ICU Management & Concerns of Acute Ischemic Stroke

Amanda Severson, RN, MSN, ACNP-BC

V. Acute Care – 25% Pg 101-139

The 2013 Stroke Guidelines for the Early Management of Acute Ischemic Stroke states:

“The importance of dedicated stroke nursing care in the

management of stroke patients cannot be overstated.”

(Jauch, et al, 2013, p.916)

Admission to NeuroCritical Care ICU

• Admit to Neuro ICU after initial imaging and/or treatment (recombinant tissue plasminogen activator (rtPA), thrombectomy).

• From door to stroke unit admission in </=3 hours.

Role of Stroke Unit

• 25% of pts with ischemic stroke will deteriorate clinically in first 1-2 days.

• Pts with ICH or SAH at risk for deterioration 2/2 hemorrhagic expansion, edema progression, & hernation

Goals of Admission 1) Close observation for changes in patient’s

condition 2) Observation & treatment to reduce bleeding

after IV rtPA 3) Facilitate measures to improve outcomes after

stroke 4) Begin measures to prevent subacute

complications 5) Initiate long-term therapies to prevent recurrent

stroke 6) Start efforts to restore neurological function

Blood Pressure Management • Maintain SBP <185 • Hypertension-> encephalopathy,

cardiac complications, & renal insufficiency

• Hypotension-> decreased perfusion to organs, especially ischemic brain

• Ideal blood pressure range not scientifically determined

• After rtPA, keep BP<180/110 to reduce ICH risk

Anti-Hypertensive Medications • Labetalol IV push 10-20mg, may repeat x 1 • Nicardipine gtt 5-15mg/hr • Nipride? No. Causes vasodilation & may

increase cerebral ischemia (Pugh, et al, 2008, p. 18)

Fluid Status in Ischemic Stroke

• Goal: Euvolemia • Hypovolemia-> hypo-perfusion-> ischemic

brain injury, renal impairment & thrombosis. • Hypervolemia-> exacerbate ischemic brain

edema & increase cardiac workload

• 1st choice: Isotonic saline (0.9% NaCl) • Avoid: D5 & 0.45% NaCl

Anticoagulation

• Goals of anticoagulation 1. Stop neurological worsening 2. Prevent early re-embolization 3. Improve neurological outcomes

• No anticoagulation or antiplatelet within 24 hours of rtPA.

• Heparin: Unfractionated (UFH) 5000 units SC BID (Subcutaneous administration of anticoagulants is recommended for treatment of immobilized patients to prevent DVT (Class I; Level of Evidence A).

Antiplatelet Therapy

• CAST (Chinese Acute Stroke Trial) & IST (International Stroke Trial)

• Aspirin dose – 325mg PO or PR within first 24 to 48 hours

• Oral administration of aspirin (initial dose is 325 mg) within 24 to 48 hours after stroke onset is recommendedfor treatment of most patients (Class I; Level of Evidence A)

• Clopidogrel not recommended

Neuroprotective Agents

Neuroprotective: Therapy to save brain tissue or delay infarction of penumbra.

• Pharmacological – Statins? Yes

• Hypothermia? No • Hyperbaric Oxygen? No

Volume Expansion? Vasodilation? Induced Hypertension?

• Acute ischemic stroke-> increased blood viscosity due to volume depletion, leukocyte activation, red cell aggregation, & elevated fibrinogen levels (Jauch, et al, 2013, p. 909)

• AHA/ASA does not recommend hemodilution or vasodilation or induced hypertension*.

• *Small subset benefit from induced hypertension in very acute period.

Induced Hypertension

• In exceptional cases with systemic hypotension producing neurological sequelae, a physician may prescribe vasopressors to improve cerebral blood flow. If drug-induced hypertension is used, close neurological and cardiac monitoring is recommended (Class I; Level of Evidence C).

Increased Intracranial Pressure (ICP) • Cerebral edema occurs in all

strokes, especially in MCA occlusion & large- volume infarcts. Manage edema with: – CO2 management – treating hyperthermia – Head of bed to 30°

• When edema leads to increased ICP: – hyperventilation – hypertonic saline – intraventricular drainage of

cerebrospinal fluid (CSF) – decompressive surgery

Recognizing Increased ICP #1 monitor? The RN!

“Of all of the neurophysiologic monitoring modalities, the neurological examination of a conscious patient allows for the most comprehensive assessment of central nervous system function.” (Jauch, et al, 2013,

p.919)

Signs of Increased Intracranial Pressure (ICP)

• Early signs: – Decreased LOC (e.g., restlessness, confusion,

change in orientation), headache, & visual disturbances.

• Late signs: – Pupillary abnormalities, changes in BP (e.g.,

widening pulse pressure), bradycardia, & changes in respiratory pattern

Invasive Brain Monitoring

• External Ventricular Drain (EVD): Revised guideline from the AHA/ASA states “Placement of a ventricular drain is useful in patients with acute hydrocephalus secondary to ischemic stroke (Jauch, et al, 2013, p.920)

EVD

• Placement of a ventricular drain is useful in patients with acute hydrocephalus secondary to ischemic stroke (Class I; Level of Evidence C).

Decompression in Ischemic Stroke Revised Stroke

guideline: “Decompressive surgical evacuation of a space-occupying cerebellar infarction is effective in preventing and treating herniation and brain stem compression” (Jauch, et al, 2013, p.920).

Respiratory Management in ICU

• Assessment includes: – respiratory rate – auscultation – oxygen (O2) saturation (>/= 92%) – Anticipate need for intubation* *Intubation is recommended for patients with

decreased consciousness or who have bulbar dysfunction that causes compromise of the airway (Jauch, et al, 2013, p.893)

Intubation

• GCS 8=Intubate • Not protecting airway • Mechanical ventilation can assist in the

management of elevated ICP or malignant brain edema after stroke. (Jauch, et al, 2013, p.888)

• EtCO2 goal: 30-35 to reduce ICP

Nutrition in the ICU

• Strictly NPO, including oral medications • SLP swallow eval for patients who fail bedside

RN swallow evaluation • Feed via feeding tube until swallow function is

restored • After rtPA, delay placement of feeding tube,

foley catheters, or arterial lines if patient can be safely managed without them.

Glycemic Control in the ICU

• Persistent hyperglycemia in first 24 hours after stroke-> worse outcomes than normoglycemia.

• Serum glucose goal: 140 to 180 mg/dL

Infection After Stroke

Pneumonia (PNA) in Stroke • PNA: significant cause of death after stroke • Preventive measures in intubated patients:

– HOB 45 degrees – suctioning, – early mobility – Measures to treat nausea and vomiting

Infection After Stroke

Urinary Tract Infection (UTI) in Stroke • 15% - 60% occurrence, predict worse

outcomes, • Prevention in patients with catheters:

– Avoid placement if possible – Think UTI if level of consciousness changes with

no other cause of neurological deterioration

• Fever after stroke should prompt testing for PNA and UTI. Start antibiotic therapy.

Subacute Complications

• DVT & PE – Sequential Compression Devices – Heparin SC & Warfarin

Risk Reduction & Education • Begin rehabilitation • Address risk factors

& lifestyle changes: • diabetes mellitus • hypertension • smoking

• Provide education and support to patient & family

“The importance of dedicated stroke nursing care in the

management of stroke patients cannot be overstated.”