Commentary: The Importance of Post-procedural Comprehensive Nursing Monitoring for Acute Ischemic Stroke Patients Post Endovascular Therapy

Disclosure: Dr. Brethour has no relevant disclosures
Pub Date: Thursday, Mar 11, 2021
Author: Mary King Brethour, PhD, ACNP-BC, RN, FAHA
Affiliation: The Joint Commission

The Rodgers et al article¹ is a much needed update to the 2009 Comprehensive Nursing Care Scientific Statement from the American Heart Association. Ischemic stroke continues to be the 5^th leading cause of death in the United States and a leading cause of long-term disability. Although IV thrombolysis has been the standard of care for Acute Ischemic Stroke (AIS), since 2015, there has been an increasing emphasis on Mechanical Thrombectomy (MT) both with and without IV thrombolysis. Mechanical Thrombectomy has emerged as an additional standard of care in the US for AIS with Large Vessel Occlusion (LVO). For the approximate 30% of patients with AIS and LVO, MT can significantly diminish severe disability and mortality.

Nursing plays an integral part in patient care for the AIS patient who has undergone MT, and the 2009 Scientific Statement, Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient, did not address best practices in the care of these patients. Now that MT has become more widely available and utilized for acute stroke intervention, the care of these unique patients must be addressed.

The 2020 Update focuses on Endovascular Nursing Care encompassing the pre-procedural, peri-procedural and post-procedural care of these patients. Stroke patients with LVO have a high risk of neurological deterioration, airway compromise, and hemodynamic complications. The Update specifically addresses pre-procedural assessments and suggests that a re-assessment should be completed every 30-60 minutes prior to MT, or more frequently if IV thrombolysis has been administered. This is a best practice and should include a pre-procedural National Institute of Health Stroke Score (NIHSS). Baseline neurovascular assessment of the patient’s extremities should also be documented. Assessments completed less frequently can compromise patient safety.

Peri-procedural assessments should be documented every 5 minutes including vital signs and level of consciousness. For MT without anesthesia providers present, nurses should monitor the patient based on current recommendations of the ASA. In addition, the Update recommends that nurses should also reference their facility’s policies and procedures for administration of moderate sedation. The authors recommend utilizing an accepted scale such as the ASA Continuum of Sedation Scale or the Ramsay Sedation scale. Again, these are best practices, and will help to ensure patient safety during the procedure.

Post-procedural assessment should begin at completion of the MT and sheath removal, as soon as hemostasis is achieved. Sheath removal time and hemostasis times should be documented in the medical record as well as a neurological assessment. Currently it is suggested for patients receiving both MT and IV thrombolysis should have a repeat neurological assessment and vital signs according to manufacturer’s guidelines for IV thrombolysis (q 15 min x 2 hours; q 30 min x 6 hours, and then q hour x 16 hours). The Update suggests that nurses restart this monitoring when the patient is admitted to the ICU. The Update also addresses hemostasis and limb immobilization whether achieved through manual pressure or a closure device, including transradial artery approach. Best practice suggests that extremity assessments be completed and documented q 15 min x 1 hour; q 30 min x 1 hour and then q hour x 4 hours.

A thorough discussion of complications associated with MT was also presented by the authors of the Update. If assessments are not completed appropriately, the potential for patient harm increases significantly. Routine ICU care needs to address not only airway, breathing, and circulation, but also neurological and supportive care. Unfortunately, at this time, there is no uniform consensus on blood pressure goals and management post MT. This research is on-going and will need to be incorporated into future updates to guide nursing care and monitoring post MT. There is definitely a need for standardization of care for MT patients, and this Update is a great stepping-off point and should be considered a template for nursing practice.