Microsoft word - 06. use of t-pa treatment in acute ischemic stroke.doc
GUIDELINES FOR USE OF T-PA (ACTIVASE) TREATMENT IN ACUTE ISCHEMIC STROKE **Physician to check appropriate boxes** Treatment of acute ischemic stroke with T-PA (Activase) must be initiated within 3 hours of stroke symptom onset. CRITERIA (All "Yes" boxes must be checked before thrombolytics are given) Yes No Age 18 or older Clinical diagnosis of acute ischemic stroke causing a measurable neurologic deficit Time of onset well-established to be less then 180 minutes before treatment would begin II. EXCLUSION CRITERIA (All "No" boxes must be checked before thrombolytics are given) Yes No Stroke, head trauma, intraspinal or intracranial surgery within 3 months Any prior history of intracranial neoplasm, hemorrhage, AV malformation or aneurysm Major surgery or serious trauma within 14 days Active internal bleeding (e.g., gastrointestinal bleeding, pulmonary or urinary bleeding) within 21 days Recent arterial puncture at non-compressible site in previous 7 days Lumbar puncture within 7 days Myocardial infarction in the past 3 months Only minor stroke symptoms or rapidly improving neurological signs History of seizure at onset with post-ictal residual neurological deficit (UNLESS this is felt to be secondary to stroke rather than a post-ictal phenomenon). Clinical presentation that suggests subarachnoid hemorrhage, even if the initial CT scan is normal Clinical presentation consistent with acute myocardial infarction Known bleeding diathesis, including but not limited to:
• Platelet count less than 100,000/mm3 or
• Patient has received heparin within 48 hours and has an elevated PTT (greater than upper
• Patient has received recent oral anticoagulant (e.g., coumadin) and has INR 1.7 or greater
Evidence of intracranial hemorrhage on noncontrast head CT scan Large cerebral infarction: edema, hypodensity, mass effect, and obliteration of sulci in more than 1/3 of the MCA territory on CT scan
On repeated measurements, SBP greater than 185 or DBP greater than 110 at the time treatment is to begin, and patient requires aggressive treatment to reduce blood pressure to within these limits. Blood glucose of less than 50 mg/dL or greater than 400 mg/dL (results required before
Evidence of active internal bleeding or acute trauma (fracture) on examination
_______________________________________ ___________________ Physician Signature Date/Time IV t-PA (ACTIVASE) TREATMENT IN ACUTE ISCHEMIC STROKE **Physician to strike through unwanted orders. These orders are not implemented until signed by the Physician** Patient Name: ______________________________________________Date: ______________________ Time: ___________ Medication Allergies: ____________________________________________________________________________________
Diagnosis: Acute Ischemic Stroke. Admit to services of Dr. ____________________________
2. Additional labs: a. Type & Screen 3. Perform NIHSS upon admit to ICU, every shift in ICU, and prior to transfer out of ICU. Perform NIHSS upon discharge from
4. Saline lock with NS flush in opposite arm - 2nd line for use of IV t-PA (Activase). 5. Foley catheter, if indicated, prior to IV t-PA infusion. 6. Provide patient/family with Activase informational brochure. 7. Patient weight: _____________ pounds. Circle: Actual / Estimated (Divide by 2.2 to = kilograms: _____________) IV t-PA (Activase) per dosage schedule: Dosage: 0.9 mg/kg (90 mg maximal dose), 10% given as IV bolus
over one minute, followed by continuous intravenous infusion over sixty minutes. A dedicated intravenous line is required for administration of IVt-PA (Activase). Dosage calculation:
• Patient's weight in kilograms____________x 0.9 mg/kg. = ___________mg (total dose) • Total stroke dose = _______________mg (Maximum total dose 90 milligrams) • Bolus = 10% of total dose. Total dose_________ x 0.1 = ____________mg IV (bolus dose). Give over 1 minute • Infusion = Total dose __________mg - bolus _________mg = ___________mg continuous IV infusion over 60 min. • CONFIRM DOSE CALCULATION WITH PHYSICIAN. WITNESS WASTE.
9. O2 at 2 - 4 L/min per nasal cannula PRN to maintain O2 sats by pulse oximetry at least 94%. 10. Continuous cardiac and pulse oximetry monitoring. 11. Angioedema Precautions:
Begin examining tongue 20 minutes before IV tPA infusion is complete, and repeat several times, until 20 minutes after tPA infusion. Look for any signs of unilateral or bilateral tongue enlargement.
If angioedema is suspected immediately: a.
Consider early discontinuation of IV tPA infusion
If tongue continues to enlarge after steps 2 a - 2c, give methylprednisolone (SoluMedrol) 125 mg IV x 1
If any further increase in angioedema: a.
Call anesthesiology service STAT for possible emergent cricotomy/tracheostomy or fiberoptic nasotracheal intubation if oral intubation is unsuccessful.
Continued Next Page PHYSICIAN ORDERS FOR IV t-PA (ACTIVASE) TREATMENT IN ACUTE ISCHEMIC STROKE **Physician to strike through unwanted orders. These orders are not implemented until signed by the Physician**
12. NO Heparin, Warfarin, Aspirin, Plavix, or Lovenox for 24 hours from the completion of IVt-PA (Activase) infusion. 13. NO Sedatives. 14. Maintain bleeding precautions for 24 hours.
Check puncture sites for bleeding or hematomas. Apply digital pressure or pressure dressing to active bleeding sites that are compressible. Evaluate urine, stool, emesis, or other secretions for visible blood. Perform Hemoccult testing if evidence of bleeding. Avoid NG tube and arterial puncture for 24 hours.
15. Call Physician immediately for evidence of bleeding, neurological deterioration, or vital signs outside the following
Systolic BP > 185 or Systolic BP < 110
Diastolic BP > 105 or Diastolic BP < 60
Decline in neurological status or worsening of stroke signs
If patient develops severe headache, acute hypertension, nausea, or vomiting, discontinue the infusion (if agent is still being administered) and obtain a STAT CT of brain without contrast.
16. I & O
17. DYSPHAGIA and DIET: Dysphagia screen must be done prior to ANY oral intake of food, liquids or medications. NPO Nurse to perform bedside swallow screen upon admit to Stroke Unit/ICU. Diet consistency per dysphagia screen. Physician has performed and documented swallow assessment and orders diet: Healthy
18. IV Fluid: Normal Saline to infuse IV at
19. Absolute Bedrest during and for 24 hours post Activase infusion. 20. Head CT without contrast 24 hours post infusion and prior to transfer out of ICU. 21. Medications:
a. Acetaminophen 650 mg PO every 4 hours PRN pain. (Not to exceed 4 g acetaminophen per 24 hours - all sources). Continued Next Page PHYSICIAN ORDERS FOR T-PA (ACTIVASE) TREATMENT IN ACUTE ISCHEMIC STROKE **Physician to strike through unwanted orders. These orders are not implemented until signed by the Physician**
22. Management of hypertension for Acute Ischemic Stroke IV-tPA candidate:
Pretreatment: Systolic BP greater than 185 OR Diastolic BP greater than 110: Give Labetalol 10 - 20 mg IV over 1 - 2 min. May repeat x 1 OR apply nitroglycerin ointment 1-2 inches. If blood pressure is not reduced and maintained at desired levels (systolic ≤ 185; diastolic ≤ 110), DO NOT administer t-PA) During and after IV t-PA (Activase) Treatment:
1. Monitor BP every 15 minutes for 2 hours, then every 30 minutes for 6 hours, and then every hour for 16 hours. 2. Diastolic BP > 140:
Give Sodium nitroprusside 0.5 mcg/kg/min IV infusion as initial dose and titrate to desired blood pressure.
3. Systolic BP > 230 OR Diastolic BP 121-140:
Give Labetalol 10 mg IV over 1-2 minutes. May repeat or double labetalol every 10 minutes to a maximum dose of 300 mg or give the initial labetalol bolus and then start a labetalol drip at 2 to 8 mg/min. OR Give Nicardipine 5 mg/hr IV infusion as initial dose; Titrate to desired effect by increasing 2.5 mg/hr every 5 minutes to maximum of 15 mg/hr. If BP is not controlled by labetalol, consider sodium nitroprusside.
4. Systolic 180-230 OR Diastolic 105-120
Labetalol 10 mg IV over 1-2 minutes. May repeat or double labetalol every 10 to 20 minutes to a maximum dose of
300 mg or give the initial labetalol bolus and then start a labetalol drip at 2 to 8 mg/min.
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