Complications in the Stroke Patient

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Complications in the Stroke Patient

• Mary-Elizabeth Cooper
• Nurse Practitioner
• Calgary Stroke Program

2
Medical Complications

• Hypertension
• Hyperglycemia
• Elevated Temperature
• Aspiration pneumonia/UTI
• GI bleed
• DVT/PE

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HYPERTENSION

• Acutely, decrease by NO MORE than 25 from
  baseline
• Be conservative with treatment
• Natural decrease in BP within first 24 hours

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HYPERTENSION

• Chronic treatment aim for BP 135/85 or less on
  average
• Choice of drug less important than target
• If choice, thiazide diuretic and ACE-I or ARB
  should be first choices for stroke patients

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HYPERTENSION

• Remember to monitor K and creatinine to ensure
  that ACE-I is not precipitating prerenal azotemia
• Always consider the cause of hypertension

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HYPERGLYCEMIA

• Patients who are diabetic or who have elevated
  blood sugars have a poorer prognosis
• Check sugar initially on all patients
• Continue monitoring on those who sugars were gt
  8mmol/ diabetic

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HYPERGLYCEMIA

• If sugars remain elevated then a sliding scale is
  appropriate short term
• Resume a patients regular diabetic meds as soon
  as is possible
• Patients on continuous enteral feeding will not
  have fasting sugars and goals are different
  (9-11mmol)

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HYPERGLYCEMIA

• Like hypertension, stress related hyperglycemia
  will resolve naturally within 24 hours.
• Administer fluids without glucose to stroke
  patients.

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ELEVATED TEMPERATURE

• Patients with elevated temperature are more
  likely to have a poor outcome
• Treat all patients with temperature gt 38.0 C with
  acetaminophen
• Use cooling measures (fans, cooling blankets) but
  avoid shivering
• Investigate cause of temperature
• Can have elevated temperature without infection
  in intracerebral hemorrhage

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PNEUMONIA

• Most common cause is aspiration of oral
  secretions
• Second is inappropriate feeding without proper
  swallowing screen first
• EVERY stroke patient should be assumed to have
  dysphagia until ruled otherwise

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PNEUMONIA

• Treatment of choice is Cefazolin 1 gm IV q8h and
  Metronidazole 500 mg IV q8h
• Can switch to oral medication after 48 hours
  afebrile for a total of 7-10 day course
• AVOID cefuroxime (potent inducer of VRE)

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URINARY TRACT INFECTIONS

• Most are treated with Amoxicillin and Septra
  (adjust according to culture results)
• Avoid unnecessary use of quinolones
• Prevent UTI by removing foley catheters as soon
  as possible
• Do not treat asymptomatic bacteruria which is
  common in older women

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GI BLEED

• Treat very ill patients and those not eating with
  Ranitidine 150 mg bid as prophylaxis
• Restart PPIs in patients who have been on them
  previously ASAP
• Initiate feeding either oral or enteral as soon
  as possible
• Avoid NSAIDS in patients on antiplatlet therapy
  (increase risk bleed, decrease efficacy of ASA)

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DVT/PE

• Consider all patients confined to bed/chair,or
  have a hemiparetic leg for DVT/PE prophylaxis
• LMWH, enoxaparin 40 mg once daily at 1800
• Intermittent pneumatic compression stockings or
  TEDS
• Among ICH strokes, safe to start LMWH 48-72h
  after stroke if stable neurologically/systemically
  
• EARLY MOBILIZATION!!!

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OTHER COMPLICATIONS

• Dysphagia
• Malnutrition
• Protection of hemiparetic limbs
• Falls
• Depression
• Skin care

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DYSPHAGIA

• Most common cause of aspiration pneumonia
• Present in large proportion of stroke population
• Often missed in brainstem or mild strokes
• Makes adequate nutritional intake and proper
  hydration a challenge

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DYSPHAGIA

• NPO if any doubts and proper swallow screen as
  soon as possible
• May need supplemental feeding and hydration with
  NG tube
• Early involvement of speech and dietician
  essential
• Post signs of diet at bedside for family and
  staff to ensure safety

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MALNUTRITION

• Need to start nutrition in whatever form ASAP
• Dysphagic patients may require supplemental feeds
  with NG to meet needs
• Requires routine blood work, especially
  prealbumin to monitor nutritional status
• Good nutrition early promotes recovery

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PROTECTION OF HEMIPARETIC LIMBS

• Needs proper support and positioning at all times
• Early intervention by OT/PT essential
• Early seating assessment with proper wheelchair
• Education of family/patient and staff on proper
  positioning is key

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FALLS/PT SAFETY

• Awareness of high risk patients
• Proper seating/wheelchair with seatbelt if
  warranted
• Close monitoring of those at risk
• Proper mobilization/transfers with appropriate
  number of staff/equipment
• Accurate communication of patients risks/needs

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DEPRESSION

• Continues to go untreated in many stroke patients
• Can be confused with flat affect and abulia
• Important not to start medication too early
• Monitor for warning signs of depression on an
  ongoing basis
• If treatment needed Celexa is drug of choice

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DEPRESSION

• Reevaluate need for antidepressant over the
  longer term
• Psychology support is important for patient and
  family during and after recovery
• Community support groups are good supports for
  stroke survivors and their families

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SKIN CARE

• Proper positioning and turning q2h essential
• Early mobilization- get them out of bed!!
• Monitor skin frequently for any signs of
  breakdown, especially diabetic patients
• Early intervention with first signs of skin
  breakdown

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FINAL THOUGHTS

• EARLY MOBILIZATION!!!
• Early involvement of OT/PT/speech
• Aggressive management of risk factors
• Appropriate referral to stroke rehab

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QUESTIONS ??