General management monitoring and complications

The success of stroke unit care is believed to depend on general management, careful monitoring and normalization of physiological parameters, as well as proactive prevention and treatment of medical complications. No RCTs address this, therefore level I class A recommendations do not exist. The recommendations are based on consensus statements of experts such as Guidelines for Management ofIschaemic Stroke and Transient Ischaemic Attack by the ESO and Recommendations for the Establishment of Primary Stroke Centers by the Brain Attack Coalition [33]. The cornerstones of this approach, as recommended by the ESO, are summarized in Tables 15.6 and 15.7 and will be discussed in more detail in Chapter 17 [2].

Table 15.6. ESO Guidelines for generalmonitoring and treatment [2].

• Intermittent monitoring of neurological status, pulse, blood pressure, temperature and oxygen saturation is recommended for 72 hours in patients with significant persisting neurological deficits

• It is recommended that oxygen should be administered if the oxygen saturation falls below 95%

• Regular monitoring of fluid balance and electrolytes is recommended in patients with severe stroke or swallowing problems (class IV, GCP)

• Normal saline (0.9%) is recommended for fluid replacement during the first 24 hours after stroke

• Routine blood pressure lowering is not recommended following acute stroke

• Cautious blood pressure lowering is recommended in patients with extremely high blood pressures (>220/120 mmHg) on repeated measurements, or with severe cardiac failure, aortic dissection or hypertensive encephalopathy

• It is recommended that abrupt blood pressure lowering be avoided. It is recommended that low blood pressure secondary to hypovolemia or associated with neurological deterioration in acute stroke should be treated with volume expanders

• Monitoring serum glucose levels is recommended

• Treatment of serum glucose levels >180mg/dl (>10mmol/l) with insulin titration is recommended

• It is recommended that severe hypoglycemia (<50mg/dl [<2.8 mmol/l]) should be treated with intravenous dextrose or infusion of 10-20% glucose

• It is recommended that the presence of pyrexia (temperature > 37.5°C) should prompt a search for concurrent infection. Treatment of pyrexia (temperature > 37.5°C) with paracetamol and fanning is recommended

• Antibiotic prophylaxis is not recommended in immunocompetent patients

• Swallowing assessment is recommended but there are insufficient data to recommend a specific approach for treatment

• Oral dietary supplements are only recommended for non-dysphagic stroke patients who are malnourished

Early commencement of nasogastric (NG) feeding (within 48 hours) is recommended in stroke patients with impaired swallowing

It is recommended that percutaneous enteral gastrostomy (PEG) feeding should not be considered in stroke patients in the first 2 weeks

Table 15.7. ESO Guidelines for management of complications [2].

• It is recommended that infections after stroke should be treated with appropriate antibiotics

• Prophylactic administration of antibiotics is not recommended, and levofloxacin can be detrimental in acute stroke patients

• Early rehydration and graded compression stockings are recommended to reduce the incidence of venous thromboembolism

• Early mobilization is recommended to prevent complications such as aspiration pneumonia, DVT and pressure ulcers

• It is recommended that low-dose subcutaneous heparin or low molecular weight heparins should be considered for patients at high risk of DVT or pulmonary embolism

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