Tissue plasminogen activator overdose in acute ischemic stroke patients linked to poorer functional outcomes

J Stroke Cerebrovasc Dis. 2014 Jan;23(1):155-9. doi: 10.1016/j.jstrokecerebrovasdis.2013.01.004. Epub 2013 Jan 31.

Abstract

Background: The dose of intravenous tissue plasminogen activator (tPA) administered in acute ischemic stroke patients is calculated using the patient's weight (0.9 mg/kg). Patients are rarely weighed before treatment in actual practice, although overestimating patient weights leads to higher doses of tPA, which may adversely influence outcome.

Methods: We investigated the weight used to calculate the dose of tPA compared to the actual measured weight in consecutive acute ischemic stroke patients treated over a 4-year period at our center. The rate of intracranial hemorrhage (ICH), discharge modified Rankin Scale (mRS) score, and mortality at 3 months were compared between groups, according to accuracy of the dose of tPA.

Results: We found that 140 of 164 (85%) acute ischemic stroke patients treated with tPA had a measured weight documented in the chart after treatment. Of these, 13 patients received ≥1.0 mg/kg and 16 patients received ≤0.8 mg/kg, based on a comparison of the weight used for the tPA dose calculation and the subsequent measured weight. Four of 13 (31%) patients treated with ≥1.0 mg/kg of tPA developed ICH. Patients who inadvertently received higher doses of tPA had a lower likelihood of a good functional outcome at discharge (mRS score 0-2; 0% v 34%; P = .009). No difference in 3-month mortality was observed, although patients who were not weighed in hospital had a threefold increase in discharge mortality (21% v 7%; P = .019).

Conclusions: Our findings provide support for the practice of accurately weighing all acute ischemic stroke patients before thrombolysis.

Keywords: Acute stroke; medical errors; thrombolytic therapy; tissue plasminogen activator.

Publication types

  • Observational Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Blood Pressure / drug effects
  • Body Weight
  • Brain Ischemia / complications*
  • Brain Ischemia / drug therapy
  • Brain Ischemia / mortality
  • Drug Overdose
  • Female
  • Fibrinolytic Agents / administration & dosage*
  • Fibrinolytic Agents / adverse effects*
  • Fibrinolytic Agents / therapeutic use
  • Humans
  • Intracranial Hemorrhages / epidemiology
  • Intracranial Hemorrhages / etiology
  • Male
  • Medical Errors
  • Middle Aged
  • Retrospective Studies
  • Stroke / complications*
  • Stroke / drug therapy
  • Stroke / mortality
  • Tissue Plasminogen Activator / administration & dosage*
  • Tissue Plasminogen Activator / adverse effects*
  • Tissue Plasminogen Activator / therapeutic use
  • Treatment Outcome
  • Young Adult

Substances

  • Fibrinolytic Agents
  • Tissue Plasminogen Activator