NURSING COLUMN
Caring for the Post Procedure
Mechanical Thrombectomy Patient
By Catrice Nakamura RN, MSN, CCRN-K, SCRN, and Diana Serondo, RN, NVRN-BC
Mechanical thrombectomy in the setting of a large vessel
occlusion has become a standard of care in the management
of acute ischemic stroke. Despite the ample literature available
to support care before and during these procedures, few
publications focus on the details surrounding care of these
patients in the immediate post-operative period. As mechanical
thrombectomies are becoming more common, the argument
could be easily be made for increased nursing education on the
care of this unique population.
Pre-Procedure
Hospitals across the country have created code stroke protocols
that allow for the rapid diagnosis and management of acute
ischemic stroke patients presenting with large vessel occlusions.
An integral part of these protocols includes performing and
documenting a thorough neurological and peripheral vascular
assessment on admission. This piece is crucial in helping providers
identify changes from the baseline exam and helps decrease
confusion and prevent complications as the patient transfers from
one location to the next. Though defined elements of the exam
and time frames may vary according to hospital protocols, most
comprehensive neurological assessments include NIHSS score,
Glascow Coma Score and motor strengths. When performing
bilateral peripheral vascular assessments in the lower limbs, make
sure to assess and document the five Ps; pain, pallor, pulses,
paresthesia and paralysis.
For patients who qualify for concurrent treatment with alteplase,
NIHSS and serial neuro checks are recommended at minimum.
These assessments shall include serial vital signs and neuro checks
at the following intervals: Q 15 minutes during infusion, Q 15
minutes x 1 hour after completion, and then Q 30 minutes x 6
hours then Q 1 hour x 16 hours as recommended by Genentech
USA Inc.
The last critical baseline pre-procedure assessment parameter is
blood pressure. Blood pressure is usually elevated in the setting of
an acute ischemic stroke as the body tries to maintain adequate
cerebral perfusion. Aggressive treatment of hypertension in these
instances is not recommended and may even be considered
harmful. Establishing clear blood pressure goals and maintaining
these goals with appropriate medications is essential.
Post-Procedural Care and Assessment
Patients are often admitted to the neuro-ICU post-procedure.
Post-op care includes diligent monitoring of neurological and
neurovascular status and continuous monitoring of vital signs.
Blood pressure goals post-procedure should be ordered and
communicated to the nursing staff and managed with appropriate
medication. Close surveillance of neurological status is crucial
because up to 37 percent of stroke patients may decline within
the first 24 hours. While serial neurological assessments are key,
some literature suggests using frequent NIHSS assessments as the
standardized serial neurological assessment. While the NIHSS
exam may take longer to perform, it has demonstrated the ability
to capture neurological changes that have can be missed by
abbreviated neurological assessments. For more information on
NIHSS assessments, see “Slim Stroke Scales for Assessing Patients
with Acute Stroke: Ease of Use of Loss of Valuable Assessment
Data?” (American Journal of Critical Care 2012; 21:442-447). Any
changes in neurological assessment should be reported to the
interventional team immediately.
Additional immediate post-procedure assessments include
assessment of the groin site and distal extremities. The groin site
should be assessed at regular intervals as per hospital protocol
and should be soft to touch and without remarkable tenderness.
Serial neurovascular assessments include assessment of the distal
extremities, again noting the five Ps with attention to pulse quality,
limb temperature and any signs of neurovascular compromise.
After the first few hours, continued care of the patient postthrombectomy
is largely similar to care of a patient who did not
receive endovascular treatment. However, care should focus on
continued serial neurological assessments and monitoring of
physiological parameters and neurovascular assessments so that
potential complications can be caught early.
Potential Complications
Post-procedural complications can be associated with the access
site. Post-procedure, the nurse should be aware of and assess for
these potential complications. Access site complications include
retroperitoneal hemorrhage, pseudoaneurysm, arterial occlusion
neuropathy and infection. For additional readings on potential
site complications after mechanical thrombectomy, see “Groin
complications in endovascular mechanical thrombectomy for
acute ischemic stroke: a 10-year single center experience” (Journal
of Neurointerventional Surgery 2016; 8: 568-570).
Another potential complication is hyperthermia. Identifying
the source of fever should be a priority of care. Patients should
be treated aggressively with antipyretics and cooling measures
and perhaps a normothermia protocol. While hypothermia has
demonstrated benefit in cardiac arrest patients, it has not been
shown to be beneficial in ischemic stroke patients.
Hyperglycemia in ischemic stroke patients is a predictor of
increased 30-day mortality and parenchymal hemorrhage within
the first seven days. The implementation and maintenance of
a normoglycemia protocol and careful management is key to
prevention of these complications especially during the first 24
hours after onset of stroke. Refer to “Correlation of hyperglycemia
with mortality after acute ischemic stroke” (Therapeutic Advances
in Neurologic Disorders 2017;11 doi: 1756285617731686)
Conclusion
Mechanical thrombectomy is a relatively new treatment offered to
acute ischemic stroke patients. While little exists in the literature
that offers guidance on post procedural assessments, basic
assessments include much of what is performed for the noninterventional
ischemic stroke patient. The goal is to establish
assessment consistency across levels of care, a clear understanding
of monitoring parameters and potential complications.
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