TPA in hyperglycemia?

Nurses General Nursing

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Hi all. I work in an ER and last night was a crazy night. A code stroke came in via EMS. The pt was weak on the entire right side of her body with minor right facial paralysis. Pt had no hx of brain bleed, on coumadin, and last known normal was 2 hours PTA. Stat CT showed no evidence of bleed. Blood glucose was 495mg/dL.

I was the charting nurse, and another nurse was "bedside nurse", whose responsibility is to start lines, administer meds, etc. The neurologist and ED resident were at the bedside, and they ordered stat TPA administration. The bedside nurse refused to initiate TPA, stating that "any blood glucose over 400" is an absolute contraindication to TPA. The neurologist and ED MD explained that the benefits outweigh the risks in this scenario, and that we would initiate insulin therapy soon, but the priority was TPA to save the patient's brain function. The bedside nurse continued to refuse. Charge nurse came in and volunteered to administer the TPA.

I guess my question is -- has anyone else been in this scenario? Is hyperglycemia above 400 really an absolute contraindication to TPA? What would YOU have done?

Looking forward to this discussion y'all.

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It is no longer an absolute contraindication. The most current AHA guidelines only keep severe hypoglycemia as absolute. I would have listened to the neurosurgeon as he has the education and responsibility I do not. I would have given the drug.

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Specializes in Critical Care.

My old AHA/ASA book lists hyperglycemia as a "warning", not an absolute contraindication, and I don't think it's even listed in the current recommendations.

What's important before standing firm and refusing to administer tPA is to understand the rationale behind the warning or contraindication. Critically low BG levels can certainly mimic a stroke, it's actually pretty impressive how well it mimics a stroke. The symptoms produced by a BG of 500 however are not such that they can't be differentiated from a stroke, I would hope that an ED nurse had seen enough patients with a BG of 500 to know that they don't commonly present with symptoms that can't be differentiated from an acute stroke.

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Hi Muno,

Thank you for your response. I checked our nursing policy and did not see that hyperglycemia >400 is contraindicated in tPA. So I ended up having a follow up conversation with the nurse who refused to administer it and asked her to show me in our hospital's nursing policy where it states that BG >400 is a contraindication to tPA. She stated that it was not in the nursing policy, however it is in the pharmacy policy. When I looked at the pharmacy policy, sure enough, it states that BG >400 is an absolute contraindication to tPA.

I'm not sure what to make of this. If the nursing policy doesn't state it, how could I have known to look in the pharmacy policy? I've never looked at pharmacy policies.

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Hi Chare,

Thank you for your response. I appreciate you posting helpful resources that help me understand the situation. However, when I was doing my research, I came across this website:

tPA Contraindications for Ischemic Stroke - MDCalc

If you look under "absolute contraindications to tPA", BG >400 is sure enough listed there. I guess I just don't know what to do in the face of contradictory information. Any thoughts?

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It might have been helpful for your bedside nurse to explain that it was an absolute contraindication per pharmacy policy while she was refusing to administer...just sayin'

Concerning your policy: If your hospital policies are anything like my hospital's policies, then sometimes they aren't necessarily updated as frequently as maybe they should be...

Sounds like something to ask your pharmacist or send the question up your chain of command.

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Hi Chare,

Thank you for your response. I appreciate you posting helpful resources that help me understand the situation. However, when I was doing my research, I came across this website:

tPA Contraindications for Ischemic Stroke - MDCalc

If you look under "absolute contraindications to tPA", BG >400 is sure enough listed there. I guess I just don't know what to do in the face of contradictory information. Any thoughts?

The website you linked is a checklist based on one study. You will find contradictory information all over the net. It's clear that tPA administration in the presence of hyperglycemia is a gray area. That being said the AHA is generally thought to be the go to organization for guidelines in treating strokes and my experience has been that an overwhelming majority of hospitals in the US adhere to their guidelines. The AHA currently does not list hyperglycemia as an absolute contraindication because, although it can in some cases, it is far less likely to mimic stroke symptoms than hypoglycemia. It appears the 2018 guideline for eligibility will only require a blood glucose of >50 with no mention of an upper limit. Unfortunately you have to balance this out with your facility's policies which are not always up to date. Sounds like you might have a project in your future.

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Specializes in Critical Care and ED.

The bottom line is that TPA is a high risk drug with both risks and benefits. However, the worst case scenario is loss of brain tissue and potential dysfunction, so the TPA should be given if the patient has been informed of the risks and has agreed to it. The nurse in question might just need to research the literature and become more comfortable with its administration. If the neurosurgeon decided that was the best course of action then she should have documented as such and given the TPA.

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Specializes in Emergency, Telemetry, Transplant.

As someone else said, I would bring it to the attention of someone (your manager, someone from the pharmacy, etc.) and find it why it is in the pharmacy policies that hyperglycemia is an absolute contraindication. It seems likely that most people do not know this is in there; it needs to be readdressed.

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