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13. Prevention of neurological deterioration or medical complications

 13. 1 the following measures should be instituted in all stroke patients

. Deep venous thrombosis (DVT) prophylaxis (pharmacologic, devices, patient mobilization).

. Aspiration precautions (swallowing assessment and nursing supervision before allowing the patient to eat).

. Gastrointestinal ulcer prophylaxis.

. Take out indwelling urinary (Foley) catheter as soon as possible.

. Monitor platelet counts if on heparin to watch for heparininduced thrombocytopenia (HIT).

13. 2 The following issues must be addressed daily

 Is the patient neurologically stable or improving?

Avoid dehydration of dysphagic patients with limited oral intake.

Avoid diuretics in patients receiving IV fluids.

Is the patient medically stable (e.g., congestive heart failure, infection)?

Is the blood pressure coming down slowly?

Is the patient eating safely?

Is the patient comfortable and sleeping well?

Ask yourself why the patient still gets blood drawn every morning for blood count, chemistry, calcium . . .

What is the mechanism of the stroke?

Is the work-up appropriate and complete?

What are we doing to prevent another stroke?

Ask yourself why the patient is not on antiplatelets, statins, ACE inhibitors – because most patients on the stroke service should be (except people with ICH or on anticoagulation).

What are we doing to promote recovery?

What are we doing to prevent complications from the stroke?

Don’t forget DVT prophylaxis.

Ask yourself why the patient still has a Foley catheter and IV fluids if the patient is being discharged soon.

What is the disposition?

Think about disposition early:

Consult physical therapy, occupational therapy and rehabilitation.

Contact primary care provider for follow-up.

Arrange home health care if indicated.

 13.3 Drug therapy in the first 72 hours

(Those most commonly started in our stroke unit)

Antiplatelets

. Aspirin 81–325mg once daily, or

. Clopidogrel (Plavix) 75mg PO once daily, or

. Aspirin 25 mg/dipyridamole 200mg extended release (Aggrenox/Asasantin) twice daily.

DVT prophylaxis

. Heparin 5000 units SC every 12 hours, or

. Enoxaparin (Lovenox, Clexane) 40mg SC once daily, or

. Dalteparin (Fragmin) 5000 units SC once daily;

. Sequential compression devices (non-drug);

. Compression (TED) stockings.

 Anticoagulants for cardioembolic stroke

. Weight-adjusted heparin (see Appendix 7).

. Warfarin (Coumadin) (start with 5–10mg day).

Insulin if needed

Temperature control with acetaminophen if needed

HMG CoA reductase inhibitors with goal of LDL <100

Oral antihypertensive agents

 ACE inhibitors:

- Lisinopril (Prinivil, Zestril) 10–40mg daily.

- Perindopril (Aceon, Coversyl) 4mg PO once daily.

- Ramipril (Altace) starting at 2.5–5mg daily; target 10mg PO once daily

. Angiotensin receptor blockers (ARBs):

- Losartan (Cozaar) 25–100mg daily.

 Diuretics:

- Hydrochlorothiazide (HCTZ), chlorthalidone (Hygroton) 25mg daily.

  Beta-blockers:

- Metoprolol (Lopressor, Toprol) 25–450mg daily.

. Calcium channel blockers:

- Amlodipine (Norvasc) 5–10mg daily.

 13.4  Stroke recovery and rehabilitation

Physical therapy (PT), occupational therapy (OT), and speech pathology should get involved early!

Patients who are eating (after swallowing assessment by speech pathology) are happy patients, and this also makes family members happy. The sooner you get the patient and family involved in the process of recovery and rehabilitation the earlier you will be able to begin working on placement at the appropriate location (home, rehabilitation, skilled nursing facility (SNF), nursing home, or long-term acute care facility [LTAC]). The rehabilitation team is the key to determining disposition.

The only times when PT/OT would not be involved early is when the patient is obtunded or needs to lie flat in bed in an attempt to maximize cerebral perfusion. It is very important to get the patient mobilized with an out-of-bed (OOB) order (e.g., out of bed with meals, with PT, etc.). Mobilization also prevents complications.

 13.5 Ischemic stroke outcome

Outcome after stroke depends on stroke severity, size, mechanism, age, premorbid functional status, whether and when the patient received TPA, and whether the patient is cared for in a stroke unit.

13.6 Mortality

Overall (data from Rochester Epidemiology Project and NOMASS):10,11

. + - 30% mortality in the first year.

. 40–50% in 5 years.

From Medicare database (age > 65 years):12

. After surviving an ischemic stroke hospitalization, 26.4% mortality in 1 year, 60% mortality after 5 years.

. After surviving a TIA hospitalization, 15% mortality in 1 year, 50% mortality in 5 years.

13.7 Disability

More importantly than mortality, patients and families usually are anxious to know their likely functional outcome. This is very difficult to predict in the first few days in an individual patient.

It is best to offer a range from ‘‘worst case’’ to ‘‘best case’’ scenarios.

13.8 At patient discharge

Be sure you have determined or done the following:

. What is the stroke location and mechanism?

. What strategies are we using to prevent another stroke?

. Is the patient on any antihypertensive, in particular ACE inhibitor?

. Is the patient on antiplatelets (e.g., aspirin, aspirin/ dipyridamole, or clopidogrel)?

. Is the patient’s LDL <100 mg/dl and is he or she on a statin?

. Get rid of unnecessary drugs.

. Is the follow-up plan established? If the patient is discharged on warfarin, who will be following the INR?

This is critically important to communicate to the primary care providers as they are the ones who will be managing the risk factors of anticoagulation on a long-term basis.

. It is important to convey the mechanism of stroke and treatment recommendations to the primary care provider who will assume the primary responsibility for management of the patient on discharge.

. Dictate a discharge summary that includes the above thought processes.

13.9 General timeline

The following is a general timeline for the care of stroke patients. It is affected by the severity of the stroke, extent of diagnostic work-up necessary to determine etiology, ability to swallow, and amount of early recovery. The goal is to get patients discharged from acute hospitalization as quickly and as safely as possible.

. Stroke unit for 1–3 days.

. Then to the general ward to finish work-up and disposition determination.

. Discharge by day 2–5.

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