Post Thrombolysis Care and Complications

1
Post Thrombolysis Care and Complications

• Gill Cluckie
• Clinical lead, stroke
• Guys and St. Thomas NHS
• Foundation Trust

2
Essential Care

• 11 Nursing for the first 24 hours?
• Bed Rest for 24 hours?
• Appropriate equipment at the patients bedside,
  EG, cardiac monitor, suction, drip stand and
  pump, oxygen, emergency equipment

3
Observations

• Consistent and full neurological observations
• - Every 15 mins for 2 hours
• - half hourly for 6 hours
• - hourly for 16 hours
• MRC grading for limb power
• NIHSS trained staff to identify significant
  clinical changes

4
Things to Remember

• No heparin, warfarin, anti-platelets
• Swallow assessment
• Do not pass NG Tube until 24 hours
• No arterial punctures or central lines
• Avoid catheterisation. If essential, 30 mins
  after completion of thrombolysis
• NO SHAVING!!

5
Complications

• Blood Pressure Management
• Intracranial Haemorrhage
• Anaphylaxis
• Extra-Cranial Haemorrhage

6
Blood Pressure

• Strict BP control to prevent increased risk of
  intra-cranial haemorrhage less than 180/100mmHg
• If either reading is above limit, recheck in 5
  minutes
• If 3 readings at least 5 minutes apart show BP
  higher than limit administer IV labetalol
  10-20mg as bolus
• Do you usually give IV labetalol in your unit?

7
Intracranial Haemorrhage

• What are the signs and symptoms?
• Symptoms nausea, vomiting, headache, altered
  limb function
• Signs increasing difficulty obtaining same GCS,
  agitation, drowsiness, drop in GCS, altered limb
  function, vomiting
• How would you observe these in a drowsy patient?

8
Intracranial Haemorrhage

• Decision on stopping the infusion if still in
  progress
• Decision on urgent repeat CT brain to confirm
  haemorrhage
• Follow protocols on referral of these patients to
  neuro-surgeons
• Decisions on escalation plans or palliative care
  option

9
Case Study 1

• 54 year old man collapsed with left face, arm and
  leg weakness
• Drowsy on assessment, clinically had R MCA
  infarct
• NIHSS 12
• Thrombolysed within 2 hours of onset

10
Case study 1

• At 14 hours improved face and leg weakness and
  less drowsy- NIH had reduced to 7
• Went for repeat CT, nurse noticed on way to CT
  that his left leg had deteriorated
• Post-CT he was much more drowsy

11
Case study 1

• Needed neurosurgery
• Died 3 weeks later

12
Extra-Cranial Haemorrhage

• What are the signs and symptoms?
• Symptoms abdominal pain or discomfort, nausea,
  obvious bleeding, malena
• Signs haematemesis, malena, haemodynamic
  compromise, pallor, increasing drowsiness, heavy
  blood loss, tachycardia

13
Extra-Cranial Haemorrhage

• Common oozing from cannulation sites, gum
  bleeding
• Post-angioplasty careful management of sheath
  site, likely to require Fem-stop device to
  prevent haematoma development
• GI bleed management of blood pressure, blood
  volume, follow protocols for surgical reviews and
  administering blood products

14
Extra-Cranial Haemorrhage

• Ecchymosis
• Watch the restless patient and cannula sites

15
Anaphylaxis

• What are the signs and symptoms to observe for?
• Symptoms increased breathlessness, tightness in
  chest, itch, tingling lips or tongue, tightness
  in throat, dysphagia
• Signs oral oedema, facial oedema, audible
  wheeze, stridor, desaturation, increased
  respiratory rate and effort, respiratory arrest

16
Anaphylaxis

• Stop infusion if still in progress
• Administer adrenaline, chlorpheniramine and
  hydrocortisone as for anaphylaxis
• Protect airway and maintain adequate oxygenation
• May require intubation urgently via crash call

17
Case Study 2

• 64 yr old female
• Thrombolysed
• Arrival at Ward
• Neuro obs unchanged
• Cardio obs unchanged
• Gum bleeding observed
• WITHIN 5 MINUTES!!
• CRASH CALL

18
Case study 2

• Tongue, face, eyes swollen
• No BP fall or tachycardia
• Difficult Intubation
• Died in ITU due to secondary cerebral oedema
• Rate around 0.5-1
• Some anecdotes that angio-oedema is more common
  in patients on ACE inhibitors on admission

19
Plan Ahead

• Hand over to on-call teams/hospital at night
• Staff coverage appropriate trained people.
• Have the ability to react quickly and
  appropriately when you notice a change no matter
  how little or subtle
• Think of weekends and nights, drug charts,
  escalation
• Never be worried to put out a Crash Call