 Avoid catheters

 Early plan of care

 Adequate hydration

 Bowels

 Privacy & dignity

 Psychological Support
 Assess mood

 Recognise grief/loss

 Talk

 Engage with family

 Interests

 Timely realistic goals

 Refer
 Pressure Sores
 Air mattress

 Two hourly turns

 Nutrition

 Hydration

 Personal hygiene
 Deep Vein Thrombosis

 Early mobilisation

 Low molecular weight heparin

 Compression devices

 TED stockings not beneficial in

stroke patients
Clots Trial 2009
 Positioning
Loss of sensation
Loss of power
Subluxation

 Supportive

 IV lines and BP cuffs avoided

on affected limb

 Assess moving and handling

 Good technique
 Nutrition
Malnourishment associated
with poor outcome

 Weight
 MUST assessment
 Naso gastric tube
 History of patients eating
habits

Controversial
 When to commence invasive
feeding regime