Predictors of critical care needs after IV thrombolysis for acute ischemic stroke.

Publisher: Public Library of Science Country of Publication: United States NLM ID: 101285081 Publication Model: eCollection Cited Medium: Internet ISSN: 1932-6203 (Electronic) Linking ISSN: 19326203 NLM ISO Abbreviation: PLoS One Subsets: MEDLINE

Original Publication: San Francisco, CA : Public Library of Science

Administration, Intravenous/*methods ; Brain Ischemia/*therapy ; Critical Care/*methods ; Stroke/*therapy ; Thrombolytic Therapy/*methods; Adult ; Aged ; Aged, 80 and over ; Blood Pressure ; Brain/pathology ; Female ; Humans ; Intensive Care Units ; Logistic Models ; Magnetic Resonance Imaging ; Male ; Middle Aged ; Multivariate Analysis ; Needs Assessment ; Odds Ratio ; Retrospective Studies ; Severity of Illness Index ; Tissue Plasminogen Activator/therapeutic use ; Tomography, X-Ray Computed

Background and Purpose: Intravenous (IV) tissue plasminogen activator (tPA) is the only Food and Drug Administration (FDA)-approved treatment for acute ischemic stroke. Post tPA patients are typically monitored in an intensive care unit (ICU) for at least 24 hours. However, rigorous evidence to support this practice is lacking. This study evaluates factors that predict ICU needs after IV thrombolysis.
Methods: A retrospective chart review was performed for 153 patients who received intravenous tPA for acute ischemic stroke. Data on stroke risk factors, physiologic parameters on presentation, and stroke severity were collected. The timing and nature of an intensive care intervention, if needed, was recorded. Using multivariable logistic regression, we determined factors associated with requiring ICU care.
Results: African American race (Odds Ratio [OR] 8.05, 95% Confidence Interval [CI] 2.65-24.48), systolic blood pressure, and National Institutes of Health Stroke Scale (NIHSS) (OR 1.20 per point increase, 95% CI 1.09-1.31) were predictors of utilization of ICU resources. Patients with an NIHSS≥10 had a 7.7 times higher risk of requiring ICU resources compared to patients who presented with an NIHSS<10 (p<0.001). Most patients with ICU needs developed them prior to the end of tPA infusion (81.0%, 95% CI 68.8-93.1). Only 7% of patients without ICU needs by the end of the tPA infusion went on to require ICU care later on. These patients were more likely to have diabetes mellitus and had significantly higher NIHSS compared to patients without further ICU needs (mean NIHSS 17.3, 95% CI 11.5-22.9 vs. 9.2, 95% CI 7.7-9.6).
Conclusion: Race, NIHSS, and systolic blood pressure predict ICU needs following tPA for acute ischemic stroke. We propose that patients without ICU needs by the end of the tPA infusion might be safely monitored in a non-ICU setting if NIHSS at presentation is low.

Neurology. 2005 Jul 26;65(2):293-5. (PMID: 16043802)
Stroke. 2013 Aug;44(8):2134-8. (PMID: 23715962)
Lancet. 2004 Mar 6;363(9411):768-74. (PMID: 15016487)
JAMA. 1990 Sep 12;264(10):1267-70. (PMID: 2388378)
Stroke. 2000 Nov;31(11):2552-7. (PMID: 11062274)
Stroke. 2013 Feb;44(2):407-13. (PMID: 23287785)
Arch Neurol. 1989 Jun;46(6):660-2. (PMID: 2730378)
Hypertension. 2008 Jun;51(6):1403-19. (PMID: 18391085)
JAMA Intern Med. 2013 Jan 14;173(1):46-51. (PMID: 23229778)
BMJ. 1999 Jun 5;318(7197):1544-7. (PMID: 10356016)
J Vasc Surg. 2013 Feb;57(2):327-37. (PMID: 23177534)
J Stroke Cerebrovasc Dis. 2000 Mar-Apr;9(2):64-9. (PMID: 17895198)
Circulation. 2011 Feb 1;123(4):e18-e209. (PMID: 21160056)
J Neurosurg. 2011 Dec;115(6):1236-41. (PMID: 21888476)
Stroke. 1996 Sep;27(9):1479-86. (PMID: 8784116)
Br Med J (Clin Res Ed). 1985 Oct 12;291(6501):1014-5. (PMID: 3931771)
Stroke. 2004 Jul;35(7):1552-6. (PMID: 15155974)
Circulation. 2010 Feb 23;121(7):948-54. (PMID: 20177011)
Stroke. 2013 Mar;44(3):870-947. (PMID: 23370205)
JAMA. 1988 Feb 19;259(7):1025-9. (PMID: 3339799)
Stroke. 1989 Jul;20(7):871-5. (PMID: 2749847)
JAMA. 2001 May 9;285(18):2370-5. (PMID: 11343485)
Ann Neurol. 2011 Apr;69(4):619-27. (PMID: 21416498)
J Neurol Neurosurg Psychiatry. 2003 Sep;74 Suppl 3:iii2-9. (PMID: 12933908)
Am J Manag Care. 2010 Jul;16(7):525-33. (PMID: 20645668)
Stroke. 1989 Jul;20(7):864-70. (PMID: 2749846)
Injury. 2012 Nov;43(11):1827-32. (PMID: 21839444)
J Neurosurg. 2012 Mar;116(3):549-57. (PMID: 22196096)
Stroke. 1999 Dec;30(12):2598-605. (PMID: 10582984)

EC 3.4.21.68 (Tissue Plasminogen Activator)

Date Created: 20140218 Date Completed: 20150109 Latest Revision: 20240322

20240322

PMC3922971

10.1371/journal.pone.0088652

24533130