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Nurse's Role in Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery
Perioperative nurses have the opportunity to play a key role in prevention and recognition of stroke in patients undergoing noncardiac, nonneurological surgery and may impact this potentially devastating complication. Effective nursing care of the older adult requires a specialized knowledge base. Scientific Statements are a cornerstone of the knowledge base that informs this care. This article summarizes the recently released American Heart Association/American Stroke Association Scientific Statement entitled: Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery and discusses the nurse's role in the care of this vulnerable patient population.
Objectives - (1) Define the perioperative nurses role in prevention, recognition and management of patients at risk for perioperative stroke. (2) Discuss the preoperative strategies to lower the risk of perioperative stroke. (3) Review nursing assessment tools for recognition of stroke. (4) Outline the Code Stroke procedures, timing and expectations. (5) Describe eligibility considerations for IV alteplase and mechanical thrombectomy in the postoperative patient.
Perioperative nurses may have the opportunity to play a key role in prevention and recognition of stroke in the surgical patient population. There is a paucity of research on nursing's impact on prevention and recognition of stroke in the perioperative setting. The purpose of this article is to inform perioperative nurses on current evidenced-based practice, encourage perioperative nurses to integrate this knowledge into their care, and inspire nursing research to measure our impact on this potentially devastating outcome.
Effective nursing care of the older adult requires a specialized knowledge base developed through evidence-based nursing practice, education, clinical inquiry, and leadership. The care received leading up to and including the day of surgery has long-range effects on the functional status of the aging patient.
Scientific Statements are a consensus of the leading experts and a cornerstone of evidence-based practice. The Scientific Statement, entitled “Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery: A Scientific Statement from the American Heart Association/American Stroke Association”
Perioperative neurological evaluation and management to lower the risk of acute stroke in patients undergoing noncardiac, nonneurological surgery: a scientific statement from the American Heart Association/American Stroke Association.
(herein referred to as the AHA/ASA Statement) was published in April 2021. The AHA/ASA Statement summarizes perioperative stroke risk factors; preoperative and intraoperative strategies to reduce risk; postoperative assessments to identify stroke; and approaches for minimizing permanent neurological dysfunction in those patients who have experienced a perioperative stroke.
Perioperative neurological evaluation and management to lower the risk of acute stroke in patients undergoing noncardiac, nonneurological surgery: a scientific statement from the American Heart Association/American Stroke Association.
High-quality evidence is lacking for many of the clinical situations addressed. The authors’ recommendations reflect the current evidence available and the consensus of experts to assist those making real-world decisions every day in clinical practice.
Perioperative neurological evaluation and management to lower the risk of acute stroke in patients undergoing noncardiac, nonneurological surgery: a scientific statement from the American Heart Association/American Stroke Association.
This article will discuss the contents of the AHA/ASA Statement and the perioperative nurse's role in prevention, assessment, and management of acute stroke in the perioperative patient. Of note, this statement addresses patients undergoing noncardiac, nonneurologic surgery. Considerations for reduction of risk of stroke in patients undergoing cardiac and thoracic aortic operations is reviewed in a separate AHA Scientific Statement published in 2020.
Considerations for reduction of risk of perioperative stroke in adult patients undergoing cardiac and thoracic aortic operations: a statement from the American Heart Association.
Nurses are held to best practice standards related to their roles in preoperative assessment, intraoperative management, and postoperative recovery. Perianesthesia nurses in all phases of care should be aware of the most current evidence-based recommendations for the care provided and are charged with integrating new knowledge into practice. Certifying bodies often review perianesthesia care during Stroke Center Certification visits. Filla
described a Joint Commission Stroke Center review that noted an opportunity for improvement that led to a formalized education process for their postanesthesia care unit (PACU) staff. Scientific Statements can be a blueprint to guide coordination with a service line Clinical Nurse Specialist in collaboration with an institution Stroke Coordinator to prepare for the next survey. Nursing practice is critical to institutional success as accreditation depends heavily on adherence to established practice recommendations and guidelines.
stressed the benefits of perianesthesia policy standardization with health care systems collaborating through a service-line approach. Creating a partnership-based culture with the practice and education team, nurses, leaders, and anesthesia providers was essential. Those policies were then incorporated into staff education. A partnership-based approach helped build relationships which were the foundation of policy integration across the system.
Impact of Perioperative Stroke
Case presentation: BT is a 63-year-old Black woman with a history of colon cancer, hypertension, atrial fibrillation, mechanical mitral valve replacement, and an ischemic stroke 2 months ago who presents for a hemicolectomy with possible colostomy. Her medications include coumadin, lisinopril/hctz, and metoprolol. Is this patient at risk for a postoperative stroke?
The AHA/ASA Statement defines perioperative stroke as an embolic, thrombotic, or hemorrhagic cerebrovascular event that occurs intraoperatively or within 30 days after surgery that results in motor, sensory, or cognitive dysfunction lasting at least 24 hours. The incidence of perioperative stroke is between 0.1% and 1.0%. Approximately 95% of perioperative strokes are ischemic. Hemorrhagic strokes in the perioperative period are rare, representing up to 5% of cases. Patients may also experience silent brain infarctions, also known as silent cerebral ischemia. In patients undergoing either noncardiac or nonvascular surgery, about 50% of strokes in the perioperative setting occur within the first 24 hours and up to 93% occur within the first 72 hours.
Key risk factors for perioperative stroke include age greater than 60, renal disease, and prior transient ischemic attack or stroke. Other risk factors have been identified as independent predictors, such as myocardial infarction within 6 months, atrial fibrillation, hypertension, chronic obstructive pulmonary disease, current smoking, female sex, and diabetes mellitus, with the presence of multiple risk factors further increasing risk. Patients who undergo emergency surgery or certain types of procedures (eg, thoracic, head and neck, intra-abdominal, vascular, transplant, orthopedic) are at higher risk.
Perioperative neurological evaluation and management to lower the risk of acute stroke in patients undergoing noncardiac, nonneurological surgery: a scientific statement from the American Heart Association/American Stroke Association.
Perioperative stroke has both a public health impact and a personal impact. Thirty-day mortality rates are up to eightfold higher in patients with perioperative stroke, with absolute rates between 21% and 26%. Additionally, length of stay and likelihood of discharge to a long-term care facility are increased following a perioperative stroke.
Perioperative neurological evaluation and management to lower the risk of acute stroke in patients undergoing noncardiac, nonneurological surgery: a scientific statement from the American Heart Association/American Stroke Association.
Mechanisms of perioperative stroke may include hypotension/low-flow states, previously undiagnosed large-artery stenosis, anemia-associated tissue hypoxia, thromboembolism (including cardiac or transcardiac), fat embolism, enhanced coagulabilty/thrombosis in the setting of systemic inflammation, endothelial dysfunction, and recent cessation of antithrombotic medications. Uncontrolled hypertension and the use of antithrombotic medications are contributing factors to perioperative hemorrhagic stroke.
Perioperative neurological evaluation and management to lower the risk of acute stroke in patients undergoing noncardiac, nonneurological surgery: a scientific statement from the American Heart Association/American Stroke Association.
Perioperative neurological evaluation and management to lower the risk of acute stroke in patients undergoing noncardiac, nonneurological surgery: a scientific statement from the American Heart Association/American Stroke Association.
to assess surgical risk. These predictions can be discussed with patients to inform shared decision-making. Although the ACS risk calculator does not directly predict the risk of stroke, patients assessed to be at high risk of serious complications are more likely to experience a stroke perioperatively.
Prior stroke confers a higher subsequent risk of stroke. The timing of surgery relative to the last event may modulate this risk. The odds of stroke were >20-fold higher in patients undergoing emergency noncardiac surgery within 3 months of a prior stroke. Similarly, for elective noncardiac surgery, stroke within 3 months before surgery carried the highest risk, which then leveled off at approximately 9 months. The authors of the AHA/ASA Statement suggest elective noncardiac surgery be deferred at least 6 months after a prior stroke, and possibly as long as 9 months. Alternatively, patients who stand to gain significant improvements in quality of life with elective surgery may consider waiting less than 6 months after a prior stroke.
Perioperative neurological evaluation and management to lower the risk of acute stroke in patients undergoing noncardiac, nonneurological surgery: a scientific statement from the American Heart Association/American Stroke Association.
Now consider the case presentation. BT is at increased risk of perioperative stroke due to her age, history of hypertension and atrial fibrillation, and recent stroke. Due to the obstructive nature of her colon lesions, the decision was made to proceed with surgery after thoughtful discussion with her providers.
Preoperative Stroke Prevention Strategies
Nurses play a key role in documenting preoperative medications and comorbid diseases. Perianesthesia nurses require competency in understanding the physiology of aging and anatomic changes that affect the older adult patient. During the preoperative assessment, potential complications can be identified such as age-related diseases, polypharmacy, and risk for adverse drug reactions.
Risk assessments may be performed by other providers, but gaining an understanding of the assessment tools may aid the nurses understanding of the impact of comorbid conditions and the rationale for recommendations made. Understanding the rationale for preoperative medication adjustment plans will aid the nurse during patient preoperative education discussions.
The AHA/ASA Statement authors discuss preoperative management and review previous guidelines that provide recommendations for specific indications. Individualized medication plans should be based on existing guidelines. Beta blockers and statins should be continued. Antithrombotic medication management is detailed as well as the use of validated scales to help quantify risks of thromboembolism and bleeding. In patients with known cerebrovascular disease, the decision to revascularize an extracranial carotid stenosis is based on the degree of stenosis and the presence of ipsilateral symptoms of ischemic stroke or transient ischemic attack, while intracranial stenosis is routinely managed medically with antithrombotic medication and aggressive risk factor modification.
Beta blockers reduce intraoperative events but clinically significant intraoperative hypotension or bradycardia is of concern. The ACC/AHA 2014 Guidelines on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery
2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
support continuation of beta blockers for patients who have been taking them long term. It is reasonable to begin beta blockers in patients who are at high risk according to preoperative testing or who have ≥3 of the risk factors in the Revised Cardiac Risk Index.
2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
Patients at risk of perioperative stroke are often taking antithrombotic medications. The challenge clinicians face is possibly increasing thrombotic risk while adjusting or holding these medications to mitigate risk of perioperative bleeding. Validated scales such as the CHA2DS2-VASc
2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society.
(Figure 2) tools may help quantify the risk of thromboembolism and bleeding for an individual patient. A CHA2DS2-VASc score of 5 to 6 confers high surgical risk. The HASBLED score ranges from 0 to 9 with 3 or greater indicating a higher risk of bleeding.
Figure 1CHA2DS2-VASc. Reprinted from January et al
2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society.
The 2018 Guideline from the American College of Surgeons includes strategies for anticoagulation management across low, moderate, and high risk categories of thromboembolic risk according to perioperative bleeding risk (Table 1).
In patients with CrCl <50 mL/min on dabigatran, the last dose should be given 3 days before the procedure for low-bleeding risk surgery, and 4 to 5 days before the procedure for high-bleeding risk operation.
In patients with CrCl <50 mL/min on dabigatran, the last dose should be given 3 days before the procedure for low-bleeding risk surgery, and 4 to 5 days before the procedure for high-bleeding risk operation.
resume 24 hours postoperatively
Intermediate thromboembolic risk
Warfarin
Give last dose 6 days before operation, determine need for bridging by clinician judgment and current evidence, resume 24 hours postoperatively
Give last dose 6 days before operation, determine need for bridging by clinician judgment and current evidence, resume 24 hours postoperatively
In patients with CrCl <50 mL/min on dabigatran, the last dose should be given 3 days before the procedure for low-bleeding risk surgery, and 4 to 5 days before the procedure for high-bleeding risk operation.
In patients with CrCl <50 mL/min on dabigatran, the last dose should be given 3 days before the procedure for low-bleeding risk surgery, and 4 to 5 days before the procedure for high-bleeding risk operation.
resume 24 hours postoperatively
Low thromboembolic risk
Warfarin
Give last dose 6 days before operation, bridging not recommended, resume 24 hours postoperatively
Give last dose 6 days before operation, bridging not recommended, resume 24 hours postoperatively
In patients with CrCl <50 mL/min on dabigatran, the last dose should be given 3 days before the procedure for low-bleeding risk surgery, and 4 to 5 days before the procedure for high-bleeding risk operation.
In patients with CrCl <50 mL/min on dabigatran, the last dose should be given 3 days before the procedure for low-bleeding risk surgery, and 4 to 5 days before the procedure for high-bleeding risk operation.
resume 24 hours postoperatively
DOAC, direct oral anticoagulant; LMWH, low-molecular-weight heparin; UFH, unfractionated heparin.
In patients with CrCl <50 mL/min on dabigatran, the last dose should be given 3 days before the procedure for low-bleeding risk surgery, and 4 to 5 days before the procedure for high-bleeding risk operation.
Stratify thromboembolic risk using the CHA2DS2-VASc score
Prosthetic heart valve thromboembolic risk
Stratify risk according to valve type, location, and individual thromboembolic risk factors (atrial fibrillation, history of thromboembolism)
Venous thromboembolism thromboembolic risk
Stratify based on time elapsed since VTE diagnosis and individual risk factors (cancer, thrombophilia); elective operation should be deferred for ≥3 months after VTE diagnosis
Elective operation should be deferred for ≥ 14 days for balloon angioplasty, 30 days for bare-metal stent placement, and 1 year for drug-eluting stent placement
Stroke thromboembolic risk
Elective operation should be deferred for ≥ 9 months after an ischemic stroke
Peripheral arterial disease thromboembolic risk
Patients presenting for surgical evaluation who receive antithrombotic medication for symptomatic peripheral arterial disease should be managed in close consultation with a vascular specialist or vascular surgeon
Procedural bleeding risk stratification
Bleeding risk inherent to patient characteristic
Stratify risk using the HAS-BLED score
Bleeding risk inherent to procedure
Largely a subjective decision of behalf of the operating surgeon; most operations under the purview of the general surgeon will be classified as at least “low risk”
Perioperative bridging therapy
Antiplatelet therapy
Currently, there is no evidence to suggest a benefit from the use of antiplatelet bridging therapy perioperatively
Direct oral anticoagulant therapy
Currently, there is no evidence to suggest a benefit from the use of heparin bridging in patients taking DOACs
Warfarin therapy
Use for those classified as high VTE risk; discontinue warfarin 5 days before and elective procedure, and when the INR falls below the patient's therapeutic range, begin LMWH at a therapeutic dose until 24 hours before the procedure; reinitiate warfarin 12-24 hours after operation; reinitiate LMWH 48-72 hours after operation
Hold 24 hours before operation; resume 48-72 hours after operation
Warfarin
Hold for 5 days before an elective operation; resume at previous dosing levels 12-24 hours after operation
Dabigatran
Normal renal function
Hold for 2 days before high-bleeding risk operation and 1 day before low-bleeding risk operation; resume 2-3 days after high-bleeding risk operation and 1 day after low-bleeding risk operation
Impaired renal function
Hold for 4 days before high-bleeding risk operation and 2 days before low-bleeding risk operation
Rivaroxaban, apixaban, edoxaban
Hold for 2 days before high-bleeding risk operation and 1 day before low-bleeding risk operation; resume 2-3 days after high-bleeding risk operation and 1 day after low-bleeding risk operation
Aspirin
Hold aspirin for 7-10 days before high-bleeding risk operation in patients who have not had a PCI; resume when bleeding risk has diminished; in patients with recent PCI, consult with cardiologist
Clopidogrel, prasugrel, ticagrelor
Hold 5-7 days before low and high-bleeding risk operation; resume when bleeding risk has diminished
Consideration in the nonelective setting
Vitamin K antagonist
Administer vitamin K and 4-factor PCC to patients with an elevated INR secondary to warfarin who are actively bleeding and/or require urgent operation
Dabigatran
Administer idarucizumab to patients with evidence of significant dabigatran levels (by history of ingestion of laboratory parameter) who are bleeding or require emergency operation
Other DOAC
Administer 4-factor PCC transfusion (50 units/kg) for partial reversal in patients with evidence of active factor Xa inhibitor as needed in emergency situation
Antiplatelet agent
Transfuse 1 pooled unit of platelets immediately before operation and redose as needed for ongoing bleeding
Perioperative neurological evaluation and management to lower the risk of acute stroke in patients undergoing noncardiac, nonneurological surgery: a scientific statement from the American Heart Association/American Stroke Association.
note that the use or adjustment of medications should be tailored to individual patient characteristics. Aspirin should be held unless the patient had a prior percutaneous coronary intervention. Patients with a mechanical heart valve receiving a vitamin K antagonist should be bridged with low-molecular-weight heparin (LMWH) or intravenous heparin. Patients at high risk of thromboembolism taking a vitamin K antagonist (eg, atrial fibrillation with a high CHA2DS2-VASc score or recent venous thromboembolic disease) may be bridged with full dose (therapeutic) LMWH or intravenous heparin.
The preoperative nurse participating in the care of the patient from our case presentation may give preoperative education on medication adjustments since BT has a mechanical mitral valve, is on coumadin, and suffered a recent stroke. BT would likely be instructed by the provider to stop taking warfarin 5 to 7 days before the procedure and bridge with low-molecular-weight heparin (LMWH). The nurse in the surgical office or preoperative clinic may share education on administration of LMWH and, recognizing her stroke risk, discuss the signs and symptoms of stroke with the patient and family members. The importance of taking her beta blocker throughout the perioperative period can also be discussed with the preoperative teaching of this patient. BT is appropriately bridged to LMWH. She continues to take her beta blocker and she proceeds with surgery. Unfortunately her intraoperative course takes 6 hours and is complicated by episodes of hypotension and excessive bleeding requiring multiple units of blood.
describing anticoagulation considerations for the perianesthesia patient with atrial fibrillation provides an excellent review of the coagulation cascade and categories of anticoagulants. Mechanism of action, dosing, and reversal agents is discussed. She notes that perianesthesia health care providers are pivotal to lead relevant stakeholders to work together to create protocols and individual plans of care for this patient population. Ideally, all stakeholders will collaborate to develop the best clinical pathways and protocols. Stakeholders vary by institution but may include the perianesthesia nurse, administrator of the area, pharmacy, blood bank, and the departments of Surgery, Anesthesiology, and Cardiology.
Periprocedural team considerations include timing of the procedure, type of intervention, and reversal protocols. The goal is a process of care that minimizes risks of the procedure and creates support for the benefits while offering appropriate alternatives. Perianesthesia nurses should be vigilant and assist in developing prevention strategies through a collaborative plan of care for this vulnerable population.
Intraoperative Management to Reduce the Risk of Stroke
The AHA/ASA Statement discusses intraoperative management considerations to maintain end-organ perfusion and reduce the risk of stroke. The Statement notes there is insufficient evidence to recommend the type of anesthetic technique, such as a general versus a regional approach. However, they do suggest intraoperative management considerations to reduce the stroke risk based on evidence for decreasing complications and overall mortality. Specifically, blood pressure and perioperative blood transfusion parameters are addressed, as well as ventilation strategies.
Intraoperative nurses recognize that overall decline in cardiac, pulmonary, and renal function decreases older adults’ ability to maintain homeostasis during times of stress such as surgery.
Intraoperative nurse play a key role in advocating for the best practices discussed below. In addition, they communicate intraoperative complications and interventions during the transition of care to the PACU, which may increase vigilance for identification of stroke symptoms.
Anesthesia providers rely on blood pressure monitoring in conjunction with oxygen saturation to ensure adequate perfusion to vital organs. States of hypotension during surgery are common and are the result of baseline patient factors, volume shifts, procedural factors, and the direct effects of anesthetic drugs on the heart, vasculature, and sympathetic nervous system. Hypotension may be a modifiable risk factor for perioperative stroke. Since the cause of hypotension is often complex and multifactorial, the treatment is often aimed at the different causal factors.
Currently, strong evidence is lacking to support any mean arterial pressure goals for specifically reducing stroke. However, the Perioperative Ischemic Evaluation Trial (POISE)
POISE Study Group Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomized controlled trial.
suggested that patients receiving metoprolol were twice as likely to have a stroke and that this was likely due to hypotension. Additionally, there is mounting evidence showing that patients who have decreases in their systolic blood pressure >20% below their baseline are at increased risk for myocardial injury, kidney injury, and death.
Relationship between intraoperative mean arterial pressure and clinical outcomes after noncardiac surgery: toward an empirical definition of hypotension.
The Statement recommends maintaining a mean arterial pressure > 70 mmHg in patients who are at moderate or high risk of perioperative stroke.
Concerning transfusion parameters, the AHA/ASA Statement echoes the recommendations put forth by the AABB (formerly known as the American Association of Blood Banks).
The authors state the same thresholds used for patients with preexisting cardiovascular disease be used for patients with preexisting cerebrovascular disease or recent strokes. Therefore, clinicians should consider a transfusion threshold of 8 g/dL for most patients with elevated stroke risk and a threshold of 9 g/dL for patients with an acute perioperative stroke, ongoing bleeding, hemodynamic instability, and known cerebrovascular insufficiency attributable to stenosis or occlusion.
Perioperative neurological evaluation and management to lower the risk of acute stroke in patients undergoing noncardiac, nonneurological surgery: a scientific statement from the American Heart Association/American Stroke Association.
The risks and benefits of transfusion should be weighed carefully when administering blood products as studies have consistently shown surgical patients who receive blood transfusions have worse outcomes.
Ventilation strategies include the avoidance of hyperventilation (which causes hypocapnia and ultimately decreases cerebral blood flow) and promotion of lung-protective ventilation. A protective ventilation strategy, defined as using tidal volumes of 6 mL/kg predicted body weight and maintaining plateau pressures less than 30 cmH2O in ventilated patients, has become the standard of care in critically ill patients. This is due to several groundbreaking studies showing a lower incidence of major pulmonary complications, sepsis, and death with this technique.
Although none of the studies analyzed stroke risk, it is reasonable to recommend this technique as an aid in stroke prevention because it adds to an overall strategy to improve perioperative outcomes.
Knowledge of the intraoperative management recommendations to reduce stroke risk may aid the intraoperative nurse and the anesthesia team in recognizing and communicating BT's increased stroke risk due to her prolonged episodes of hypotension and low hemoglobin. By the end of the surgery, BT is hemodynamically stable and taken to the PACU. BT requires post-transfusion labs and during the transfer of care this is conveyed with the transfusion goal of 8 g/dL.
Identification of Perioperative Stroke
Patients experiencing stroke in the hospital are more likely to have longer hospitalizations, worse outcomes, higher mortality, and lower probability of discharge to home compared with patients who have a stroke in the community.
They are less likely to receive thrombolytic therapy and more likely to have delays in time to brain imaging. More than 60% of in-hospital strokes are likely perioperative or periprocedural.
the depressed neurocognitive state of patients recovering from anesthesia warrants special consideration for identification and management of perioperative stroke. Stroke onset may be during surgery and lingering effects of general anesthesia or incomplete recovery confound the identification of stroke.
Nurses should be especially aware of a sudden onset of focal neurological deficits. In the postoperative period, the exact onset of symptoms often cannot be determined. The presentation may also be nonfocal, such as changes in mental status, agitated delirium, autonomic instability, or delayed emergence from anesthesia. If stroke is suspected, consideration should be given to reversing medications that may affect mental status.
Perioperative neurological evaluation and management to lower the risk of acute stroke in patients undergoing noncardiac, nonneurological surgery: a scientific statement from the American Heart Association/American Stroke Association.
PACU nurses should be aware of the patient's baseline and routinely performing neurological assessments in high-risk patients for early stroke recognition. Level of arousal, speech/language, and motor function should be evaluated. A valid stroke scale that allows medical and nursing personnel to easily recognize stroke might facilitate early appropriate neurologic referral and initiation of timely treatment.
on behalf of the Study Group for Perioperative Stroke In China (POSIC) Clinical diagnostic tools for screening of perioperative stroke in general surgery: a systematic review.
on behalf of the Study Group for Perioperative Stroke In China (POSIC) Clinical diagnostic tools for screening of perioperative stroke in general surgery: a systematic review.
on behalf of the Study Group for Perioperative Stroke In China (POSIC) Clinical diagnostic tools for screening of perioperative stroke in general surgery: a systematic review.
The NIHSS is a 15-item scale that can be completed in 7 minutes and has been used to detect stroke in cardiac and neurological surgery patients. A 2-point increase had a specificity of 94%. It requires extensive training and may be considered impractical in the PACU setting due to the administration time.
on behalf of the Study Group for Perioperative Stroke In China (POSIC) Clinical diagnostic tools for screening of perioperative stroke in general surgery: a systematic review.
The modified NIHSS removed redundant test items. It has good interrater reliability and may be completed in 1 minute. An abnormality in any one of the items on the CPSS had a sensitivity of 66% and specificity of 87% in identifying a stroke patient when performed by prehospital personnel and physicians, with a higher sensitivity for large vessel occlusion (LVO) strokes.
Perioperative neurological evaluation and management to lower the risk of acute stroke in patients undergoing noncardiac, nonneurological surgery: a scientific statement from the American Heart Association/American Stroke Association.
on behalf of the Study Group for Perioperative Stroke In China (POSIC) Clinical diagnostic tools for screening of perioperative stroke in general surgery: a systematic review.
BT was received in the PACU after her 6-hour procedure. Thirty minutes into recovery, BT's PACU nurse notes the patient is agitated. Further assessment reveals the patient does not know the month but can follow commands. Her eyes are partially deviated to the right but her visual fields are intact. She has a left facial droop and left arm and leg drift to the bed when she is asked to hold them up for 10 seconds. She does not appreciate light touch to her left side but has no neglect. Her naming and language are intact. Her modified NIHSS is 7 and her CPSS is 3.
The choice of screening tool will depend on nursing expertise and time constraints. Challenges remain to incorporate a baseline screening preoperatively for comparison with postoperative assessments so baseline deficits are not scored postoperatively. If BT had residual deficits from her prior stroke the above scores may not be as significant. Nursing research is needed to develop educational interventions, templates, and workflows that can be researched and validated.
detailed a PACU/Interventional Radiology educational intervention to improve knowledge regarding assessment, management, and escalation of the acute stroke event. The multimodal educational intervention included a PowerPoint presentation, evidenced-based standards for neurological assessment, and assessment-focused case studies. Interprofessional discussion reinforced available institutional resources and standards for assessment, management, and escalation of stroke symptoms. Quarterly mock stroke and escalation education events were conducted in collaboration with anesthesiologists to maintain competencies. The intervention included an algorithm-based clinical decision aid to guide escalation of care based on assessment findings. In addition, the electronic medical record was updated to include stroke assessment documentation.
All centers performing surgery should consider establishing algorithms for the evaluation and treatment of perioperative stroke by Code Stroke Teams with protocols in place for immediate treatment or transfer to hospitals capable of providing advanced care. If stroke is suspected in the perioperative area, an institutional Code Stroke should be activated with a rapid response team to ensure immediate neurological assessment, facilitate timely imaging, and initiate therapeutic medications and interventions. If a facility does not have a code stroke team, creation of a perioperative structured response team could be considered. Nurses aware of the therapeutic options of thrombolysis and endovascular clot retrieval can advocate for timely, appropriate care if stroke is suspected. All health care professionals, including nurses, should be educated about the signs of stroke and be empowered to initiate a Code Stroke.
Perioperative neurological evaluation and management to lower the risk of acute stroke in patients undergoing noncardiac, nonneurological surgery: a scientific statement from the American Heart Association/American Stroke Association.
The response team should immediately assess blood pressure, pulse, temperature, glucose level, and metabolic status. A noncontrast head computed tomography (CT) scan should be obtained emergently to rule out intracranial hemorrhage, with CT angiography and perfusion studies done in patients suspected of having a LVO stroke. An abbreviated magnetic resonance imaging (MRI) may be performed in select circumstances but CT is faster, more available, and better tolerated. Patients eligible for intravenous (IV) thrombolytic treatment, mechanical embolectomy or both must be identified as early as possible. Table 3 provides a suggested algorithm for the evaluation of a patient with suspected stroke.
Perioperative neurological evaluation and management to lower the risk of acute stroke in patients undergoing noncardiac, nonneurological surgery: a scientific statement from the American Heart Association/American Stroke Association.
Confirm last known well (LKW) -may be anesthesia induction time Locate family for history and consent
Stroke Symptom Discovery to CT/MRI <25 minutes
•
Noncontrasted CT brain
CT phone #__________
•
If suspected Large Vessel Occlusion: additional CT angiography and perfusion studies or abbreviated MRI with perfusion /diffusion sequences if indicated. MRI phone #_________
Stroke Symptom Discovery to CT/MRI result <45 minutes
•
Obtain Radiologic Interpretation
Contact #____________
Stroke Symptom Discovery to Initiation of Treatment <60 minutes (alert to needle) <75 minutes (alert to puncture)
•
LKW<4.5 hours consider IV alteplase, along with mechanical embolectomy if LVO
•
LKW<24 hours consider mechanical embolectomy if LVO
•
Unknown time of onset of symptoms noted upon awakening, with favorable advanced imaging and no LVO, consider IV alteplase
•
Reversal of anticoagulation in patients with hemorrhagic stroke
•
Transfer to ED/ICU/Stroke Unit or stroke center
Contact #____________
Individualized risk/benefit discussion with all providers and the patient/family
Perioperative neurological evaluation and management to lower the risk of acute stroke in patients undergoing noncardiac, nonneurological surgery: a scientific statement from the American Heart Association/American Stroke Association.
implemented an evidence-based inpatient stroke event checklist. A retrospective chart review of 168 patients after implementation of the checklist indicated that treatment with IV thrombolysis increased from 0% to 11% and all-cause mortality decreased from 23.1% to 15%. The authors concluded that use of a structured response system with an evidenced-based checklist can potentially increase adherence to guidelines for appropriate treatment and reduce mortality. Further nursing research on successful integration of nursing check lists and protocols to create structured response systems is needed.
Acute Stroke Treatment
Restoring blood flow to the brain is critically important. Considerations for treatment are detailed in the AHA/ASA Statement. Patients with no hemorrhage on head CT can be considered for IV alteplase as long as treatment is initiated within 4.5 hours of time the patient was last known well (which may be procedure start time). Thrombolytic therapy with IV alteplase should be considered after a careful, individualized risk-benefit discussion between all health care professionals and the patient. In many cases, the adverse effects of a major stroke may be much greater than the risk of significant surgical bleeding. Intracranial or intraspinal surgery in the last 3 months is an absolute contraindication for thrombolytic therapy. Select patients may be cautiously considered for treatment with IV alteplase in the extended time window (beyond 4.5 hours) after meeting rigorous selection criteria, undergoing advanced imaging with MRI or CT perfusion
and with a well-documented informed consent process.
Patients experiencing a perioperative stroke may be ineligible for IV alteplase because of the risk of surgical bleeding but may be considered for mechanical thrombectomy. Patients with suspected LVO strokes (NIH Stroke Scale >6 and/or cortical deficits on examination) should undergo immediate CT angiography to determine eligibility for mechanical thrombectomy. It is reasonable to consider mechanical thrombectomy up to 24 hours from last known well in select patients.
Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association [published correction appears in Stroke. 2019;50:e440–e441].
Mechanical thrombectomy can be performed without systemic anticoagulation or thrombolytic agents. If a surgical procedure is performed at a center that is not thrombectomy capable, provisions for transfer to an advanced stroke center if a perioperative stroke is identified should be established beforehand.
Perioperative neurological evaluation and management to lower the risk of acute stroke in patients undergoing noncardiac, nonneurological surgery: a scientific statement from the American Heart Association/American Stroke Association.
BT underwent a CT brain with angiography which revealed a right middle cerebral artery occlusion with a small area of early ischemia and a large area of salvageable penumbra. After consultation with the anesthesia, surgical, and neurology teams, she was deemed high risk of bleeding from IV alteplase and underwent successful thrombectomy with restoration of blood flow to the right hemisphere. She was discharged to a rehabilitation facility 6 days later.
Conclusion
By understanding risk factors for perioperative stroke, educating patients to implement risk-lowering strategies, and participating in early recognition and treatment of stroke, perioperative nurses have the opportunity to positively impact patient outcomes of this potentially devastating complication. The American Society of PeriAnesthesia Nursing's (ASPAN) core value of excellence is achieved though building a knowledge base that is the foundation of our care. Integrating this knowledge into our perianesthesia care workflow supports ASPAN's mission to empower and advance the unique specialty of perianesthesia nursing. Nursing research opportunities exist to quantify our impact, develop validated assessment scales, and to create work flows that improve treatment times and outcomes.
Acknowledgments
The authors acknowledge and thank the members of the perioperative neurological evaluation and management to lower the risk of acute stroke in patients undergoing noncardiac, non-neurological surgery: a scientific statement from the American Heart Association/American Stroke Association writing group; Curtis Benesch, MD, MPH, Chair, Laurent G. Glance, MD, Vice Chair, Colin P Derdevn, MD, Lee A Fleisher, MD, FAHA, Robert G Holloway, MD, MPH, Steven R Messe, MD, Christina Mijalski, MD, MPH, M. Timothy Nelson, MD, Martha Power, MSN, ANP, FAHA, Babu G. Welch MD.
Test ID W062722 – Expiration Date June 30, 2024
Nurse's Role in Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery
1.5 Contact Hours
Purpose of the Journal of PeriAnesthesia Nursing: To facilitate communication about and deliver education specific to the body of knowledge unique to the practice of perianesthesia nursing.
Outcome of this CNE Activity: To enable the nurse to increase knowledge on neurological evaluation and management
Target Audience: All perianesthesia nurses
Article Objectives
1.
Define the perioperative nurses role in prevention, recognition and management of patients at risk for perioperative stroke.
2.
Discuss the preoperative strategies to lower the risk of perioperative stroke.
3.
Review nursing assessment tools for recognition of stroke.
4.
Outline the Code Stroke procedures, timing and expectations.
5.
Describe eligibility considerations for IV alteplase and mechanical thrombectomy in the postoperative patient.
Accreditation
American Society of Perianesthesia Nurses is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation.
Provider approved by the California Board of Registered Nursing, Provider Number CEP5197, for 1.5 contact hours.
Additional provider numbers: Alabama #ABNP0074
Contact hours: Registered nurse participants can receive 1.5 contact hours for this activity.
Standards for Integrity and Independence
The ASPAN ANCC Accredited Provider Unit collects information from all individuals in a position to control content regarding financial relationships with ineligible companies, analyzes the data for relevant financial relationships related to the educational content; and mitigates relevant financial relationships. The results of this analysis are reported below.
Planners and Author Disclosures
None of the planners or authors for this educational activity have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
Requirements for Successful Completion To receive contact hours for this continuing nursing education activity you must complete the registration form and payment, read the article, complete the online posttest and achieve a minimum grade of 100%, and complete the online evaluation.
Directions
A multiple-choice examination, designed to test your understanding of Nurse's Role in Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery according to the objectives listed, is available on the ASPAN website: https://learn.aspan.org/
To earn contact hours from the American Society of Perianesthesia Nurses (ASPAN) Continuing Nursing Education Accredited Provider Unit go to the ASPAN website: (1) select the article, complete the registration form and payment; (2) read the article; (3) complete the posttest on the ASPAN Website and achieve a minimum score of 100%; and (4) complete the online evaluation.
This all must be completed prior to the expiration date of June 30, 2024.
Your certificate will be available for you to print upon successful completion of the activity and completion of the online evaluation.
Online payment is required: ASPAN member: FREE per test; nonmember: $15.00 per test.
Perioperative neurological evaluation and management to lower the risk of acute stroke in patients undergoing noncardiac, nonneurological surgery: a scientific statement from the American Heart Association/American Stroke Association.
Considerations for reduction of risk of perioperative stroke in adult patients undergoing cardiac and thoracic aortic operations: a statement from the American Heart Association.
2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society.
Relationship between intraoperative mean arterial pressure and clinical outcomes after noncardiac surgery: toward an empirical definition of hypotension.
Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association [published correction appears in Stroke. 2019;50:e440–e441].
In patients with CrCl <50 mL/min on dabigatran, the last dose should be given 3 days before the procedure for low-bleeding risk surgery, and 4 to 5 days before the procedure for high-bleeding risk operation.
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