AISTpaPos

Posted On February 17, 2020

Risks

• For treatment within 3 hours, good outcome with tpa 33% vs 23% for control group. (10% better chance of good outcome)
• Risk of symptomatic intracerebral hemorrhage: 6.8% in tpa group, 1.3% of control group. (1 in 14 will have a bleed. )
• Risk of Fatal intracerebral hemorrhage within 7 days: tpa group 2.7%, control group 0.4%.
• Death at 90 days: tpa group 17.9% vs 16.5% in control group

Other considerations

• The only factor known to independently alter response to tPA is time to treatment.
• Age > 80, appear to benefit from tpa, but has a higher mortality rate.

Review exclusion criteria

Final check:

• CT head no bleed
• Glucose > 50
• BP systolic < 185
• Exclusion criteria reviewed

TPA dose

• 0.9 mg/kg, up to 90 mg
• 10 percent IV bolus, remaing dose over 1 hr

BP management

Before giving TPA

• If Systolic >185, Diastolic >110
  • Labetalol 10-20 mg iv over 2 min, may repeat once, or
  • Nicardipine 5 mg/hour, titrate by 2.5 mg/hr every 5-15 min, max 15 mg/hr
  • Clevidipine 1-2 mg/hour iv, tritrate by doubling dose ever 2-5 minutes
• If BP cannot be brought to acceptable level, no TPA

During and after giving TPA

• Monitor BP q 15 min for 2 hr, then q 30 min for 6 hr, then q hour for 16 hours
• If Systolic >180, or Diastolic >105
  • Labetalol 10 mg iv over 2 min, then continuous infusion 2-8 mg/min, or
  • Nicardipine 5 mg/hour, titrate by 2.5 mg/hr every 5-15 min, max 15 mg/hr
  • Clevidipine 1-2 mg/hour iv, titrate by doubling dose every 2-5 min, max 21 mg/h