Early Mobilization Protocol Safely Initiated Post Intravenous Alteplase Treatment

The study found the approach could be utilized in the intensive care unit without adverse effects on neurological or functional outcomes.

For appropriately selected patients with acute ischemic stroke (AIS), early mobilization treatment can be initiated in the intensive care unit (ICU) following intravenous alteplase treatment without any adverse effects on neurological and functional outcomes, a recent study found.1

Data were presented at the 2022 International Stroke Conference (ISC), February 9-11, in New Orleans, Louisiana, which included analyses from consecutive patients admitted to the ICU with AIS who received IV alteplase between Oct 2019 to June 2021 and were considered for early mobilization protocol. A total of 241 patients were admitted within the study period, with 137 (56.8%) patients eligible for the protocol. Included patients were a mean age of 63.4 years (standard deviation [SD], 16.6) and excluded patients were a mean age of 66.2 years (SD, 17.0). Included patients had a mean National Institutes of Health Stroke Scale (NIHSS) score of 5.3 (SD, 4.4) at baseline, compared with excluded patients, who had a mean score of 9.9 (SD, 7.3).

In eligible patients, early mobilization protocol was initiated at 18.3 hours (SD, 3.6), when compared with routine mobilization, which was initiated at 41.6 hours (SD, 19.8 hours) in excluded patients (P <.001). When compared with those who were not eligible for early mobilization protocol, patients who were included had significantly lower mean NIHSS score at discharge (1.0 [SD, 2.2] vs 4.2 [SD, 7.0]; P <.001) and significantly higher rate of modified Rankin scale 0-1 at discharge (86.9% vs 67.3%; P = .0003).

“Current guidelines recommend bed rest for 24 hours after receiving intravenous alteplase which may not be necessary and delay rehabilitation in a large proportion of acute ischemic stroke patients,” Sachin M. Bhagavan, MD, neurology resident, University of Missouri School of Medicine, et al wrote.1

READ MORE: Black Patients Present Greater Association With Comorbidities Prior to Ischemic Stroke

To be eligible, patients were required to by 18 years or older with minor, moderate, or severe ischemic stroke, defined as an NIHSS score of 22 or less. Mobilization was initiated within 13-24 hours after intravenous alteplase administrations. Patients were excluded in the event they had hemodynamic instability, were on mechanical ventilation, had an unstable neurological examination or progressive symptoms, or had presence of external ventricular drain for hemorrhagic transformation within 24 hours of intravenous alteplase.

In 2020, high dose, intensive training of very early mobilization (VEM) was found to increase mortality in patients within 14 days poststroke when compared to usual care (UC). Findings were supported by tertiary results of the prospective, parallel group, randomized A Very Early Rehabilitation Trial (AVERT).2

Those enrolled in AVERT treated with VEM had an adjusted odds ratio of death of 1.76 (95% CI, 1.06–2.92; P = .029) within 14 days post-stroke, compared with patients treated with UC. Within this time frame, 48 patients had died in the VEM group (4.56%) and 32 in the UC group (3.05%), for an overall fatality rate of 3.8% (n = 80). Most deaths were caused by stroke-related events (VEM, n = 29; UC, n = 16).

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1. Bhagavan S, Ishfaq MF, Pullimamidi S, et al. “Early Mobilization Protocol” can be initiated in the intensive care unit in acute ischemic stroke patients after receiving intravenous alteplase. Presented at ISC 2022; February 9-11; New Orleans, LA and Virtual. Abstract 5.
2. Bernhardt J, Borschmann, K, Collier JM, et. al. Fatal and non-fatal events within 14 days after early, intensive, mobilization post-stroke. Neurology. 2020;96(8):e1156-e1166. doi: 10.1212/WNL.0000000000011106