Abstract WP429: Choosing Wisely: Is 24 Hour ICU Monitoring Post-tPA Really Necessary?

Abstract

Introduction: After treatment with intravenous tissue plasminogen activator (IV tPA) or intra-arterial thrombolysis (IA lysis) patients are monitored intensely for evidence of change in neurological examination and possible intracranial hemorrhage (ICH) for 24 hours. This typically requires an intensive care unit and significant nursing resources. The half-life of IV tPA and resulting coagulopathy is much shorter. Therefore, patients may not require such prolonged monitoring. We evaluate the frequency and timing of change in neurological examination for patients treated with IV tPA and IA lysis for acute stroke. Methods: All patients presenting with acute ischemic stroke who were treated with IV tPA and/or IA lysis at our institution between 2016 and 2018 were prospectively followed per protocol for 24 hours post-treatment for changes in neurological examination (every 15 minutes x 8, every 30 minutes x 12, hourly thereafter up to 24 hours). Any neurological deterioration (level of consciousness, cranial nerves, motor, sensory), exam changes occurring after 12 hours, and those requiring action (eg., noncontrast head CT) were recorded, along with patient demographics, medical variables, stroke severity, and outcomes. Results: 172 patients were treated (IV:135, IA:64, both:30). 107 patients (63%) were noted to have a change in neurological examination at some point during the first 24 hours of admission; however only 11 (6%) had changes after 12 hours post-treatment that were not associated with a nursing shift change, and only 3 of these changes resulted in additional action (head CT) by the medical team. None of these patients required additional intervention (none were diagnosed with ICH). Higher stroke severity (p=0.033) was associated with a change in exam (though not after 12 hours), and changes in exam were associated with higher discharge (p=0.001) and 90 day modified Rankin scores (p<0.001). Conclusion: Patients with more severe strokes are more likely to have changes in neurological examination following acute stroke treatment, especially within the first 12 hours. Significant change in exam after 12 hours is uncommon. This may indicate that prolonged intensive monitoring in an ICU setting is unnecessary post-tPA.