What is the target blood glucose range in mmol/L for patients post tissue plasminogen activator (tPA) for stroke?

Target Blood Glucose Range for Post-tPA Stroke Patients

The target blood glucose range for patients who have received tissue plasminogen activator (tPA) for acute ischemic stroke is 7.8-10.0 mmol/L (140-180 mg/dL). 1

Rationale for Blood Glucose Management

Hyperglycemia in acute ischemic stroke patients who receive tPA is associated with:

• Increased risk of hemorrhagic transformation (75% increased risk per 100 mg/dL rise in blood glucose) 2
• Poorer functional outcomes 2
• Increased infarct size 2
• Longer hospital stays (7 vs 6 days) 2
• Higher 30-day mortality 2
• Increased healthcare costs 2

Monitoring Protocol

For patients who have received tPA:

• Check blood glucose on admission
• For patients with admission glucose >7.8 mmol/L (>140 mg/dL), monitor glucose every 1-2 hours initially 2, 1
• For patients without elevated glucose, monitor every 6 hours in the first 24-48 hours 2

Treatment Algorithm

1. When to initiate treatment:

   • Start insulin therapy when blood glucose is ≥10.0 mmol/L (≥180 mg/dL) 1

2. Target range:

   • Maintain blood glucose between 7.8-10.0 mmol/L (140-180 mg/dL) 2, 1
   • Avoid glucose <2.7 mmol/L (<50 mg/dL) as this is an exclusion criterion for tPA administration 2

3. Treatment options:

   • For severe hyperglycemia: Consider intravenous insulin infusion
   • For less severe hyperglycemia: Subcutaneous insulin protocols can safely maintain blood glucose below 10.0 mmol/L (180 mg/dL) 1

Important Considerations

• Avoid aggressive correction: Overly aggressive therapy should be avoided as it can result in fluid shifts, electrolyte abnormalities, and hypoglycemia, all of which can be detrimental to the brain 2

• Hypoglycemia management: Promptly treat hypoglycemia (blood glucose <3.3 mmol/L or <60 mg/dL) 1

• Recanalization impact: The detrimental effect of hyperglycemia is more pronounced in patients who achieve early reperfusion (<3 hours) compared to those with delayed or no reperfusion 3

Scientific Evidence

The recommendation for a target range of 7.8-10.0 mmol/L (140-180 mg/dL) is supported by multiple guidelines and studies:

• The American Heart Association/American Stroke Association guidelines recommend this range to balance the risks of hyperglycemia against the dangers of hypoglycemia 1

• The Lancet Diabetes and Endocrinology recommends targeting a glucose concentration of 7.8-10.0 mmol/L (140-180 mg/dL) for the majority of critically ill patients with hyperglycemia 2

• Research shows that patients with admission glucose >8.8 mmol/L (>158 mg/dL) have lower recanalization rates (16% vs 36.1%) and higher NIHSS scores at 48 hours (14.5 vs 7) 4

By maintaining blood glucose within the recommended range of 7.8-10.0 mmol/L (140-180 mg/dL), you can optimize outcomes for patients who have received tPA for acute ischemic stroke.