Nursing Guidelines for Thrombolytic Therapy
ELIGIBILITY CRITERIA
• Inclusion Criteria
1. Symptom onset of less than three hours.
2. Clinical diagnosis of ischemic stroke with measurable deficit on the National Institutes of Health's Stroke Scale
3. Older than 18 years.
4. CT Criteria: Absence of high-density lesion consistent with intracerebral hemorrhage; absence of significant mass effect or midline shift; absence of parenchymal hypodensity, and/or effacement of cerebral sulci more than 33% of the middle cerebral artery territory.
• Exclusion Criteria
1. Stroke or serious head trauma within past three months.
2. Systolic blood pressure (BP) more than 185 mm Hg or diastolic BP more than 110 mm Hg, or BP readings that require aggressive treatment.
3. Conditions that could precipitate or suggest parenchymal bleeding (subarachnoid and ICH, recent onset myocardial infarction, seizures at onset, major surgery within past 14 days, gastrointestinal or urinary tract hemorrhage within previous 21 days, and arterial puncture of a noncompressible site or lumbar puncture within previous seven days).
4. Glucose less than 50 mg/dL or more than 400 mg/dL; INR more than 1.7; platelet count less than 100,000/mm.
5. Rapidly improving or deteriorating neurologic signs or minor symptoms.
6. Recent myocardial infarction.
7. Recent treatment with IV or subcutaneous heparin within past 48 hours and has an elevated partial thromboplastin time.
8. Woman of child-bearing age who has a positive pregnancy test.
DOSING INFORMATION
1. Alteplase Activase 0.9 mg/kg body weight total or maximum 90 mg.
2. Administer 10% of total dose as bolus for 1-2 minutes.
3. Infuse remaining dose over 60 minutes.
4. Immediately follow completed infusion with 50 mL normal saline.
5. No intervening saline or other intravenous solution during the infusion.
PRETREATMENT GUIDELINES
1. Confirm stroke onset — must be less than three hours before drug administration.
2. Confirm patient eligibility (see previous inclusion and exclusion criteria).
3. Obtain urgent laboratory tests: CBC, head CT, electrolytes and chemistry profile, PT/INR and aPTT, glucose (may do a fingerstick), ECG, and pregnancy test (if applicable).
4. BP with neurologic checks every 15 minutes; keep SBP at or less than 185 mm Hg or DBP at or less than 110 mm Hg; use medications that do not cause a precipitous drop in BP (see guidelines for blood pressure management).
5. Establish total of 2-3 IV lines.
6. Obtain patient actual or estimated weight.
7. Continuous cardiac monitoring.
8. Re-evaluate symptoms for clinical worsening or improvement; reverify dose calculation (see dosing guidelines).
POST-TREATMENT GUIDELINES
1. Admit to intensive care unit for 24 hours.
2. Vital signs every 15 minutes for two hours; every 30 minutes for six hours; every one hour for 16 hours.
3. Serial neurologic checks; notify physician for any changes in neurologic status. Decrease in level of consciousness or deterioration in any neurologic signs and symptoms that occurs within 36 hours of t-PA administration may be attributed to intracerebral hemorrhage.
4. Assess for signs of internal bleeding: tachycardia, hypotension, pallor, restlessness, complaints of low back pain, muscle weakness, or numbness in lower extremities.
5. Assess for signs of external bleeding: IV sites, gums, urine.
6. Check all gastric secretions, urine, and stool for occult blood.
7. Maintain SBP at or less than 185 mm Hg or DBP at or less than 110 mm Hg (see guidelines for blood pressure management).
8. Accurate intake and output.
9. Monitor serial laboratory tests: hemoglobin, hematocrit, and coagulation values.
10. No heparin, coumadin, or antiplatelet agent for 24 hours after thrombolytic infusion.
11. Avoid invasive catheters: bladder catheter for 30 minutes, nasogastric tube and venipuncture for 24 hours.
12. Maintain adequate oxygenation.
GUIDELINES IF BLEEDING IS SUSPECTED
1. Discontinue thrombolytic agent.
2. Prepare for emergency noncontrast head CT; obtain coagulation panel.
3. Type and crossmatch four units of packed cells and four to six units of cryoprecipitate or fresh frozen plasma.
4. Obtain neurosurgical consultation.
GUIDELINES FOR BLOOD PRESSURE MANAGEMENT
• Treatment of hypotension
Hypotension is often related to hypovolemia and requires immediate intervention to prevent decreased cerebral blood flow.
1. Administer IV fluid such as normal saline; fluids that contain dextrose may contribute to the development of cerebral edema and increased lactate levels.
2. Evaluate current medications that may contribute to lowering the BP; adjust or discontinue dose as applicable.
• Treatment of Hypertension
1. Before treatment with thrombolytic agent, use agents that gently lower the BP; preferred agents are topical nitroglycerin (Nitropaste) because this can be wiped off easily, oral angiotensin-converting enzyme (ACE) inhibitors, and IV beta-adrenergic blocking agents such as labetalol, a short-acting drug. Give labetalol 10 to 20 mg IVP repeated one to two times; if BP is not decreased to SBP at or less than 185 mm Hg or DBP at or less than 110 mm Hg, the patient is not eligible for thrombolytic therapy. A patient with unremitting hypertension is at high risk for developing ICH.
2. During and after thrombolytic therapy:
a. For SBP more than 185 mm Hg or DBP more than 110 mm Hg on two or more readings, give labetalol 10 to 20 mg IV over 1-2 minutes; may repeat every 10 to 20 minutes (not to exceed 150 mg), or hydralazine 10 to 20 mg IV; may repeat every 30 minutes.
b. For SBP more than 230 mm Hg or DBP more than 120 mm Hg (despite above treatment) or DBP more than 140 mm Hg on two or more readings 5 to 10 minutes apart, give sodium nitroprusside infusion (start at 0.25 mg/kg/min, titrate as needed, not to exceed 10 mg/kg/min) to keep SBP less than 185 mm HG, but more than 140 mm Hg and DBP less than 110 mm Hg but more than 75 mm Gh.
c. Give esmolol 500 mg/kg IV bolus over one minute, follow with esmolol drip at 25 mg/kg/min; increase by 25 mg/kg/min every 5 minutes as needed. Titrate to keep SBP less than 185 mm Hg but more than 140 mm Hg, and DBP less than 110 mm Hg but more than 75 mm Hg.
Source: American Association of Neuroscience Nurses: Clinical Guideline Series: Recommendation for the Nursing Management of the Hyperacute Ischemic Stroke Patient. Chicago: AANN; 1998. Used with permission. Contact: AANN, 4700 W. Lake Ave., Glenview, IL 60025-1485. Web site: www.aann.org.
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