national-clinical-guidelines-for-stroke-fourth-edition

Evidence to recommendations
Studies have shown that stroke patients are at high risk of developing dehydration,
malnutrition, infections, hypoxia and hyperglycaemia. The evidence for stroke unit
management rather than non-specialist care is robust. Middleton et al 2011 have shown
that introducing protocols and training into stroke unit care can significantly improve
outcomes. Management of blood pressure after stroke remains an area where there is
little evidence to guide care and the recommendations made are based upon the
consensus of the working party and the NICE Guideline Development Group. There is
no evidence for the use of hyperbaric oxygen therapy in stroke (Bennett et al 2009) and
from the evidence available, the working party feels that mannitol for the treatment of
cerebral oedema should not be used outside of the context of a clinical trial.
4.12.1 Recommendations
A All patients with acute stroke should be admitted directly to a stroke unit that has
protocols to maintain normal physiological status, and has staff trained in their use.
B The patient’s physiological state should be monitored closely to include:
● blood glucose
● blood pressure
● oxygenation
● nourishment and hydration
● temperature.
C People who have had a stroke should receive supplemental oxygen only if their oxygen
saturation drops below 95% and there is no contraindication. The routine use of
supplemental oxygen is not recommended in people with acute stroke who are not
hypoxic.
D People with acute stroke should be treated to maintain a blood glucose concentration
between 4 and 11 mmol/L.
E Optimal insulin therapy, which can be achieved by the use of intravenous insulin and
glucose, should be provided to all adults with diabetes who have stroke. Critical care
and emergency departments should have a protocol for such management.
F Antihypertensive treatment in people with acute stroke is recommended only if there
is a hypertensive emergency or one or more of the following serious concomitant
medical issues:
● hypertensive encephalopathy
● hypertensive nephropathy
● hypertensive cardiac failure/myocardial infarction
● aortic dissection
● pre-eclampsia/eclampsia
4 Acute phase care
● intracerebral haemorrhage with systolic blood pressure over 200 mmHg.
G Blood pressure reduction to 185/110 mmHg or lower should be considered in people
who are candidates for thrombolysis.
H Non-dysphagic patients admitted on antihypertensive medication should continue
oral treatment unless there is a contraindication or they are being included in a trial
of blood-pressure control.
© Royal College of Physicians 2012 53