Post Thrombolysis Care Post Thrombolysis Care and Complicationsand Complications

Gill CluckieGill CluckieClinical lead, strokeClinical lead, stroke

Guy’s and St. Thomas’ NHS Guy’s and St. Thomas’ NHS Foundation TrustFoundation Trust

Essential CareEssential Care

1:1 Nursing for the first 24 hours?1:1 Nursing for the first 24 hours? Bed Rest for 24 hours?Bed Rest for 24 hours? Appropriate equipment at the patients Appropriate equipment at the patients

bedside, EG, cardiac monitor, suction, bedside, EG, cardiac monitor, suction, drip stand and pump, oxygen, emergency drip stand and pump, oxygen, emergency equipmentequipment

ObservationsObservations Consistent and full neurological Consistent and full neurological

observations:observations:

- Every 15 mins for 2 hours- Every 15 mins for 2 hours

- half hourly for 6 hours- half hourly for 6 hours

- hourly for 16 hours- hourly for 16 hours MRC grading for limb powerMRC grading for limb power NIHSS trained staff to identify significant NIHSS trained staff to identify significant

clinical changesclinical changes

Things to RememberThings to Remember

No heparin, warfarin, anti-plateletsNo heparin, warfarin, anti-platelets Swallow assessmentSwallow assessment Do not pass NG Tube until 24 hoursDo not pass NG Tube until 24 hours No arterial punctures or central linesNo arterial punctures or central lines Avoid catheterisation. If essential, 30 Avoid catheterisation. If essential, 30

mins after completion of thrombolysis mins after completion of thrombolysis

NO SHAVING!!NO SHAVING!!

ComplicationsComplications

Blood Pressure ManagementBlood Pressure Management Intracranial HaemorrhageIntracranial Haemorrhage AnaphylaxisAnaphylaxis Extra-Cranial HaemorrhageExtra-Cranial Haemorrhage

Blood PressureBlood Pressure Strict BP control to prevent increased risk Strict BP control to prevent increased risk

of intra-cranial haemorrhage – less than of intra-cranial haemorrhage – less than 180/100mmHg180/100mmHg

If either reading is above limit, recheck in 5 If either reading is above limit, recheck in 5 minutesminutes

If 3 readings at least 5 minutes apart show If 3 readings at least 5 minutes apart show BP higher than limit – administer IV BP higher than limit – administer IV labetalol 10-20mg as boluslabetalol 10-20mg as bolus

Do you usually give IV labetalol in your Do you usually give IV labetalol in your unit?unit?

Intracranial HaemorrhageIntracranial Haemorrhage What are the signs and symptoms?What are the signs and symptoms? Symptoms: nausea, vomiting, headache, Symptoms: nausea, vomiting, headache,

altered limb functionaltered limb function

Signs: increasing difficulty obtaining same Signs: increasing difficulty obtaining same GCS, agitation, drowsiness, drop in GCS, GCS, agitation, drowsiness, drop in GCS, altered limb function, vomiting altered limb function, vomiting

How would you observe these in a drowsy How would you observe these in a drowsy patient?patient?

Intracranial HaemorrhageIntracranial Haemorrhage

Decision on stopping the infusion if still in Decision on stopping the infusion if still in progressprogress

Decision on urgent repeat CT brain to Decision on urgent repeat CT brain to confirm haemorrhageconfirm haemorrhage

Follow protocols on referral of these Follow protocols on referral of these patients to neuro-surgeonspatients to neuro-surgeons

Decisions on escalation plans or Decisions on escalation plans or palliative care optionpalliative care option

Case Study 1Case Study 1

54 year old man collapsed with left face, 54 year old man collapsed with left face, arm and leg weaknessarm and leg weakness

Drowsy on assessment, clinically had R Drowsy on assessment, clinically had R MCA infarctMCA infarct

NIHSS = 12 NIHSS = 12 Thrombolysed within 2 hours of onsetThrombolysed within 2 hours of onset

Case study 1Case study 1

At 14 hours – improved face and leg At 14 hours – improved face and leg weakness and less drowsy- NIH had weakness and less drowsy- NIH had reduced to 7reduced to 7

Went for repeat CT, nurse noticed on way to Went for repeat CT, nurse noticed on way to CT that his left leg had deterioratedCT that his left leg had deteriorated

Post-CT he was much more drowsyPost-CT he was much more drowsy

Case study 1Case study 1

Needed neurosurgeryNeeded neurosurgeryDied 3 weeks laterDied 3 weeks later

Extra-Cranial Extra-Cranial HaemorrhageHaemorrhage

What are the signs and symptoms?What are the signs and symptoms?

Symptoms: abdominal pain or discomfort, Symptoms: abdominal pain or discomfort, nausea, obvious bleeding, malenanausea, obvious bleeding, malena

Signs: haematemesis, malena, Signs: haematemesis, malena, haemodynamic compromise, pallor, haemodynamic compromise, pallor, increasing drowsiness, heavy blood loss, increasing drowsiness, heavy blood loss, tachycardiatachycardia

Extra-Cranial Extra-Cranial HaemorrhageHaemorrhage

Common oozing from cannulation sites, Common oozing from cannulation sites, gum bleedinggum bleeding

Post-angioplasty – careful management of Post-angioplasty – careful management of sheath site, likely to require Fem-stop sheath site, likely to require Fem-stop device to prevent haematoma developmentdevice to prevent haematoma development

GI bleed – management of blood pressure, GI bleed – management of blood pressure, blood volume, follow protocols for surgical blood volume, follow protocols for surgical reviews and administering blood productsreviews and administering blood products

Extra-Cranial Extra-Cranial HaemorrhageHaemorrhage

EcchymosisEcchymosis Watch the restless patient and cannula sitesWatch the restless patient and cannula sites

AnaphylaxisAnaphylaxis What are the signs and symptoms to What are the signs and symptoms to

observe for?observe for?

Symptoms: increased breathlessness, Symptoms: increased breathlessness, tightness in chest, itch, tingling lips or tightness in chest, itch, tingling lips or tongue, tightness in throat, dysphagiatongue, tightness in throat, dysphagia

Signs: oral oedema, facial oedema, audible Signs: oral oedema, facial oedema, audible wheeze, stridor, desaturation, increased wheeze, stridor, desaturation, increased respiratory rate and effort, respiratory respiratory rate and effort, respiratory arrestarrest

AnaphylaxisAnaphylaxis

Stop infusion if still in progressStop infusion if still in progress Administer adrenaline, chlorpheniramine Administer adrenaline, chlorpheniramine

and hydrocortisone as for anaphylaxisand hydrocortisone as for anaphylaxis Protect airway and maintain adequate Protect airway and maintain adequate

oxygenationoxygenation May require intubation urgently via crash May require intubation urgently via crash

callcall

Case Study 2Case Study 2

64 yr old female 64 yr old female ThrombolysedThrombolysed Arrival at WardArrival at Ward Neuro obs unchangedNeuro obs unchanged Cardio obs unchangedCardio obs unchanged Gum bleeding Gum bleeding

observedobserved

WITHIN 5 MINUTES!!WITHIN 5 MINUTES!!CRASH CALLCRASH CALL

Case study 2Case study 2

Tongue, face, eyes swollenTongue, face, eyes swollen No BP fall or tachycardiaNo BP fall or tachycardia Difficult Intubation Difficult Intubation Died in ITU due to secondary cerebral Died in ITU due to secondary cerebral

oedemaoedema

Rate around 0.5-1%Rate around 0.5-1%Some anecdotes that angio-oedema is more Some anecdotes that angio-oedema is more

common in patients on ACE inhibitors on common in patients on ACE inhibitors on admissionadmission

Plan AheadPlan Ahead Hand over to on-call teams/hospital at nightHand over to on-call teams/hospital at night Staff coverage – appropriate trained Staff coverage – appropriate trained

people. people. Have the ability to react quickly and Have the ability to react quickly and

appropriately when you notice a change no appropriately when you notice a change no matter how little or subtlematter how little or subtle

Think of weekends and nights, drug charts, Think of weekends and nights, drug charts, escalationescalation

Never be worried to put out a Crash CallNever be worried to put out a Crash Call