By Catrice Nakamura, RN, MSN, CCRN-K, SCRN, and Diana Serondo, RN, NVRN-BC
Mechanical thrombectomy in the setting of a large vessel occlusion has become a standard of care in the management of acute ischemic stroke. Despite the ample literature available to support care before and during these procedures, few publications focus on the details surrounding care of these patients in the immediate post-operative period. As mechanical thrombectomies are becoming more common, the argument could be easily be made for increased nursing education on the care of this unique population.
Hospitals across the country have created code stroke protocols that allow for the rapid diagnosis and management of acute ischemic stroke patients presenting with large vessel occlusions. An integral part of these protocols includes performing and documenting a thorough neurological and peripheral vascular assessment on admission. This piece is crucial in helping providers identify changes from the baseline exam and helps decrease confusion and prevent complications as the patient transfers from one location to the next. Though defined elements of the exam and time frames may vary according to hospital protocols, most comprehensive neurological assessments include NIHSS score, Glascow Coma Score and motor strengths. When performing bilateral peripheral vascular assessments in the lower limbs, make sure to assess and document the five Ps; pain, pallor, pulses, paresthesia and paralysis.
For patients who qualify for concurrent treatment with alteplase, NIHSS and serial neuro checks are recommended at minimum. These assessments shall include serial vital signs and neuro checks at the following intervals: Q 15 minutes during infusion, Q 15 minutes x 1 hour after completion, and then Q 30 minutes x 6 hours then Q 1 hour x 16 hours as recommended by Genentech USA Inc.
The last critical baseline pre-procedure assessment parameter is blood pressure. Blood pressure is usually elevated in the setting of an acute ischemic stroke as the body tries to maintain adequate cerebral perfusion. Aggressive treatment of hypertension in these instances is not recommended and may even be considered harmful. Establishing clear blood pressure goals and maintaining these goals with appropriate medications is essential.
Post-Procedural Care and Assessment
Patients are often admitted to the neuro-ICU post-procedure. Post-op care includes diligent monitoring of neurological and neurovascular status and continuous monitoring of vital signs. Blood pressure goals post-procedure should be ordered and communicated to the nursing staff and managed with appropriate medication. Close surveillance of neurological status is crucial because up to 37 percent of stroke patients may decline within the first 24 hours. While serial neurological assessments are key, some literature suggests using frequent NIHSS assessments as the standardized serial neurological assessment. While the NIHSS exam may take longer to perform, it has demonstrated the ability to capture neurological changes that have can be missed by abbreviated neurological assessments. For more information on NIHSS assessments, see “Slim Stroke Scales for Assessing Patients with Acute Stroke: Ease of Use of Loss of Valuable Assessment Data?” (American Journal of Critical Care 2012; 21:442-447). Any changes in neurological assessment should be reported to the interventional team immediately.
Additional immediate post-procedure assessments include assessment of the groin site and distal extremities. The groin site should be assessed at regular intervals as per hospital protocol and should be soft to touch and without remarkable tenderness. Serial neurovascular assessments include assessment of the distal extremities, again noting the five Ps with attention to pulse quality, limb temperature and any signs of neurovascular compromise.
After the first few hours, continued care of the patient post-thrombectomy is largely similar to care of a patient who did not receive endovascular treatment. However, care should focus on continued serial neurological assessments and monitoring of physiological parameters and neurovascular assessments so that potential complications can be caught early.
Post-procedural complications can be associated with the access site. Post-procedure, the nurse should be aware of and assess for these potential complications. Access site complications include retroperitoneal hemorrhage, pseudoaneurysm, arterial occlusion neuropathy and infection. For additional readings on potential site complications after mechanical thrombectomy, see “Groin complications in endovascular mechanical thrombectomy for acute ischemic stroke: a 10-year single center experience” (Journal of Neurointerventional Surgery 2016; 8: 568-570).
Another potential complication is hyperthermia. Identifying the source of fever should be a priority of care. Patients should be treated aggressively with antipyretics and cooling measures and perhaps a normothermia protocol. While hypothermia has demonstrated benefit in cardiac arrest patients, it has not been shown to be beneficial in ischemic stroke patients.
Hyperglycemia in ischemic stroke patients is a predictor of increased 30-day mortality and parenchymal hemorrhage within the first seven days. The implementation and maintenance of a normoglycemia protocol and careful management is key to prevention of these complications especially during the first 24 hours after onset of stroke. Refer to “Correlation of hyperglycemia with mortality after acute ischemic stroke” (Therapeutic Advances in Neurologic Disorders 2017;11 doi: 1756285617731686)
Mechanical thrombectomy is a relatively new treatment offered to acute ischemic stroke patients. While little exists in the literature that offers guidance on post procedural assessments, basic assessments include much of what is performed for the non-interventional ischemic stroke patient. The goal is to establish assessment consistency across levels of care, a clear understanding of monitoring parameters and potential complications.
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