Habilidades dos enfermeiros no uso terapêutico do alteplase em unidade de pronto atendimento / Abilities of nurses in therapeutic use of alteplase in emergency care unit / Habilidades de enfermeros en el uso terapéutico de alteplase en una unidad de atención de emergencia

Objetivo: avaliar as habilidades dos enfermeiros, no uso terapêutico do Alteplase, como terapia fibrinolítica, em pacientes com diagnóstico de infarto agudo do miocárdio. Método: A pesquisa foi realizada por meio de um estudo descritivo transversal, quantitativo, realizado por meio de questionário como instrumento de coleta, contendo 10 questões de múltipla escolha elaboradas pelo autor. A amostra foi constituída por 24 enfermeiros. A coleta de dados foi realizada em julho de 2019, com CAAE n° 13159219.7.0000.5493. Os dados foram analisados e tratados por meio da análise descritiva. Resultado: Os resultados mostraram que os participantes da pesquisa possuem habilidades para o manuseio e aplicabilidade da terapia fibrinolítica, Alteplase, em pacientes acometidos por infarto agudo do miocárdio. Conclusão:Os resultados obtidos demonstram que os enfermeiros possuem habilidade para o manuseio, administração, aplicabilidade do Alteplase, bem como na avaliação dos sintomas e contraindicações do medicamento em pacientes acometidos por Infarto Agudo do Miocárdio. Entretanto, foi identificado uma porcentagem que apresentam dificuldades na execução de todas as atividades. Portanto, o estudo contribuirá na elaboração de protocolos aos profissionais da área da saúde envolvidos de modo direto ou indireto aos cuidados aos pacientes que necessitam desta intervenção farmacológica como tratamento.(AU)

Objective: to evaluate the abilities of nurses in the therapeutic use of Alteplase, as fibrinolytic therapy, in patients diagnosed with acute myocardial infarction. Method: The research was carried out by means of a transversal, quantitative descriptive study, carried out by means of a questionnaire as a collection instrument, containing 10 multiple choice questions elaborated by the author. The sample consisted of 24 nurses. The data collection was carried out in July 2019, with CAAE No. 13159219.7.0000.5493. The data were analyzed and treated through descriptive analysis. Result: The results showed that the research participants have skills for the handling and applicability of fibrinolytic therapy, Alteplase, in patients affected by acute myocardial infarction. Conclusion: The results show that the nurses have skills in the handling, administration and applicability of Alteplase, as well as in the evaluation of the symptoms and contraindications of the drug in patients affected by Acute Myocardial Infarction. However, it was identified a percentage that present difficulties in performing all activities. Therefore, the study will contribute in the elaboration of protocols to the professionals of the health area involved in a direct or indirect way to the care of patients who need this pharmacological intervention as treatment.(AU)

Objetivo: evaluar las capacidades de las enfermeras en el uso terapéutico de la Alteplasa, como terapia fibrinolítica, en pacientes diagnosticados con infarto agudo de miocardio. Material y método: La investigación se realizó mediante un estudio descriptivo cuantitativo transversal, realizado mediante un cuestionario como instrumento de recopilación, que contenía 10 preguntas de opción múltiple preparadas por el autor. La muestra constaba de 24 enfermeras. La recopilación de datos se llevó a cabo en julio de 2019, con el CAAE Nº 13159219.7.0000.5493. Los datos fueron analizados y tratados mediante un análisis descriptivo. Resultado: Los resultados mostraron que los participantes en la investigación tienen habilidades en el manejo y la aplicabilidad del tratamiento fibrinolítico, Alteplase, en pacientes afectados por un infarto agudo de miocardio. Conclusión: Los resultados muestran que las enfermeras tienen aptitudes para el manejo, la administración y la aplicabilidad del Alteplase, así como para la evaluación de los síntomas y las contraindicaciones del fármaco en los pacientes afectados por un infarto agudo de miocardio. Sin embargo, se identificó un porcentaje que presenta dificultades para realizar todas las actividades. Por lo tanto, el estudio contribuirá a la elaboración de protocolos para los profesionales de la salud que participan directa o indirectamente en la atención de los pacientes que necesitan esta intervención farmacológica como tratamiento.(AU)

Guía de práctica clínica en derrame pleural paraneumónico y empiema pleural / Guide of clinical practice on parapneumonic pleural efussion and pleural empyema

La acumulación de fluido purulento o la presencia de bacterias en la tinción de Gram en el líquido pleural se define como empiema, se puede desarrollar entre 2- 12 por ciento de los niños con neumonía, por lo general bacteriana. Evoluciona en tres fases, la exudativa, fibrinopurulenta y organizada. El cuadro clínico está dado por manifestaciones respiratorias con fiebre persistente y malestar general. Los estudios radiológicos son importantes para el diagnóstico y es el ultrasonido pleural la modalidad de imagen preferida pues confirma la presencia y volumen de fluido pleural, así como la existencia de septos o tabiques. El tratamiento se basa en antibioticoterapia y drenaje a través de una pleurostomía; si hay presencia de tabiques, esfacelos o el estudio bioquímico del líquido pleural informa pH /7; glucosa /2,2 mmol/L; LDH/ 1000 UI, se comienza con estreptoquinasa intrapleural. El tratamiento quirúrgico se indica si hay deterioro clínico y radiológico después de concluir el uso de fibrinolíticos, persistencia de sepsis asociada a colección pleural a pesar del drenaje, coraza de fibrina que impide la reexpansión pulmonar y fístula broncopleural con neumotórax. La mortalidad es baja(AU)

The accumulation of purulent fluids or the presence of bacteria in the Gram´s stain in the pleural liquid is defined as empyema. It can develop in the 2 to 12 percent of children with pneumonia, generally the bacterial one. It evolves in three phases: exudative, fibrinopurulent and organized. The clinical picture is a consequence of respiratory manifestations with persistent fever and general discomfort. The radiology studies are important for the diagnosis and the pleural ultrasound is the preferred imaging modality because it confirms the presence and volume of the pleural fluid, as well as the existence of septa. The treatment is based in the use of antibiotic therapy and the drainage through a pleurostomy; if there is presence of septa, slough or the biochemical study of the pleural liquid informs of pH/7, glucose /2.2 mmol/L, LDH / 1000 UI, so it is started the use of intrapleural streptokinase. The surgical treatment is indicated if there is a clinical and radiological worsening after finishing the use of fibrinolytics, persistence of sepsis associated to pleural collection in spite of the drainage, fibrin shell that hampers pulmonar reexpanding; and bronchopleural fistula with pneumothorax(AU)

Evolución del protocolo de trombolisis endovenosa en ataque cerebrovascular isquémico agudo / Intravenous thrombolysis for acute ischemic stroke. A four years’ experience in a Chilean public hospital

Background: Intravenous thrombolysis (IVT) with alteplase (tissue plasminogen activator) is the standard pharmacological treatment in acute ischemic stroke (AIS), reducing disability in patients. Aim: To report the results a thrombolysis protocol during four years in a regional public hospital. Material and Methods: Data from 106 consecutive patients aged 68 ± 13 years (57% men) who were treated with IVT, from May 2012 until April 2016, was analyzed. Results: The median door-to-needle time was 80 minutes (interquartile range = 57-113). The median National Institute of Health Stroke Scale (NIHSS) scores on admission and at discharge were was 11.5 and 5 points respectively. At discharge, 27% of hospitalized patients had a favorable outcome (n = 99), defined as having 0 to 1 points in the modified Rankin scale. Symptomatic intracerebral hemorrhage and mortality rates were 5.7 and 13.1%, respectively. The thrombolysis rate rose from 0.7% in 2012 to 6% in 2016. Conclusions: The implementation of 24/7 neurology shifts in the Emergency Department allowed us to increase the amount and quality of IVT in our hospital, as measured by the rate of thrombolysis and by process indicators such as door-to-needle time.

Management of spontaneous large intra cerebral hematoma with minimal invasive procedure (twist drill burr hole) with fibrinolytic therapy

Background: Spontaneous intracerebral haemorrhage (ICH) is associated with the high mortality among cerebrovascular events, and most of the survivors end with significant morbidity. Spontaneous intracerebral haemorrhage (ICH) is the second most common cause of stroke comprising 7.5-30% of all strokes. Surgery mainly helps in decrease in secondary injury and early rehabilitation. Aim: To analyse the outcome and advantages of minimal invasive surgery i.e., burr hole or twist drill craniostomy with intraclot streptokinase injection to dissolve clot and aspiration to reduce mass effect in primary intracerebral hematoma, this help to prevent secondary injury and recovery of salvageable brain. Materials and methods: Prospective study was done over from November 2014 to January 2017 in our department for the patients of spontaneous large intra cerebral hematoma > 80ml who underwent clot evacuation with fibrinolytic therapy with minimally invasive procedure with twist drill burr hole. Total 62 patients were included in the study. All the patients were followed with CT sequential scans to see for the clot size and followed with clinical status. Karla Ravi, Nandigama Pratap Kumar, Ginjupally Dhanunjaya Rao, Savarapu Sai Kalyan, Gollapudi Prakash Rao. Management of spontaneous large intra cerebral hematoma with minimal invasive procedure (twist drill burr hole) with fibrinolytic therapy. IAIM, 2017; 4(11): 229-240. Page 230 Results: Our analysis of 62 patients was consistent with the hypothesis that hematoma evacuation leads to improved neurological outcome, the outcome has been correlated with the rate of clot reduction. Conclusion: Minimally invasive surgery is a safe and effective option in the management of spontaneous ICH especially in the patients whom major surgical procedures pose a significant risk. MIS is associated with lower mortality and better outcomes compared to surgical evacuation or conservative management. Our study have clearly shown an improved outcome after minimally invasive surgery and still there is some emptiness to determine the exact protocol to insist these type of studies to deal with bed occupancy and a burden to the society.

Fibrinolytic therapy in radiation-induced brachial plexopathy:16 cases report and review / 中华显微外科杂志

Objective To explore the feasibility and curative effect of extracellular matrix (ECM) fibrinolytic therapy in order to cure radiation-induced brachial plexopathy (RIBP) and to discuss the principle, indication and precautions. Methods The treatment was taken on 16 cases that had a definite clinical diagnosis and we took a systematic examination to make sure that there was no recurrence or metastasis of the tumor.Brachial plexus and tender area block was taken once a week by injection of mixture of hyaluronidase, hexadecadrol, Vitamine B12 and lidocaine. The therapy was applied for 6 to 12 weeks. Results All the patients were followed up for a period of 0.5 to 10 years. Four cases had an evident alleviation of the symptoms and got a function resumption of hands; 5 cases had an alleviation of pain and improvement of sensation and the progress of illness were terminated, but motor function didn't have improvement; 7 cases had a continued aggravation of the symptoms. All the cases found improvement in electromyography. Concluslon The aim of fibrinolytic therapy is to dissolve the extra ECM such as hyaluronic acid around nerves in order to achieve a new homeostasis. It can relieve the conglutination and entrapment at nerve inside and outside, reduce the pressure of neuraxon and create an availing condition for the regenesis of nerve and the regain of function.

Effectiveness and safety of fibrinolytic therapy combined with clopidogrel for patients with acute st segment elevation myocardial infarction / 中国实用内科杂志

Objective To observe the effectiveness and safety of clopidogrel combined with fibrinolytic therapy for acute ST segment elevation myocardial infarction(STEMI).Methods From January 2004 to December 2006,a total of 158 STEMI patients in our hospital were treated with fibrinolytic agents combined with or without clopidogrel.There were 84 patients in clopidogrel group,including 66(78.6%)male,18(21.4%)female and 45(53.6%)elderly patients(aged ≥ 60 years);74 patients were in control group,including 58(78.4%)male,16 female(21.6%)and 40(54.1%)elderly patients.Clinical characteristics,patency of infarct-related artery(IRA),30 d major adverse cardiac events(MACE),recurrent angina and hemorrhage events of the two groups were retrospectively analyzed.Efficacy and safety of fibrinolytic therapy combined with clopidogrel in elderly patients(≥60 years old)subgroup were also estimated.Results Baseline clinical characteristics between the two groups were comparable.Clopidogrel therapy was associated with a higher proportion of patent IRA(69.1% vs 51.4%,P=0.035)and lower rates of cardiac death(0 vs 6.8%,P=0.047)and MACE(2.4% vs 12.2%,P=0.036).There was no significant difference in the incidence of recurrent angina(3.6% vs 2.7%,P=0.885),slight and severe hemorrhage events(7.1% vs 9.5%,P=0.811;1.2% vs 1.4%,P=0.533)between the two groups.In elderly patients,clopidogrel therapy was associated with a higher proportion of patent IRA(68.9% vs 45.0%,P=0.045),the declining tendency in MACE(2.2% vs 12.5%,P=0.155),but no significant differences in the other indexes.There were no significant differences in above-mentioned indexes between the elderly and younger patients in clopidogrel group.Conclusion Addition of clopidogrel to fibrinolytic therapy is safe and effective for both the elderly and younger STEMI patients.

Analysis of Clinical Treatment in Early Hospitalized Patients with Acute ST-segment Elevated Myocardial Infarction / 中国慢性病预防与控制

Objective To investigate clinical treatment status in early hospitalized patients with acute ST-segment elevated myocardial infarction(STEMI).Methods The data of hospitalized patients with STEMI admitted between January 2001 and June 2005 were retrospectively collected and studied from medical records of the 2nd Hospital of Tianjin Medical University.Results A total of 773 cases were investigated,71.80% of the patients were male,the median age was 66.0 years,and the hospitalization duration was 11.0 days.The median duration from the onset of STEMI to the arrival in the wards was 210 min.The median initiation time of door-to-needle or door-to-balloon treatment for reperfusion therapy was 60 and 100 minutes,respectively.As to the selection of the reperfusion strategies,patients who were male,younger(age

Ultrasound-guided Evacuation of Spontaneous Intracerebral Hemorrhage in Basal Ganglia

OBJECTIVE: Ultrasound can be used in the treatment of large intracerebral hematoma. The authors present our experiences with Ultrasound-guided catheter placement for lysis and drainage of ganglionic hematoma, with emphasis on technical aspects. METHODS: The authors applied real-time ultrasonography for the aspiration of intracerebral hematoma in 6cases. Ultrasound-guided aspiration via a burrhole was performed under local anesthesia. We selected a temporal entry point instead of the frequently used precoronal approach in ganglionic hematoma. A burrhole was made 4 to 6cm posterior from posterior border of frontal process of the zygomatic bone at the level of 4 to 5cm above the external auditory meatus. RESULTS: In all patients, the catheter was placed accurately into the hematoma target. All patients were irrigated with urokinase once to three times a day. The catheter could be removed within two or three days. The mean hematoma volume was reduced from initially 32mL to 5mL in an average of two days. There were no intraoperative complications related to the use of real-time ultrasonography and no postoperative infections were noted. CONCLUSION: Ultrasound allows an easy and precise localization of the hematoma and the distance from the surface to the target can be calculated. Ultrasound-guided catheter placement for fibrinolysis and hematoma drainage is a simple and safe procedure.

Estrategias para mejorar la reperfusión con terapia fibrinolítica en infarto con elevación del ST-T / Strategies to improve reperfusion with fibrinolytic therapy in ST-T elevation myocardial infarction

Las estrategias de reperfusión en la fase temprana del infarto con elevación del ST-T tienen como principal objetivo restituir y mantener la perfusión tisular. La terapia fibrinolítica puede considerarse como el tratamiento estándar por su accesibilidad y efectividad para disminuir daño miocárdico y mortalidad. La principal imperfección de esta estrategia de reperfusión radica en el porcentaje no despreciable de fracaso terapéutico y reoclusión por fenómenos de resistencia y retrombosis. La terapia fibrinolítica asociada al ácido acetilsalicílico, puede considerarse como el avance más importante en el tratamiento del infarto con elevación del ST-T. En el sitio del daño vascular, la trombosis inducida por trombina y agregación plaquetaria son los factores más importantes en la fisiopatología de los SCA y el principal mecanismo que puede limitar la efectividad de la terapia fibrinolítica. El conocimiento actual de la fisiopatología subyacente a la trombosis coronaria sugiere que la terapia fibrinolítica puede fracasar para inducir lisis óptima del trombo y refuerza el raciocinio para la combinación de estrategias antitrombóticas y de reperfusión. Podría mejorar su efectividad, un tratamiento adjunto antiplaquetario y antitrombínico intenso y moderno, que a través de diferentes mecanismos modificaría los principales componentes del trombo coronario. El propósito de este artículo es revisar y discutir los mecanismos de resistencia a la terapia fibrinolítica, las estrategias modernas para mejorar la perfusión que incluyen dosis aceleradas de fibrinolíticos, fibrinólisis facilitada, experiencia con heparina de bajo peso molecular y el posible papel de los nuevos antitrombóticos que han demostrado efectividad en el tratamiento de los síndromes coronarios agudos sin elevación del ST-T.

The main targets in reperfusion strategies in early ST-T elevation acute myocardial infarction phase are to improve and sustain tisular perfusion. Due to its accessibility and effectiveness in reducing myocardial damage and mortality, fibrinolytic therapy has been considered as the standard treatment. The most serious fibrinolytic therapy dilemma is the high failure and reoclusion rate, secondary to resistance and rethrombosis phenomena. In ST-T elevation acute myocardial infarction, therapy fibrinolytic in combination with aspirin could be considered the most important treatment advance. In the injury vascular setting, thrombosis induced by thrombin and platelet aggregability is the responsible mechanism and could limit the effectiveness of fibrinolytic therapy. The current knowledge of coronary thrombus physiopathogenesis establishes the limitations of fibrinolytic therapy in the achievement of optimal lysis, and suggests the necessity of antithrombotic and reperfusion strategy combination. Through this synergism it is feasibly to modify thrombus components improving efficiently. The propose of this review is to deeply analyze the fibrinolytic therapy resistance mechanisms, the modern approach to improve tisular perfusion, including accelerated fibrin-olytic regimens, facilitated fibrinolysis, low molecular weight heparin experience and the role of new antithrombotic drugs, that has proved effectiveness in non-ST elevation acute myocardial syndromes treatment. (Arch Cardiol Mex 2003; 73:46-58).

Effect of Fibrinolytic Therapy in Reperfusion of the Coronary Artery on the Prognosis in Acute Myocardial Infarction

PURPOSE: The most significant advance in treatment of acute myocardial infarction is reperfusion therapy with fibrinolytics and percutaneous coronary intervention (PCI). The aim of this study was to assess the efficacy of reperfusion and the clinical outcomes of patients with acute myocardial infarction (AMI) who underwent fibrinolytic therapy. METHODS: A retrospective chart review was done for 226 patients with acute myocardial infarction who met the criteria for fibrinolytic therapy. We compared the thrombolysisin-myocardia-infarction (TIMI) flow in angiography of the infarct-related artery and the clinical outcomes between patients with and without fibrinolytic therapy. Also we analyzed the effects of fibrinolytics in various treatment modalities. The clinical outcomes included the 30-day mortality, repeat AMI/unstable angina, and coronary artery bypass graft (CABG). RESULTS: Angiography after fibrinolytic therapy revealed TIMI grades 0/1, 2, or 3 flow in 15.1%, 21.4%, and 63.5% of vessels, respectively, but in patients without fibrinolytic therapy those percent were 35.0%, 26.0%, and 39.0%, respectively. A significantly increased mortality was seen in patients with lower TIMI grade flow (11.1%, 0%, and 0.8% with TIMI grade 0/1, 2 and 3, respectively, p =0.001). The 30-day mortality were significantly lower in patients with fibrinolytic therapy than in patients without fibrinolytic therapy, particularly in patients with TIMI grade 0-2 flow. There was no significant difference in the 30-day mortality and the clinical outcomes among patients with fibrinolytic therapy, emergency PCI, and delayed PCI. CONCLUSION: Fibrinolytic therapy improved the TIMI flow in angiography and reduced the 30-day mortality.