Thrombolysis Nursing Thrombolysis Nursing CompetenciesCompetencies

ObjectivesObjectives Nursing Care of a Thrombolysed patientNursing Care of a Thrombolysed patient

What informed the Stroke What informed the Stroke StrategyStrategy

RCP Sentinel Audits (2002-2006)RCP Sentinel Audits (2002-2006)

NAO Report (Nov 2005)NAO Report (Nov 2005) Stroke strategy framework 2007Stroke strategy framework 2007 NiceNice

““There is a massive and There is a massive and regular failure to respond to regular failure to respond to

the emergency of stroke” (NAO the emergency of stroke” (NAO 2005)2005)

Low public awareness of symptoms, Low public awareness of symptoms, prevention & managementprevention & management

Slow admission to hospital, Difficult Slow admission to hospital, Difficult access to imaging, Insufficient access to imaging, Insufficient specialist resourcesspecialist resources

Less than 1% of pts thrombolysed Less than 1% of pts thrombolysed compared to 9% in Australiacompared to 9% in Australia

Stroke is a Medical Stroke is a Medical Emergency ’Time is Brain’Emergency ’Time is Brain’

Speedy diagnosis Speedy diagnosis Rapid access to imagingRapid access to imaging ThrombolysisThrombolysis Rapid access to supportive therapy Rapid access to supportive therapy

(HASU)(HASU) Rapid secondary prevention Rapid secondary prevention Rapid surgical/ radiological intervention Rapid surgical/ radiological intervention

in arterial disease (carotid / vertebral) in arterial disease (carotid / vertebral)

80% of Strokes = Ischaemic80% of Strokes = Ischaemic

80% of Ischaemic stroke caused by 80% of Ischaemic stroke caused by embolism fromembolism from

HeartHeart Aortic archAortic arch Extracranial arteries to the brainExtracranial arteries to the brain

ThrombolysisThrombolysis

Thrombus= clotThrombus= clot Lysis = destruction of cellsLysis = destruction of cells Thrombolysis is achieved by using Thrombolysis is achieved by using

rt-PA (alteplase)rt-PA (alteplase) rt-PA reverses underperfusion, rt-PA reverses underperfusion,

allowing ischaemic penumbra to allowing ischaemic penumbra to recoverrecover

ThrombolysisThrombolysis

rt-PA= recombinant rt-PA= recombinant tissue tissue plasminogen activatorplasminogen activator

Plasmin is the enzyme that degrades Plasmin is the enzyme that degrades fibrin, the protein which is the main fibrin, the protein which is the main constituent of blood clotsconstituent of blood clots

rt-PA activates the release of plasmin rt-PA activates the release of plasmin as plasminogenas 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

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

ThrombolysisThrombolysis

Must be given within 4.5 hours of strokeMust be given within 4.5 hours of stroke Strict inclusion criteriaStrict inclusion criteria Licensed for IV use in under 80’sLicensed for IV use in under 80’s Consultant decision: intra-arterial, 80+ Consultant decision: intra-arterial, 80+ Dramatic increase in post-strokeDramatic increase in post-stroke

quality of life quality of life

Cerebral infarctCerebral infarct - onset - onsetCerebral infarctCerebral infarct - onset - onset

Onset

Infarct

Ischaemic penumbra

Cerebral infarctCerebral infarct – 6 hours – 6 hoursCerebral infarctCerebral infarct – 6 hours – 6 hours

6 Hours

Infarct

Ischaemic penumbra

Cerebral infarctCerebral infarct – 24 hours – 24 hoursCerebral infarctCerebral infarct – 24 hours – 24 hours

24 Hours

Infarct

Ischaemic penumbra

Without thrombolysis

2hrs2hrs

Thrombolysis - The Thrombolysis - The EvidenceEvidence

NINDS trial 1995 (National Institute of NINDS trial 1995 (National Institute of Neurological Diseases & Stroke)Neurological Diseases & Stroke)

ECASS 1 and ECASS 2 (European Co-ECASS 1 and ECASS 2 (European Co-operative Stroke Study) up to 3 hoursoperative Stroke Study) up to 3 hours

ECASS 3 showed benefit up to 4.5 ECASS 3 showed benefit up to 4.5 hourshours

2009 American stroke association 2009 American stroke association widens use of rTPa to 4.5 hourswidens use of rTPa to 4.5 hours

RCP Audit 2006 - RCP Audit 2006 - ThrombolysisThrombolysis

Only 10% admitted directly to unit Only 10% admitted directly to unit with acute facilitieswith acute facilities

18% of hospitals do thrombolysis18% of hospitals do thrombolysis 30 hospitals thrombolysed 218 30 hospitals thrombolysed 218

patientspatients

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 Thrombolysis - The EvidenceEvidence

Fewer complicationsFewer complications Frequently, dramatic lack of disabilityFrequently, dramatic lack of disability Quicker recoveryQuicker recovery Reduction in LOSReduction in LOS

‘‘Time is Brain’ - Stroke Time is Brain’ - Stroke PathwayPathway

Triage, FAST testTriage, FAST test Speedy call to Stroke Team Speedy call to Stroke Team

(whatever severity)(whatever severity) Rapid admission to ASURapid 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

ABCABC

AirwayAirway

BreathingBreathing

CirculationCirculation

After ABCAfter ABC

GCSGCS

ECGECG

Blood glucoseBlood glucose

Fluid accessFluid access

Hydration Hydration

Bloods Bloods

Nil by MouthNil by Mouth

Transfer to CT-continue ABCTransfer to CT-continue ABC

Time is brainTime is brain

1.9 million neurons are lost 1.9 million neurons are lost each minute after a strokeeach minute after a stroke

Protect ischaemic Protect ischaemic penumbrapenumbra

Stroke 2006Stroke 2006

CTCT

Known time of Known time of symptoms <4 hours symptoms <4 hours

NIHSS scoreNIHSS score No haemorrhageNo haemorrhage No No

contraindicationscontraindications ConsentConsent AgeAge

Thrombolysis Thrombolysis

Alteplase rTPAAlteplase rTPA

0.9mg /Kg0.9mg /Kg

10% of total dose –Bolus 2-3 10% of total dose –Bolus 2-3 minsmins

90% of total dose –Infuse over 90% of total dose –Infuse over 60 mins60 mins

rTPA Alteplase

Do not mix t-PADo not mix t-PA with any other with any other medications.medications.

Do notDo not use IV tubing with infusion filters. use IV tubing with infusion filters. All patients must be on a All patients must be on a cardiac monitorcardiac monitor When infusion is complete, saline flush When infusion is complete, saline flush

with Normal salinewith Normal saline t-PA must be used within 8 hours of mixing t-PA must be used within 8 hours of mixing

when stored at room temperature or when stored at room temperature or within 24 hours if refrigeratedwithin 24 hours if refrigerated

Complications of Complications of ThrombolysisThrombolysis

Intra -cerebral haemorrhage-1.7%Intra -cerebral haemorrhage-1.7% (1 in 77 patients) 0.28% fatal(1 in 77 patients) 0.28% fatal SITS MOST 2007SITS MOST 2007

Bleeding-minor bleeding is common Bleeding-minor bleeding is common (IV site)(IV site)

Anaphylaxis- 1% Anaphylaxis- 1%

Ace inhibitors Frontal & insular Ace inhibitors Frontal & insular lesionslesions

Angiodoema 1.3% Canadian study Angiodoema 1.3% Canadian study 1,135 pts 1,135 pts

Major Heamorrhage 0.4% Major Heamorrhage 0.4%

Angioedema

Patient StoryPatient Story

Mr X 88 years of ageMr X 88 years of age

Jet pilot in the war & last flew Jet pilot in the war & last flew in 1986in 1986

Collapsed right sided Collapsed right sided weaknessweakness

Unable to talk . Couldn’t think Unable to talk . Couldn’t think clearly.clearly.

999 ambulance to A%E999 ambulance to A%E

““Clock work military precision Clock work military precision like gun team at Earls court”like gun team at Earls court”

First 24 hoursFirst 24 hours

30% of all stroke patients will 30% of all stroke patients will deteriorate in the first 24hoursdeteriorate in the first 24hours

Stroke 2009Stroke 2009

Monitor GCSMonitor GCS

Ability to engage with Ability to engage with

immediate surroundingsimmediate surroundings

Standardised stimuliStandardised stimuli

E1-E4E1-E4

V1-V5V1-V5

M1-M6M1-M6

Best and Worst ScoreBest and Worst Score

GCS 15- E4 V5 M6 GCS 15- E4 V5 M6

Awake, alert and fully Awake, alert and fully responsiveresponsive

GCS 3-E1 V1 M1GCS 3-E1 V1 M1

No cerebrally mediated No cerebrally mediated response to stimulusresponse to stimulus

NIHSS - A Research ToolNIHSS - A Research Tool

Fifteen item Fifteen item impairment scaleimpairment scale

Neurological outcomeNeurological outcome

Degree of recoveryDegree of recovery

Physiological MonitoringPhysiological Monitoring

1. 1. HypoxiaHypoxiaRespirationsRespirationsSaturations <92%Saturations <92%Associated with neurological Associated with neurological

deteriorationdeterioration

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

3. 3. ArrhythmiasArrhythmiasContinuous ECGContinuous ECGEarly detection and treatment of Early detection and treatment of

AFAFRight hemisphere /insular lesionsRight hemisphere /insular lesions

Physiological Monitoring Physiological Monitoring contdcontd

4.Blood pressure4.Blood pressure

Non thrombolysed patientsNon thrombolysed patients

BP Not treated unless:BP Not treated unless: Systolic >220mmHg orSystolic >220mmHg or Diastolic >120mmHg with 2 Diastolic >120mmHg with 2

consecutive readingsconsecutive readings

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

consecutive readingsconsecutive readings

Abrupt fall in BP may affect Abrupt fall in BP may affect cerebral perfusion pressure cerebral perfusion pressure

Physiological Monitoring Physiological Monitoring contdcontd

5.Blood Sugar5.Blood Sugar

Hyperglycaemia BM>10 treat Hyperglycaemia BM>10 treat & monitor & monitor

Hypoglycaemia –immediate Hypoglycaemia –immediate treatment with glucosetreatment with glucose

Hyperglycaemia is associated Hyperglycaemia is associated with poor clinical outcomewith poor clinical outcome

Physiological Monitoring Physiological Monitoring ContdContd

6.6. HydrationHydration

GlucoseGlucose

Cerebral perfusionCerebral perfusion

7. Anuria7. Anuria PolyuriaPolyuria

Circulatory failureCirculatory failure

Complications of StrokeComplications of Stroke

Aspiration PneumoniaAspiration Pneumonia Urinary infection Urinary infection DVTDVT Pulmonary EmbolusPulmonary Embolus Shoulder subluxationShoulder subluxation DepressionDepression MalnourishmentMalnourishment Pressure soresPressure sores FallsFalls SeizuresSeizures

Swallow ComplicationsSwallow Complications(Dysphagia)(Dysphagia)

Chest InfectionChest Infection

Aspiration Pneumonias Aspiration Pneumonias

50% are silent50% are silent

Swallow screenSwallow screen Nil by mouth first 24hours Nil by mouth first 24hours Guided eating & drinking regimeGuided eating & drinking regime Encourage to coughEncourage to cough Sitting out of bedSitting out of bed MobilisationMobilisation

Mouth CareMouth Care

Increased risk of Increased risk of infectioninfection

Pain and discomfortPain and discomfort

Effects swallowEffects swallow

Gentle mouth careGentle mouth care Adequate hydrationAdequate hydration Gentle tooth brushingGentle tooth brushing

Head PositionHead Position

ControversialControversial

Head in a neutral positionHead in a neutral position

Flat if tolerated.Flat if tolerated.

Or 30 –40 degreesOr 30 –40 degrees

Aids venous drainage & Aids venous drainage & improves cerebral perfusionimproves cerebral perfusion

Bladder &BowelsBladder &Bowels

Urinary incontinenceUrinary incontinence Urinary infectionUrinary infection

Avoid cathetersAvoid catheters

Early plan of careEarly plan of care

Adequate hydrationAdequate hydration

BowelsBowels

Privacy & dignityPrivacy & dignity

Psychological SupportPsychological Support

Assess moodAssess mood

Recognise grief/lossRecognise grief/loss

TalkTalk

Engage with familyEngage with family

InterestsInterests

Timely realistic goalsTimely realistic goals

ReferRefer

Pressure SoresPressure Sores

Air mattressAir mattress

Two hourly turnsTwo hourly turns

NutritionNutrition

HydrationHydration

Personal hygienePersonal hygiene

Deep Vein ThrombosisDeep Vein Thrombosis

Early mobilisationEarly mobilisation

Low molecular weight Low molecular weight heparinheparin

Compression devicesCompression devices

TED stockings not beneficial TED stockings not beneficial in stroke patientsin stroke patients

Clots Trial 2009 Clots Trial 2009

PositioningPositioning Loss of sensationLoss of sensation

Loss of powerLoss of power

SubluxationSubluxation

Supportive Supportive

IV lines and BP cuffs IV lines and BP cuffs avoided on affected limbavoided on affected limb

Assess moving and Assess moving and handlinghandling

Good techniqueGood technique

NutritionNutrition

Malnourishment Malnourishment associated with poor associated with poor outcomeoutcome

WeightWeight MUST assessmentMUST assessment Naso gastric tubeNaso gastric tube History of patients eating History of patients eating

habitshabits

ControversialControversial When to commence invasive When to commence invasive

feeding regimefeeding regime