Tissue Plasminogen Activator Overdose in Acute Ischemic Stroke Patients Linked to Poorer Functional Outcomes

Sahlas, Demetrios J.; Gould, Linda; Swartz, Richard H.; Mohammed, Naufal; Naufal, Fahd; Oczkowski, Wieslaw

doi:10.1016/j.jstrokecerebrovasdis.2013.01.004

Cited by 18 publications

(13 citation statements)

References 23 publications

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“…These results agree with those reported by Breuer et al in another study. 3 Overdosing, on the other hand, may be associated with a higher risk of intracerebral hemorrhage, 4 with a 3-fold increased likelihood of cerebral bleeding per each 10% increase in dose above the optimal 0.90 mg/kg, as we described. 2 With all the above, we recommend to obtain, whenever possible, the patient's weight directly from the patient him/herself rather than relying on the clinicians estimation.…”

Section: To the Editormentioning

confidence: 53%

Letter by García Pastor et al Regarding Article, “Estimating Weight of Patients With Acute Stroke When Dosing for Thrombolysis”

García-Pastor

Fernando

Gil‐Núñez

2016

Stroke

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We read with great interest the recent article by Barrow et al 1 in which the authors noted that clinicians are poor at estimating patient weight. Estimation errors lead to alteplase misdosing, and this seemed to affect patient outcome. The authors observed a tendency to underestimate weight and, therefore, to underdose a significant proportion of patients. This finding seemed to be more evident in heavier patients. Furthermore, heavier patients had less improvement in the National Institute of Health Stroke Scale by day 7/discharge, and thus, the authors considered that poorer outcomes may be because of underdosing of alteplase.We have recently published a similar study. 2 In our work, estimation errors were recorded in 22.7%, and patient weight was generally overestimated (mean difference between estimated and actual weight was +2.182 kg). We also noted that estimation errors were related to extreme values of weight: in our case, overestimation was significantly higher in patients weighing <60 kg than in patients weighing >60 kg.We missed further information from Barrow et al on the source of weight estimation. Was the estimation only performed by the clinicians? In our series, we observed that weight estimation accuracy improved when obtained from the patient or his/her relatives (only 11% of patients misreported their own weight).According to the authors' results, alteplase underdosage seems to have a negative impact on patient outcome. These results agree with those reported by Breuer et al in another study. Overdosing, on the other hand, may be associated with a higher risk of intracerebral hemorrhage, 4 with a 3-fold increased likelihood of cerebral bleeding per each 10% increase in dose above the optimal 0.90 mg/kg, as we described. 2With all the above, we recommend to obtain, whenever possible, the patient's weight directly from the patient him/herself rather than relying on the clinicians estimation. We conclude as did the authors that standardized weighing methods with beds or stretchers equipped with a built-in scale before intravenous thrombolysis should be considered. DisclosuresNone. Andrés García-Pastor

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Section: To the Editormentioning

confidence: 53%

Letter by García Pastor et al Regarding Article, “Estimating Weight of Patients With Acute Stroke When Dosing for Thrombolysis”

García-Pastor

Fernando

Gil‐Núñez

2016

Stroke

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“…Although our study is one of the largest conducted on weight estimation in the acute stroke setting to date and the only study to include NIHSS outcomes in addition to mRS, [1][2][3] many limitations need to be considered. This was a retrospective study and subject to that bias.…”

Section: Discussionmentioning

confidence: 99%

“…A deviation of ±10% dose from 0.9 mg/kg was used as a range for acceptable dosing of r-tPA. [1][2][3] Frequencies were then obtained for patients receiving an acceptable dose of 0.81 to 0.99 mg/kg, overdose >0.99 mg or underdose <0.81 mg/kg. To investigate whether misdosing had an effect on functional outcome, we categorized the mRS at 7 days/on discharge into 2 separate dichotomous variables.…”

Section: Statistical Analysesmentioning

confidence: 99%

Estimating Weight of Patients With Acute Stroke When Dosing for Thrombolysis

Barrow

Khan

Halse

et al. 2016

Stroke

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Background and Purpose-Estimating patient weight forms an important part of emergency ischemic stroke management guiding the dose of alteplase (tissue-type plasminogen activator). Weighing patients with stroke can be logistically challenging and time consuming, potentially delaying treatment times. We aimed to assess the reliability of approximating weight to determine recombinant tissue-type plasminogen activator dose and whether potential inaccurate dosing affected patient outcomes. Methods-Two hundred forty-two consecutive patients were studied at a large tertiary stroke center. Estimated and actual measured weight, alteplase dose, and pre-and post-modified Rankin Scale/National Institute of Health Stroke Scale outcome were recorded for each patient. Results-Clinicians significantly underestimated weights by 1.13 kg (range, −43 to +18 kg; SD, 7.14; P<0.05). The difference between estimated and actual weight proved to be greatest in the heaviest third of patients (−4.51 kg; SD, 8.35; P<0.001), resulting in 19.7% of patients receiving a deviation of at least 10% from the recommended recombinant tissue-type plasminogen activator dose. On average, the heaviest third of patients received an underdose of 0.04 mg/kg and were found to have a greater baseline National Institute of Health Stroke Scale on admission (P<0.001). National Institute of Health Stroke Scale improvement by day 7 or on discharge was significantly reduced in patients weighing >78 kg (National Institute of Health Stroke Scale score difference of 4.0 points, P<0.05) than in lighter individuals. Conclusions-Clinicians

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“…[2][3][4][5][6] Inaccuracies in estimation of patient weight are reported to occur in 12-37% of thrombolysis cases. [3][4][5] This may be attributable to the inability of stroke patients to communicate their weight and challenges in quickly weighing patients given the urgency of the thrombolysis setting. 4 For this reason, it is common for patients' estimated weight to be used when dosing t-PA in AIS.…”

Section: Dear Editormentioning

confidence: 99%

Estimated weight is not a reliable measure for dosing tissue plasminogen activator for thrombolysis in acute ischaemic stroke

Halsey

Kalkat

Patel

et al. 2016

International Journal of Stroke

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Tissue Plasminogen Activator Overdose in Acute Ischemic Stroke Patients Linked to Poorer Functional Outcomes

Cited by 18 publications

References 23 publications

Letter by García Pastor et al Regarding Article, “Estimating Weight of Patients With Acute Stroke When Dosing for Thrombolysis”

Letter by García Pastor et al Regarding Article, “Estimating Weight of Patients With Acute Stroke When Dosing for Thrombolysis”

Estimating Weight of Patients With Acute Stroke When Dosing for Thrombolysis

Estimated weight is not a reliable measure for dosing tissue plasminogen activator for thrombolysis in acute ischaemic stroke

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