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rTPA ASSESSMENT GUIDES

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posted:
11/19/2011
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7
Thrombolysis Protocol for use in acute stroke

AIM – ARRIVAL TO DRUG ADMINISTRATION ≤ 30 minutes

NAME ONSET Date Lysis team called at

ONSET Time Bloods taken at

D.O.B. ADMISSION Date

HOSP. No ADMISSION Time



ON ARRIVAL TO A&E /MAU

If approximate onset time is 1.4

Stop infusion if any evidence of bleeding, if neuro signs deteriorate of if there is a massive increase in BP.

Complete treatment record, assessments, NIHSS, Rankin, Barthel on page 4 and SITS register form.

Admit to the Acute Stroke Unit

Hand over thrombolysis care plan to ward staff

Inform the thrombolysis phone holder on call of patient if lysis was done by a doctor in A&E



Check that the following information has been recorded in the patients notes:

Names(s) of the Doctors responsible for reading C.T. Scan

Dosage of rtPA given

File original of this in the notes and send copy to Dr C. Roffe for SITS register

REMEMBER if out of time for therapeutic thrombolysis, rTPA can be given as part of the IST-3 trial up

to 6 h after symptom onset, or up to 9 hours as part of DIAS-4 (working hours only).



Thrombolysis pathway and docs Christine.roffe@northstaffs.nhs.uk 24 03 2011 adapted from a pathway provided by G. Ford 1 of 7

BODY WEIGHT/DOSE CHART FOR rtPA DRUG DOSAGE AND

(Alteplase) ADMINISTRATION







Body Body Total 10% 90% IV No. of PATIENTS MUST BE

Weight Weight rtPA Bolus Infusion 50mg CONTINUOUSLY MONITORED

(Stones) (Kg) Dose (ml) (ml/hr) rtPA PRIOR TO AND DURING DRUG

(mg) vials ADMINISTRATION, and for at least 24

needed hours following administration.

6st 4 40 36 4 32 1

6st 8 42 38 4 34 1

7st 44 40 4 36 1 1. Total dose: 0.9mg/kg.

7st 3 46 41 4 37 1 MAXIMUM DOSE IS 90 MG.

(See body weight/dose chart)

7st 7 48 43 4 39 1

7st 12 50 45 5 40 1 2. Should be prescribed by, and

8st 2 52 47 5 42 1 administration supervised by, a

8st 6 54 49 5 44 1 Doctor from the stroke team.

8st 12 56 50 5 45 2

9st 1 58 52 5 47 2 3. 10% of total dose given as an

9st 6 60 54 5 49 2 I.V. push over 2 minutes by a

9st 10 62 56 6 50 2 Doctor from the stroke team.

10st 64 58 6 52 2 4. Give remaining 90% of dose

10st 5 66 59 6 53 2 I.V. over 60 minutes via infusion

10st 9 68 61 6 55 2 pump.

11st 70 63 6 57 2

11st 4 72 65 6 59 2 5. Observe patient for any

11st 9 74 67 7 60 2 deterioration during infusion.

12st 76 68 7 61 2

12st 3 78 70 7 63 2

12st 8 80 72 7 65 2

12st 12 82 74 7 67 2

13st 3 84 76 8 68 2

13st 7 86 77 8 69 2

13st 12 88 79 8 71 2

14st 90 81 8 73 2

14st 6 92 83 8 75 2

14st 11 94 85 8 77 2

15st 2 96 86 9 77 2

15st 7 98 88 9 79 2

15st 10 100 90 9 81 2









Thrombolysis pathway and docs Christine.roffe@northstaffs.nhs.uk 24 03 2011 adapted from a pathway provided by G. Ford 2 of 7

INCLUSION CRITERIA



ANSWER TO THE FOLLOWING QUESTIONS MUST BE YES YES NO

Intracranial haemorrhage excluded by CT head scan

Onset of symptoms less than 3 h ago (may extend to 4.5 h if thrombolysis consultant agrees)

Previously independent

Verbal or written informed consent or assent



EXCLUSION CRITERIA



ANSWER TO ALL OF THE FOLLOWING QUESTIONS MUST BE NO YES NO

Uncontrolled hypertension (systolic >185mmHg or diastolic >110mmHg)*

BP,

BM









Blood glucose 22 mmol/l*

Coma

Seizure at stroke onset*

Stroke within the preceding 3 months*

Rapidly resolving symptoms*

Head injury at the time of stroke or within the preceding 3 months*

CNS exclusions









H/O intracranial haemorrhage (e.g. SAH, SDH, ICH) any time in the past*

Symptoms suggestive of SAH even if CT normal)*

Non-ischaemic pathology (e.g. functional, migraine, brain tumour, septic embolus etc

likely)*

Any history of CNS damage (AVM, neoplasm, intracranial or spinal surgery)

Potential source of GI bleed (colitis, liver disease, pancreatitis, oesophageal varices,

active peptic ulcer disease)*

Endocarditis, pericarditis, recent MI, aortic aneurysm or ventricular aneurysm

Other sources of









Trauma with fracture or internal injuries within previous 4 weeks

Surgery or visceral biopsy, cardiopulmonary resuscitation within previous 4 weeks or

bleeding









arterial or lumbar puncture within 7 days)*

Pregnancy, or childbirth within the previous 4 weeks or breastfeeding

Haemorrhagic retinopathy (e.g. untreated proliferative diabetic retinopathy)

On warfarin, heparin or equivalent anticoagulation (unless INR 3 hrs (consider IST-3 up to 6 h and DIAS-4 up to 8h)

Age>80 (consider IST-3)

N.I.H. Score ≤ 4 or >=25 (consider IST-3)

Fixed head or eye deviation (relative contraindication, consider IST-3) b

Others









Hypodensity or sulcal effacement in >1/3 of MCA territory (relative contraindication,

consider IST-3) b

Brain stem stroke: i.a. thrombolysis may be considered even in unconscious patients,

Intraarteri









and delivered up to 12 h after symptom onset if there is basilar artery occlusion.

al lysis









Do CT angiogram and conisder ia thrombolysis if hyperdense MCA, age<75 and fit for

GA, time form onset 3-6h in ant circ stroke or in brain stem stroke (see pathway for

ia thrombolysis on www.thrombolysis.info)

This list includes all exclusions given in the product license. *exclusions also listed in NIH trial

Relative contraindications are those mentioned in SITS-MOST protocol, but not in the NIH trial

a

If there is no clinical reason whatsoever to suspect an abnormal FBC or INR thrombolysis should not be delayed

b

to wait for the results. exclusion in SITS, but not in product license or in NIH trial



Thrombolysis pathway and docs Christine.roffe@northstaffs.nhs.uk 24 03 2011 adapted from a pathway provided by G. Ford 3 of 7

SITS No Name:

Unit No:

Date of lysis

Thrombolysis Log and Follow-up

For SITS/ SINAP/ AUDIT

C.T. read by Comments/ Details:

Decision to lyse made by (name)

Grade of decision maker

(F2 SpR SG Cons SRN ConsN)

Specialty of decision maker

(A&E, stroke, neuro, other)

Thormbolysis decision supported by stroke

specialist (give name):

In person/ via phone/ phone w CT link / via videolink

Stroke/ Thrombolysis specialist consulted

(give name or say no )

Mode of specialist consultation

(in person/ phone/ Phone with CT link/

videolink/ none/ other )

Body wt (known/ estimate)

Dosage Bolus

Dosage Infusion

Dosage total

Thrombolysis start time

Thrombolysis completion time

Excluded (give reason in comments box )

No Anticoagulants or antithrombotics to be

given for 24 h documented on drug chart

Care plan handed over to ward staff



Assessments Baseline After lysis 24h 1 week or DC if

(1h-2h) earlier

Date+time



NIHSS



Blood Pressure x

Complications/ adverse Yes /no Yes /no Y N

Angiooedema

events (if yes specify) Symptomat. Brain Haemorrh.

Extracranial Haemorrhage

Other





CT head scan 0 hrs 24-48 h Other

Date and time

Result









6 weeks 3 months

Follow-up Discharge

(clinic) (phone)

Date

Rankin



NIHSS See above









Thrombolysis pathway and docs Christine.roffe@northstaffs.nhs.uk 24 03 2011 adapted from a pathway provided by G. Ford 4 of 7

Nursing Care Pathway for thrombolysis (adapted from IST-3 Website)





Prepare for arrival of patient to ward

Minimum equipment required:



 O2 and O2 saturation monitor



 Suction



 Drip stand



 Syringe pump and attachments



 Manual sphygmomanometer









On arrival of patient – record



 GCS



 BP, Pulse, T, Pulse



 O2 saturation









Next:



 Initial bolus of treatment given by doctor over 1-2 minutes



 Remainder of treatment to be given by syringe driver over 1 hour









Record GCS and vital signs:



 Every 15 minutes for 2 hours



 Every 30 minutes for the next 6 hours



 Hourly for a further 6 hours



 4 hourly for the next 36 hours









IF THERE ARE ANY SIGNS OF BLEEDING OR THE PATIENT DETERIORATES IN ANY

WAY CALL THE SENIOR NURSE IN CHARGE AND THE RESPONSIBLE MEDICAL TEAM

and



inform Thrombolysis consultant on call



Management of complications is outlined in the thrombolysis training folder or can be

downloaded from www.thrombolysis.info



Thrombolysis pathway and docs Christine.roffe@northstaffs.nhs.uk 24 03 2011 adapted from a pathway provided by G. Ford 5 of 7

In the 24 hours following treatment avoid:



 Urinary catheterisation



 NG insertion



 Central venous access



 Anticoagulation



 im injections (for 48 hrs)



 Aspirin until 24 h post treatment CT scan results available



If essential discuss with thrombolysis consultant on call









Additional instructions for patients who have had intra-arterial

thrombolysis



Check femoral catheter for bleeding during each observation

(schedule as above)



Do not mobilize out of bed until 4 h after catheter removed



Catheter should be removed by a trained person 24 h after the end

of lysis. Site must be compressed manually for at least 20 min after

catheter removal (follow instructions of operator)



If the patient has a urinary catheter remove this 24 h after the end of

lysis (unless this is a permanent indwelling catheter)









Thrombolysis pathway and docs Christine.roffe@northstaffs.nhs.uk 24 03 2011 adapted from a pathway provided by G. Ford 6 of 7

Patient Information Leaflet.



Thrombolysis (treatment with a clot dissolving drug – alteplase) for acute stroke



Your doctor and the medical staff looking after you have decided that your symptoms

are caused by a blood clot blocking one of the vessels that supplies blood to part of

your brain. This may result in a disabling stroke unless the blood supply is restored to

the part of your brain that is affected.



Alteplase is a drug which is routinely used in the treatment of heart attacks. It has also

been shown to be effective in the treatment of acute stroke. This is best if the

treatment is started within 3 hours of the stroke starting. Alteplase breaks down blood

clots and this is why it is used in some strokes. The aim is to try and get the blood

flowing back into the affected area of the brain. This treatment has been checked and

approved by regulatory authorities in Europe and Great Britain (NICE.)



Aleplase does not always make the blood clot go away because they vary in size and

what they are made of. Giving you alteplase can cause bleeding in the brain. This can

be serious and lead to worsening in your condition and death. Nevertheless, alteplase

is a very good treatment that may make your condition better or lead to a big

improvement over the next few hours. In trials of this treatment, for every 100 patients

given alteplase, 10 more have improved so much that they have become able to look

after themselves when compared to 100 with no treatment. However, 7 of the 100

patients who had the drug had a bleed into their head.



To make sure that patients get the most benefit and the smallest risk, we need to start

this treatment within 3 hours of the start of your stroke. The drug is given via a ‘drip’

into a vein over one hour. You will be very closely monitored while you are having the

treatment and over the next 24 hours. Otherwise your care will be exactly the same as

it is for all our patients who suffer a stroke. You will have another CT scan (like the

one you have just had) done 22-36 hours after the drug.



To allow us to plan care for future patients, your treatment and its effect will be stored

on a special database. This data will be recorded in such a way that your identity will

not be revealed to anyone outside of the study. The data that we store may be looked

at by scientists and the results published for guiding future treatment and education.

Your identity will not be revealed.



Please contact a member of the team treating you or Dr C Roffe (01782 55 5880) for

any queries.









Thrombolysis pathway and docs Christine.roffe@northstaffs.nhs.uk 24 03 2011 adapted from a pathway provided by G. Ford 7 of 7



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