Management of blood pressure temperature and glucose in acute ischemic stroke

Airway, Breathing, and Oxygenation

  • Airway support and ventilatory assistance are recommended for the treatment of patients with acute stroke who have decreased consciousness or who have bulbar dysfunction that causes compromise of the airway.
  • Supplemental oxygen should be provided to maintain oxygen saturation >94%.
  • Supplemental oxygen is not recommended in nonhypoxic patients with AIS.
  • Hyperbaric oxygen is not recommended for patients with AIS except when caused by air embolization.

Blood Pressure

  • Hypotension and hypovolemia should be corrected to maintain systemic perfusion levels necessary to support organ function.
  • Patients who have elevated BP and are otherwise eligible for treatment with IV alteplase should have their BP carefully lowered so that their systolic BP is <185 mm Hg and their diastolic BP is <110 mm Hg before IV fibrinolytic therapy is initiated.
  • The usefulness of drug-induced hypertension in patients with AIS is not well established.

Patient otherwise eligible for acute reperfusion therapy except that BP is >185/110 mm Hg:

  • Labetalol 10–20 mg IV over 1–2 min, may repeat 1 time; or
  • Nicardipine 5 mg/h IV, titrate up by 2.5 mg/h every 5–15 min, maximum 15 mg/h; when desired BP reached, adjust to maintain proper BP limits; or
  • Clevidipine 1–2 mg/h IV, titrate by doubling the dose every 2–5 min until desired BP reached; maximum 21 mg/h
  • Other agents (eg, hydralazine, enalaprilat) may also be considered
  • If BP is not maintained ≤185/110 mm Hg, do not administer alteplase

Management of BP during and after alteplase or other acute reperfusion therapy to maintain BP ≤180/105 mm Hg:

  • Monitor BP every 15 min for 2 h from the start of alteplase therapy, then every 30 min for 6 h, and then every hour for 16 h

If systolic BP >180–230 mm Hg or diastolic BP >105–120 mm Hg:

  • Labetalol 10 mg IV followed by continuous IV infusion 2–8 mg/min; or
  • Nicardipine 5 mg/h IV, titrate up to desired effect by 2.5 mg/h every 5–15 min, maximum 15 mg/h; or
  • Clevidipine 1–2 mg/h IV, titrate by doubling the dose every 2–5 min until desired BP reached; maximum 21 mg/h
  • If BP not controlled or diastolic BP >140 mm Hg, consider IV sodium nitroprusside

Temperature

  • Sources of hyperthermia (temperature >38°C) should be identified and treated, and antipyretic medications should be administered to lower temperature in hyperthermic patients with stroke.
  • The benefit of induced hypothermia for treating patients with ischemic stroke is not well established. Hypothermia should be offered only in the context of ongoing clinical trials.

Blood Glucose

  • Evidence indicates that persistent in-hospital hyperglycemia during the first 24 hours after AIS is associated with worse outcomes than normoglycemia and thus, it is reasonable to treat hyperglycemia to achieve blood glucose levels in a range of 140 to 180 mg/dL and to closely monitor to prevent hypoglycemia in patients with AIS.
  • Hypoglycemia (blood glucose <60 mg/dL) should be treated in patients with AIS

Notes

  • AIS = acute ischemic stroke
  • BP = blood pressure
  • IV = intravenous
  • LOE = Level of Evidence.


References

  • 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke, Stroke. 2018 Mar;49(3):e46-e110 doi: 10.1161/STR.0000000000000158