Question about TPA

[takotsubo]

Say you have a patient with working dx of ischemic stroke within window and significant NIHSS.

You give TPA.

If the patient improves rapidly say 100%, and the tpa gtt is not done, do you stop it or let the gtt finish?

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[TUGM]

Dosing for rt-PA for acute ischemic stroke is weight based at 0.9 mg/kg infused over 1 hour. 10% of this dose is given as bolus over 1 minute. The remaining 90% is given over 1 hour. They should receive the entire dose, so, in short, yes, the t-PA "gtt" should be allowed to finish.

 

[LMPyleDO]

You've already started the t-PA, finish it. You may not give it originally if they have rapid improvement but since you've started it and they improved rapidly their improvement may be due to clot break-up and you should finish the dose. Did you get CT perfusion?

 

[neglect]

Say you have a patient with working dx of ischemic stroke within window and significant NIHSS.

You give full dose TPA.

If the patient improves rapidly say 100%, and the tpa gtt is not done, do you stop it or let the gtt finish?

Obviously full dose. If you deviate from the trial protocols, then you are on the hook, but more importantly, consider the outcomes:
1 stays with NIHSS 0: you are the hero with or without turning it off.
2 worse due to stroke re-occlusion: you are a loser and there really is a case against you at this point. Also, you will feel bad.
3 worse due to hemorrhage: you did your job, gave the medication, and patient suffered treatment effect. Hard to press a case against you. You will feel not as bad as #2.

I think the interesting question is when the family balks, but you really think tPA is needed, could discuss using lower dose tPA.

 

[typhoonegator]

Lower dose? Based on what?

 

[neglect]

Lower dose? Based on what?

Based on selling a needed therapy to the occasional idiot refuseniks that you come across. So one of my partners saw a family who didn't want tPA, he really thought it was needed, and he told them that he'd only use 3/4 dose. I think they said half, he agreed, and that's what they did. No outcome data. Great neurologst.

But as I wrote that, I recalled that I was once at a talk in which a stroke neurologist was bragging that he would do something like: give 1/2 dose, then send them to a cath lab for the "full dose" IA dose. I didn't follow and it made my brain hurt, but I think he had data about his weird dosing. When I did a 0.024 second google search, there were some hits, but then I remembered that the data isn't germane to the question.

 

[neurologist]

Based on selling a needed therapy to the occasional idiot refuseniks that you come across. So one of my partners saw a family who didn't want tPA, he really thought it was needed, and he told them that he'd only use 3/4 dose. I think they said half, he agreed, and that's what they did. No outcome data. Great neurologst.

Why bother getting consent from family at all? Unless they happen to roll in with the ambulance and are already there when you are starting your eval, you don't need family consent even if the patient's aphasic and unable to consent - "lifesaving standard-of-care time-limited emergent treatment" and all that . . . as long as inclusion/exclusion criteria are met, shoot 'em up.

 

[neglect]

Why bother getting consent from family at all? Unless they happen to roll in with the ambulance and are already there when you are starting your eval, you don't need family consent even if the patient's aphasic and unable to consent - "lifesaving standard-of-care time-limited emergent treatment" and all that . . . as long as inclusion/exclusion criteria are met, shoot 'em up.

I agree and do this. This was an unusual case, and I guess I see enough unusual cases that they seem usual.

 

[typhoonegator]

Consent behaviors differ across centers. I give tPA across 34 hospitals, and the ED docs do all sorts of different things based on their own interpretation of the data, laws, and risk management. As long as the family is signing while the tPA is being mixed, I'm ok with it -- whatever facilitates calling neurology for treatment consideration is OK with me. I only really consider formal consent in the 3-4.5h window, and even then if no family then that goes out the window.

 

[guillanbarre]

Complete the full tpa infusion. Rapid improvement can occur for a number of reasons including recanalization, laying with HOB flat and receiving IV normal saline. The last two are especially true if there is a perfusion deficit. In which case the improvement may only be temporary.
To my knowledge, there is no evidence for half or 3/4th dose tpa.