Part 9: Adult Stroke / V-117 TABLE 4 to elevated blood Pressure in Acute ischemic Stroke Blood pressur Hg Treatment A. Not eligible for fibrinolytic therapy Systolic≤2200 R diastolic≤120 Observe unless other end-organ involvement (eg, aortic dissection, acute myocardial infarction, pulmonary edema, hypertensive alopathy) Treat other symptoms of stroke Treat other acute complications of stroke dache, pain, agitation, nausea, vomiting) including hypoxia, increased intracranial pressure. Systolic >220 OR diastolic 121 to 140 Labetalol 10 to 20 mg I for 1 to 2 min May repeat or double every 10 min(max dose 300 mg) nicardipine 5 mg/h I infusion as initial dose; titrate to desired effect by increasing 2.5 mg/h every 5 min to max of 15 mg/h Aim for a 10% to 15% reduction in blood pressure Diastolic >140 russide 0.5 ug/kg per minute Iv infusion as initial dose with continuous blood pressure for a 10% to 15% reduction in blood pressure B. Eligible for fibrinolytic therapy Pretreatment Labetalol 10 to 20 mg I for 1 to 2 min May repeat 1 time or nitropaste 1 to 2 in During/after treatment 1. Monitor blood pressure Check blood pressure every 15 min for 2 h, then every 30 min for 6 h, and finally every hour for 2. Diastolic >140 Sodium nitroprusside 0.5 ug/kg per minute Iv infusion as initial dose and titrate to desired blood 3. Systolic >230 OR diastolic 121 to 140 abetalol 10 mg Iv for 1 to 2 min repeat or double labetalol every 10 min to maximum dose of 300 mg, or give initial labetalol se, then start labetalol drip at 2 to 8 mg/min g/h I infusion as initial dose and titrate to desired effect by increasing 2.5 mg/h ery 5 min to maximum of 15 mg/; if blood pressure is not controlled by labetalol, consider sodium nitroprusside alol 10 mg IV for 1 to 2 min May repeat or double labetalol every 10 to 20 mi ximum dose of 300 mg, or give initial labetalol dose, then start labetalol drip at 2 to 8 There is a relationship between violations of the NINDs General Stroke Care reatment protocol and increased risk of symptomatic intra- Admit the patient to a stroke unit (if available)for careful cerebral hemorrhage and death. 62 In Germany there was an observation(Box 11), including monitoring of blood pressure increased risk of death after administration of tPA for acute and neurologic status and treatment of hypertension if indicated ischemic stroke in hospitals that treated s5 patients per year, (Table 4). If the patients neurologic status deteriorates, order an which suggests that clinical experience is an important factor emergent CT scan to determine if cerebral edema or hemorrhage in ensuring adherence to protocol 63 Adding a dedicated is responsible for the deterioration and treat if possible stroke team to a community hospital can increase the number Hyperglycemia is associated with worse clinical outcom of patients with acute stroke treated with fibrinolytic therapy in patients with acute ischemic stroke than is normoglyce and produce excellent clinical outcomes. 76 These findings mia, 87-94 but there is no direct evidence that active glucose show that it is important to have an institutional commitment control improves clinical outcome. 95, 96 There is evidence that to ensure optimal patient outcomes insulin treatment of hyperglycemia in other critically ill Evidence from 2 prospective randomized studies in adults patients improves survival rates(LOE 7 for stroke). 97 For this and a meta-analysis77, 78 and additional case series79-86 docu- reason administration of Iv or subcutaneous insulin may be mented improved outcome from therapies such as intra-arte- considered( Class IIb)to lower blood glucose in patients with rial tPA. Thus, for patients with acute ischemic stroke who acute ischemic stroke when the serum glucose level is ot candidates for standard IV fibrinolysis, administrat >10 mmolL (about 200 mg/dL) of intra-arterial fibrinolysis in centers that have the resources Additional stroke care includes support of the airway and expertise available may be considered within the first few oxygenation and ventilation, and nutritional support. Admin hours after the onset of symptoms( Class IIb). Intra-arterial ister approximately 75 to 100 mLh of normal saline to administration of tPA has not yet been approved by the Us maintain euvolemia if needed. Seizure prophylaxis is no Food and Drug Administration (FDA) recommended. but we recommend treatment of acute seizuresThere is a relationship between violations of the NINDS treatment protocol and increased risk of symptomatic intra￾cerebral hemorrhage and death.62 In Germany there was an increased risk of death after administration of tPA for acute ischemic stroke in hospitals that treated
5 patients per year, which suggests that clinical experience is an important factor in ensuring adherence to protocol.63 Adding a dedicated stroke team to a community hospital can increase the number of patients with acute stroke treated with fibrinolytic therapy and produce excellent clinical outcomes.76 These findings show that it is important to have an institutional commitment to ensure optimal patient outcomes. Evidence from 2 prospective randomized studies in adults and a meta-analysis77,78 and additional case series79 – 86 docu￾mented improved outcome from therapies such as intra-arte￾rial tPA. Thus, for patients with acute ischemic stroke who are not candidates for standard IV fibrinolysis, administration of intra-arterial fibrinolysis in centers that have the resources and expertise available may be considered within the first few hours after the onset of symptoms (Class IIb). Intra-arterial administration of tPA has not yet been approved by the US Food and Drug Administration (FDA). General Stroke Care Admit the patient to a stroke unit (if available) for careful observation (Box 11), including monitoring of blood pressure and neurologic status and treatment of hypertension if indicated (Table 4). If the patient’s neurologic status deteriorates, order an emergent CT scan to determine if cerebral edema or hemorrhage is responsible for the deterioration and treat if possible. Hyperglycemia is associated with worse clinical outcome in patients with acute ischemic stroke than is normoglyce￾mia,87–94 but there is no direct evidence that active glucose control improves clinical outcome.95,96 There is evidence that insulin treatment of hyperglycemia in other critically ill patients improves survival rates (LOE 7 for stroke).97 For this reason administration of IV or subcutaneous insulin may be considered (Class IIb) to lower blood glucose in patients with acute ischemic stroke when the serum glucose level is 10 mmol/L (about 200 mg/dL). Additional stroke care includes support of the airway, oxygenation and ventilation, and nutritional support. Admin￾ister approximately 75 to 100 mL/h of normal saline to maintain euvolemia if needed. Seizure prophylaxis is not recommended, but we recommend treatment of acute seizures TABLE 4. Approach to Elevated Blood Pressure in Acute Ischemic Stroke9 Blood Pressure Level, mm Hg Treatment A. Not eligible for fibrinolytic therapy Systolic
220 OR diastolic
120 Observe unless other end-organ involvement (eg, aortic dissection, acute myocardial infarction, pulmonary edema, hypertensive encephalopathy) Treat other symptoms of stroke (eg, headache, pain, agitation, nausea, vomiting) Treat other acute complications of stroke, including hypoxia, increased intracranial pressure, seizures, or hypoglycemia Systolic 220 OR diastolic 121 to 140 Labetalol 10 to 20 mg IV for 1 to 2 min May repeat or double every 10 min (max dose 300 mg) OR Nicardipine 5 mg/h IV infusion as initial dose; titrate to desired effect by increasing 2.5 mg/h every 5 min to max of 15 mg/h Aim for a 10% to 15% reduction in blood pressure Diastolic 140 Nitroprusside 0.5 g/kg per minute IV infusion as initial dose with continuous blood pressure monitoring Aim for a 10% to 15% reduction in blood pressure B. Eligible for fibrinolytic therapy Pretreatment Systolic 185 OR diastolic 110 Labetalol 10 to 20 mg IV for 1 to 2 min May repeat 1 time or nitropaste 1 to 2 in During/after treatment 1. Monitor blood pressure Check blood pressure every 15 min for 2 h, then every 30 min for 6 h, and finally every hour for 16 h 2. Diastolic 140 Sodium nitroprusside 0.5 g/kg per minute IV infusion as initial dose and titrate to desired blood pressure 3. Systolic 230 OR diastolic 121 to 140 Labetalol 10 mg IV for 1 to 2 min May repeat or double labetalol every 10 min to maximum dose of 300 mg, or give initial labetalol dose, then start labetalol drip at 2 to 8 mg/min OR Nicarpidine 5 mg/h IV infusion as initial dose and titrate to desired effect by increasing 2.5 mg/h every 5 min to maximum of 15 mg/h; if blood pressure is not controlled by labetalol, consider sodium nitroprusside 4. Systolic 180 to 230 OR diastolic 105 to 120 Labetalol 10 mg IV for 1 to 2 min May repeat or double labetalol every 10 to 20 min to maximum dose of 300 mg, or give initial labetalol dose, then start labetalol drip at 2 to 8 mg/min Part 9: Adult Stroke IV-117