Transcript Evidence Based Stroke Nursing

Update on Stroke Management
Cynthia Bautista, PhD, RN, CNRN
Nursing Brains, LLC
Clinical Guidelines
• Overview of the current evidence about the
evaluation and treatment of adults with Ischemic
Stroke, Hemorrhagic Stroke, or
Aneurysmal Subarachnoid Hemorrhage.
• American Stroke Association
• Neurocritical Care Society
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Nursing and Interdisciplinary
care of the
Acute Ischemic Stroke Patient
2009
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Nursing & Interdisciplinary Care of
Acute Ischemic Stroke (2009)
I. Stroke Patient Triage and Care
• Class I Recommendations “Should be performed”
• ED should establish procedure/protocol to expeditiously
triage stroke patient
• Protocol to evaluate/treat eligible stroke patient with rtPA
• Treatment with rtPA should be within 1 hour of arrival to ED
• Treat eligible rtPA patients between 3 – 4.5 hour window
• NIHSS < 25, < 80 years old, no DM, no previous stroke,
not on coumadin
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Nursing & Interdisciplinary Care of
Acute Ischemic Stroke (2009)
II. Emergency Nursing Interventions/Hyperacute Phase
• Class I Recommendations “Should be performed”
• ED personnel highly trained in stroke care
• Frequent stroke assessments, more frequently with rtPA
• Supplemental oxygen with oxygen saturation < 92%
• Head in neutral alignment and HOB 25° – 30°
• NPO until swallow assessed
• At least 2 IV sites
• Use nondextrose, normotonic IV fluids (normal saline)
• Give IV rtPA without delay
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Nursing & Interdisciplinary Care of
Acute Ischemic Stroke (2009)
II. Emergency Nursing Interventions/Hyperacute Phase
• Class I Recommendations “Should be performed”
• Medical Recommendations
• CT/MRI performed emergently
• Rapid laboratory tests (CBC, chemistry, coagulation)
• IA thrombolysis with large MCA clot presenting within 6° or
contraindications to IV thrombolysis
• Interventional treatment in comprehensive stroke center
• When IA rtPA is considered, give IV rtPA is eligible
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Nursing & Interdisciplinary Care of
Acute Ischemic Stroke (2009)
II. Emergency Nursing Interventions/Hyperacute Phase
• Class IIa Recommendations “Reasonable to perform”
• Medical Recommendations
• Use of Merci Retriever and Penumbra System
• Use of IA thrombolysis
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Nursing & Interdisciplinary Care of
Acute Ischemic Stroke (2009)
III. Acute Phase
• Class I Recommendations “Should be performed”
• Neurological assessments every 4 hours
• Treat temperatures > 99.6°
• Continuous cardiac monitoring for at least 24°- 48°
• Monitor neurological deficits/bleeding for up to 24° after tPA
• Treat hyperglycemia (>140mg/dL)
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Nursing & Interdisciplinary Care of
Acute Ischemic Stroke (2009)
III. Acute Phase (con’t)
• Class I Recommendations “Should be performed”
• Cautiously treat hypertension
• Monitor oxygen saturation
• Auscultate lungs, assess for respiratory compromise
• Assess for dysphagia
• Immediately treat seizure activity (no prophylactic treatment)
• Class IIa Recommendations “Reasonable to perform”
• Preprinted order sets/protocols to organize stroke care
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Nursing & Interdisciplinary Care of
Acute Ischemic Stroke (2009)
IV. Diagnostic Testing
• Class I Recommendations “Should be performed”
• Nurses should be familiar with basic neuroimaging testing
so they can educate patient/family
• CT, MRI, MRA, CTA, Angiography, Carotid Ultrasound,
TTE, TEE
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Nursing & Interdisciplinary Care of
Acute Ischemic Stroke (2009)
V. General Supportive Care
• Class I Recommendations “Should be performed”
• Infections should be identified and treated immediately
with antibiotics
• Institute early bowel/bladder care – prevent constipation,
urinary retention/infection
• Early implementation of anticoagulant therapy/physical
compression modalities – unable to ambulate at 2
days/risk for DVT/PE
• Early mobilization
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Nursing & Interdisciplinary Care of
Acute Ischemic Stroke (2009)
V. General Supportive Care (con’t)
• Class I Recommendations “Should be performed”
• Initiate fall precautions
• Prevent skin breakdown provide frequent turning if
bedridden
• Use Braden Scale in prediction of pressure ulcer
development
• Provide ROM in early phase of
acute stroke care
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Nursing & Interdisciplinary Care of
Acute Ischemic Stroke (2009)
V. General Supportive Care (con’t)
• Class I Recommendations “Should be performed”
• Keep patient NPO until swallow screen performed
• Perform swallow screen in first 24 hours after stroke
preferably by speech language pathologist
• Nurse to be familiar with bedside swallow assessment if
formal evaluation cannot be done within 24 hours
• NG tube placed if patient cannot swallow, consider PEG if
warranted
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Nursing & Interdisciplinary Care of
Acute Ischemic Stroke (2009)
V. General Supportive Care (con’t)
• Class IIa Recommendations “Reasonable to perform”
• Provide excellent pericare if indwelling catheter is
required (prevent infection)
• Provide feedings by IV, NG, or PEG
• Class IIb Recommendations “May be considered”
• Provide ROM between PT visits
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Nursing & Interdisciplinary Care of
Acute Ischemic Stroke (2009)
Secondary Stroke Prevention - Hypertension
• Provide antihypertensive treatment
• Individualize target BP level
• Average reduction of < 10/5 mmHg
• Provide lifestyle modifications (diet & exercise)
• Use diuretics and ACEI
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Nursing & Interdisciplinary Care of
Acute Ischemic Stroke (2009)
Secondary Stroke Prevention - Diabetes
• More rigorous control of BP and lipids
• Use ACEI and ARBS
• Provide near-normoglycemic levels
• A1c ≤ 7%
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Nursing & Interdisciplinary Care of
Acute Ischemic Stroke (2009)
Secondary Stroke Prevention - Cholesterol
• Provide lifestyle modification, dietary guidelines and
medication
• Statin agents are recommended
• LDL-C of < 100 mg/dL
• LDL-C of < 70mg/dL for high risk patient
• Consider statin for no preexisting indications
• Provide niacin or gemfibrozil(Lopid) for LOW HDL-C
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Nursing & Interdisciplinary Care of
Acute Ischemic Stroke (2009)
Secondary Stroke Prevention - Smoking
• Strongly encourage not to smoke
• Avoid environmental smoke
• Consider counseling, nicotine products, and oral
smoking cessation medications
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Nursing & Interdisciplinary Care of
Acute Ischemic Stroke (2009)
Secondary Stroke Prevention - Alcohol
• Eliminate or reduce consumption of alcohol
• Men – light to moderate levels of ≤ 2 drinks per day
• Women – light to moderate levels of 1 drink per day
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Nursing & Interdisciplinary Care of
Acute Ischemic Stroke (2009)
Secondary Stroke Prevention - Obesity
• Consider weight reduction
• Goal BMI of 18.5 to 24.9 kg/m2
• Waist circumference of < 35 inches women
• Waist circumference of < 40 for men
• Encourage weight management
• Caloric intake, physical
activity, behavioral counseling
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Nursing & Interdisciplinary Care of
Acute Ischemic Stroke (2009)
Secondary Stroke Prevention – Physical Activity
• Most days
• At least 30 minutes
• Moderate-intensity physical exercise
• Patient with disability, recommend supervised
therapeutic exercise regimen
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Nursing & Interdisciplinary Care of
Acute Ischemic Stroke (2009)
Stroke and Carotid Disease
• Recommend Carotid Endarterectomy
• TIA/stroke within past 6 months
• Ipsilateral severe (70-99%) stenosis
• Surgeon with perioperative morbidity/mortality of < 6%
• Recent TIA/stroke
• Ipsilateral moderate (50-69%) stenosis
• Within 2 weeks
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Nursing & Interdisciplinary Care of
Acute Ischemic Stroke (2009)
Stroke and Carotid Disease
• Recommend Carotid Artery Stent
• Symptomatic
• Severe stenosis (>70%)
• Difficult surgical candidate
• Surgeon with perioperative morbidity/mortality of 4-6%
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Nursing & Interdisciplinary Care of
Acute Ischemic Stroke (2009)
Stroke and Atrial Fibrillation
• Provide anticoagulation with adjusted-dose warfarin
• Target INR 2.5
• Range 2-3
• Unable to take oral anticoagulants use aspirin 325mg/d
• May, 2009 NEJM (ACTIVE Trial)
• Treatment with clopidogrel (75mg) plus aspirin(75-100mg)
reduced the rate of vascular events among patients with
atrial fibrillation. There was significant increase in risk of
major hemorrhage.
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Management of Spontaneous
Intracerebral Hemorrhage
2010
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Management of Spontaneous
Intracerebral Hemorrhage in Adults (2010)
I. Emergency Diagnosis & Assessment of ICH
• Class I Recommendation “Useful & Effective”
• Rapid neuroimaging with CT or MRI
• Class IIa Recommendation “In favor of”
• CTA, CTV, CT with contrast, MRI, MRA, MRV
• Class IIb Recommendation “Less well established”
• CT angiography & contrast-enhanced CT
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Management of Spontaneous
Intracerebral Hemorrhage in Adults (2010)
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II. Medical Treatment for ICH
• Class I Recommendation “Useful & Effective”
• Provide appropriate factor replacement therapy or
platelets for severe coagulation factor deficiency or
severe thrombocytopenia
• Class I Recommendation “Useful & Effective”
• INR elevated due to oral anticoagulants, hold warfarin,
give therapy to replace vitamin K-dependent factors,
correct INR, give IV Vitamin K
Management of Spontaneous
Intracerebral Hemorrhage in Adults (2010)
II. Medical Treatment for ICH (con’t)
• Class IIa Recommendation “In favor of”
• Consider giving Prothrombin Complex Concentrate (PCC)
• Class III Recommendation “Not Useful Effect”
• rFVIIa is not routinely recommended
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Management of Spontaneous
Intracerebral Hemorrhage in Adults (2010)
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II. Medical Treatment for ICH (con’t)
• Class I Recommendation “Useful & Effective
• Provide intermittent pneumatic compression prevent DVT
• Class IIb Recommendation “Less well established”
• After cessation of bleeding, give low-dose sc LMWH or
UFH with lack of mobility after 1 to 4 days from onset
Management of Spontaneous
Intracerebral Hemorrhage in Adults (2010)
III. Blood Pressure
• Class IIa Recommendation “In favor of”
• SBP 150 – 220 lower SBP to 140
• Class IIb Recommendation “Less well established”
• SBP > 200 or MAP > 150 give IV infusion
• SBP > 180 or MAP > 130 ↑ICP monitor ICP,
give intermittent or continuous IV medication
• SBP > 180 or MAP > 130 maintain BP 160/90 or
MAP 110 with intermittent or continuous IV medication
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Management of Spontaneous
Intracerebral Hemorrhage (2010)
IV. Inpatient Management
• Class I Recommendation “Useful & Effective”
• ICU care
• Treat fever to maintain normothermia
• Monitor glucose, maintain normoglycemia
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Management of Spontaneous
Intracerebral Hemorrhage (2010)
IV. Inpatient Management (con’t)
• Class I Recommendation “Useful & Effective”
• Treat clinical seizures with antiepileptic drugs
• Class IIa Recommendation “In favor of”
• Continuous EEG monitoring with decreased LOC
• Class III Recommendation “Not Useful”
• Prophylactic anticonvulsant medication
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Management of Spontaneous
Intracerebral Hemorrhage (2010)
V. Procedures
• Class IIb Recommendation “Less well established”
• ICP monitoring for
• GCS ≤ 8
• Herniation
• IVH
• Hydrocephalus
• Maintain CPP 50 to 70
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Management of Spontaneous
Intracerebral Hemorrhage (2010)
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V. Procedures (con’t)
• Class IIa Recommendation “In favor of”
• Treat hydrocephalus with ventricular drain with ↓LOC
• Class IIb Recommendation “Less well established”
• Administration of intraventricular rtPA for IVH is
considered investigational
Management of Spontaneous
Intracerebral Hemorrhage (2010)
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VI. Clot Removal
• Class I Recommendation “Useful & Effective”
• Surgery ASAP for ….
• Cerebellar hemorrhage >3cm
• Deteriorating neurologically
• Brain stem compression
• Hydrocephalus
Management of Spontaneous
Intracerebral Hemorrhage (2010)
VI. Clot Removal (con’t)
• Class IIb Recommendation “Less well established”
• Usefulness of surgery is uncertain
• Lobar clot > 30mL and within 1cm of surface
• Use of minimally invasive technique
• Class III Recommendation “Not Useful”
• Very early craniotomy (increase risk of rebleed)
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Management of Spontaneous
Intracerebral Hemorrhage in Adults (2010)
VII. Withdrawal of Technological Support
• Class IIa Recommendations “In favor of”
• Aggressive full care until at least the second full day of
hospitalization
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Management of Spontaneous
Intracerebral Hemorrhage in Adults (2010)
VIII. Prevention of Recurrent ICH
• Class I Recommendations “Should be performed”
• Treat hypertension
• Discontinue
• Smoking
• Heavy alcohol use
• Cocaine use
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Management of Spontaneous
Intracerebral Hemorrhage in Adults (2010)
VIII. Prevention of Recurrent ICH (con’t)
• Class IIa Recommendations “In favor of”
• Risk factors for ICH recurrence
• Lobar location
• Older age
• Ongoing anticoagulation
• Greater number of microbleeds on MRI
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Critical Care Management of
Aneurysmal
Subarachnoid Hemorrhage
2011
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2011 Neurocritical Care Society
Recommendations for aSAH
• Classification of Recommendations
• High– “Further research unlikely to change effect”
• Moderate– “Further research is likely to change effect”
• Low – “Further research is very likely to change effect”
• Very Low – “Very uncertain of effect”
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Medical Measures to
Prevent Rebleed
• Early aneurysm repair (High)
• Early short course of antifibrinolytic – Amicar prior to
aneurysm repair (Low)
• Avoid antifibrinolytic therapy > 48 post ictus or > 3
days, concern with side effects (High)
• Screen for DVT while on Amicar (Moderate)
• Discontinue Amicar 2 hours prior to treatment
(Very Low)
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Medical Measures to
Prevent Rebleed (con’t)
• Treat extreme hypertension in unsecured (Low)
• Do not treat modest hypertension (MAP <110) (Low)
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Seizures and
Prophylactic Anticonvulsant Use
• Do not use phenytoin for prophylaxis(Low)
• Consider other anticonvulsants for prophylaxis
(Very Low)
• Short course (3-7days) AED prophylaxis (Low)
• Give anticonvulsant with seizure presentation (Low)
• Consider continuous EEG (Low)
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Cardiopulmonary Complications
• Obtain baseline cardiac assessment (Strong)
• Monitor CO may be useful (Low)
• Treat pulmonary edema by maintaining euvolemia
(Moderate)
• Treat heart failure while maintaining CPP/MAP for
cerebral perfusion (Moderate)
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Monitoring Intravascular Volume
• Monitor volume status (Moderate)
• No specific modality is recommended
• Use clinical assessment
• Vigilant fluid balance management (Moderate)
• Do not place central venous lines solely for
measurement (Moderate)
• Routine use of PACs is not recommended (Moderate)
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Managing Intravascular Volume
• Target euvolemia (High)
• Avoid hypervolemia (High)
• Use isotonic crystalloid for replacement (Moderate)
• Consider fludrocortisone or hydrocortisone for
persistent negative fluid balance (Moderate)
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Glucose Management
• Avoid hypoglycemia (<80 mg/dL) (High)
• Maintain glucose <200 mg/dL (Moderate)
• May adjust serum glucose with use of microdialysis
(Very Low)
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Management of Pyrexia
• Frequent temperature monitoring (High)
• Seek and treat infectious fever (High)
• Control fever during risk for delayed cerebral
ischemia (Low)
• Use acetaminophen, ibuprofen as first line agents
(Moderate)
• Surface/intravascular cooling when antipyretics fail
(High)
• Monitor & treat shivering with cooling (High)
Deep Vein Thrombosis Prophylaxis
• Provide DVT prophylaxis (High)
• Use SCDs routinely (High)
• Withhold prophylaxis LMWH or UFH in untreated
patients (Low)
• Start UFH 24 hours after surgery (Moderate)
• Withhold LMWH or UFH 24 hours before and after
intracranial procedures (Moderate)
• Duration of DVT prophylaxis is uncertain (Low)
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Statins and Magnesium
 Continue statin if previously on it (Low)
 Consider statin for statin-naïve patient (Moderate)
 Do not induce hypermagnesemia (Moderate)
 Avoid hypomagnesemia (Moderate)
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Monitoring for DCI and
Triggers for Interventions
 Monitor for delayed cerebral ischemia (DCI) in
environment with expertise in SAH (Moderate)
 Give Nimodipine 60mg every 4 hours x21 days (High)
 Detect DCI with TCD, DSA, CTA, EEG, PbtO2
(Moderate)
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Hemodynamic Management of DCI
 Maintain euvolemia (Moderate)
 Consider saline bolus to increase CBF (Moderate)
 Trial induced hypertension with DCI (Moderate)
 Choose vasopressor based of effects (Moderate)
 Augment BP based on MAP in stepwise fashion (Poor)
 Change dose of nimodipine if hypotension occurs –
discontinue with persistent hypotension (Poor)
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Hemodynamic Management of DCI
(con’t)
 Consider inotropic (Dobutamine) (Low)
 May need to augment with vasopressor (High)
 IABP maybe useful (Low)
 Do not provide hemodilution (Moderate)
 Caution with increasing BP in unsecured (Low)
 Unruptured should not influence management
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(Moderate)
Endovascular Management of DCI
• Consider IA vasodilators and/or angioplasty (Moderate)
• Timing of endovascular treatment is unclear (Moderate)
• Do not provide prophylactic angioplasty (High)
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Anemia and Transfusion
• Minimize blood loss from blood draws (Low)
• Give PRBC maintain hemoglobin 8-10g/dl (Moderate)
• Higher hemoglobin may be appropriate for patient at
risk for DCI – uncertain if transfusion is useful
(No Evidence)
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Management of Hyponatremia
• Do not fluid restrict (Weak)
• Early treatment with hydrocortisone or fludrocortisone
(Moderate)
• Mild hypertonic saline (Very Low)
• Avoid hypovolemia if using vasopressin-receptor
antagonists (Weak)
• Limit free water intake (Very Low)
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Endocrine Function
• Consider hypothalamic dysfunction when not
responding to vasopressor (Moderate)
• Do not give high dose corticosteroids (High)
• Consider mineralocorticoids (Moderate)
• Consider
• Stress-dose corticosteroids with vasospasm and
no response to induced hypertension (Weak)
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High Volume Centers
• Treat at high volume center (Moderate)
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Stroke Care
What people are writing about..
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January, 2012
• Statin Use during Ischemic Stroke
Hospitalization is Strongly Associated with
Improved Poststroke Survival
• Flint, A. et al Stroke, 43(1) 147-154
• Statin use early in stroke hospitalization is strongly
associated with improved poststroke survival, and
statin withdrawal in the hospital is associated with
worsened survival
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February, 2012
• Female Caregivers of Stroke Survivors:
Coping & Adapting to a Life that Once Was
• Saban, K and Hogan, N. Journal of Neuroscience Nursing,
44(1), 1-14
• Describe experience of female caregiver (N = 46)
• Losing the life that once was
• Coping with daily burdens
• Creating a new normal
• Interacting with healthcare providers
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March, 2012
• Delirium in Acute Stroke
• Shi, Q. et al Stroke, 53(3), 645-649
• Systematic Review and Meta-Analysis (10 studies)
• Stroke patients with development of delirium have
unfavorable outcomes (high mortality, longer
hospitalization, greater degree of dependence)
• Prevention and early recognition of delirium may
improve stroke outcomes
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March, 2012
• Lumbar Drainage of CSF after Aneurysmal
Subarachnoid Hemorrhage (LUMAS)
• Al-Tamimi, Y. et al Stroke, 43(3), 677-682
• N = 210
• Lumbar drainage of CSF showed to
• Reduce prevalence of delayed ischemic neurological deficit
• Improve early clinical outcome
• Failed to improve outcome at 6 months
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March , 2012
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• Predicting the Lack of Development of Delayed
Cerebral Ischemia after Aneurysmal
Subarachnoid Hemorrhage
• Crobeddu, E. et al Stroke, 43(3), 697-701
• N=307
• Patients who will not develop DCI
• Age ≥ 68
• WFNS I – III
• Modified Fisher Grade 1 – 2
• Consider these patient for early transfer to the floor
April, 2012
• Trends in the Hospitalization of Ischemic Stroke
in the US, 2007
• Lee, L. et al International Journal of Stroke, 7(4), 195-201
• Decreased rate of ischemic stroke hospitalization
• Increased rate among young adults
• Decreased mortality
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April, 2012
• Alcohol Consumption & Risk of Stroke in Women
• Jimenez, M. et al Stroke, 43(4), 939-945
• Light to moderate alcohol consumption was associated with
lower risk of total stroke.
• .83 relative risk for 5 – 14g/d (1/2 to 1 glass)
• .79 relative risk for 15 – 29.9g/d (1 to 2 glasses)
• 1.06 relative risk for 30 – 45g/d (2 to 3 glasses)
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April, 2012
• Impact of Emergency Department Transitions of
Care on Thrombolytic Use in Acute ischemic
Stroke
• Madej-Fermo, O. et al Stroke, 43(4), 1067-1074
• Stroke presentation during change of shift did NOT
delay rt-PA use
• Presentation at night did result in delay of care
undergoing interventional therapy
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May, 2012
• Correlation between ED Symptoms and Clinical
Outcomes in the Patient with Aneurysmal SAH
• Adkins, K. et al. Journal of Emergency Nursing,
38(3), 226-33
• Poor clinical grade (H&H >3) and bradycardia significant
predictor of death at 30 days
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May, 2012
• Frontal Infarcts and Anxiety in Stroke
• Tang, W. et al Stroke, 43(5), 1426-428
• Association between posttroke anxiety symptoms and
frontal lobe infarcts
• N= 693
• Poststroke anxiety patients were more likely to have
RIGHT frontal acute infarcts
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June, 2012
• Wakeup or unclear-onset strokes: are they
waking up to the world of thrombolysis therapy?
• Kang, D. et al International Journal of Stroke, 7(4),
311-320
• 25% of strokes occur as wakeup or unclear onset
• Many do not receive rt-PA
• Actual onset time of wake-up stroke is close to the wakeup time
• Advanced imaging can identify favorable patient
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“Time is Brain”
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