JCPSLP July 2014_Vol16_no2

Table 1. Logan Hospital Dysphagia Clinical Protocol for Thrombolysed Patients

Other factors to consider in the 4 hours–6 hours post-thrombolysis (continued) • Insertion of lines, catheters, feeding tubes and injections remains contraindicated ° Insertion of NGT/venous cannulae is contraindicated during this time period ° Intramuscular injections or subcutaneous injections contraindicated during this time period – Recommended that patients remain NBM pending swallow assessment, or, if placed NBM post swallow assessment, that NGT/IV/ subcutaneous fluids not be inserted until post 24hours. – Utilisation of already insitu line access is not contraindicated for hydration or nutrition • Not for teeth brushing (due to risk of oral mucosa trauma) ° Due to the risk of mucosal trauma associated with mastication of hard, crunchy foods (not dissimilar to teeth brushing), it is recommended that swallow assessments only be completed using textures considered safe within a soft, mince-moist or puree diet, until 24hours post- thrombolysis – Recommend only utilising safe soft, mince-mash or puree consistencies during trial of solids, as deemed clinically appropriate – Nil limitations for consistencies of fluid trials

6 hrs–24 hrs post- thrombolysis

Continued heightened risk of haemorrhage

Swallow assessment may be completed; however, caution required

Seek consent from medical team for speech pathologist CBE. Complete swallow assessment if consent gained, using the below factors to guide assessment specifics

Other factors to consider in 6 hours–24 hours post-thrombolysis • Continued heightened risk of haemorrhage ° CBE can be completed with caution, however, seek medical consent for same prior to assessment – Recommend seeking medical consent prior to speech pathology review, to ensure patent medical safe for assessment • Insertion of lines, catheters, feeding tubes and injections remains contraindicated ° Insertion of NGT/venous cannulae is contraindicated during this time period ° Intramuscular injections or subcutaneous injections contraindicated during this time period – Recommended that patients remain NBM pending swallow assessment, or, if placed NBM post swallow assessment, that NGT/IV/ subcutaneous fluids not be inserted until post 24hours. – Utilisation of already insitu line access is not contraindicated for hydration or nutrition • Not for teeth brushing (due to risk of oral mucosa trauma) ° Due to the risk of mucosal trauma associated with mastication of hard, crunchy foods (not dissimilar to teeth brushing), it is recommended that swallow assessments only be completed using textures considered safe within a soft, mince-moist or puree diet, until 24hours post- thrombolysis. – Recommend only utilising safe soft, mince-mash or puree consistencies during trial of solids, as deemed clinically appropriate – Nil limitations for consistencies of fluid trials

> 24 hours post- thrombolysis

Thrombolysis protocol completed Nil contraindications for swallow assessment

Complete swallow assessment

Other factors to consider in > 24 hours post-thrombolysis • Able to teeth brush

° Nil contraindications for swallow assessment of full diet including hard, crunchy textures – Reassessment / initial assessment of swallow able to incorporate all texture options • No further contraindication for insertion of lines, catheters, feeding tubes and injections ° Insertion of NGT/venous cannulae may be considered ° Intramuscular injections or subcutaneous injections may be considered – Recommended that patients remain NBM pending swallow assessment, or, if placed NBM post swallow assessment, that NGT feeding and or IV/subcutaneous fluids be considered by MDT.

Abbreviation list: CBE: Clinical bedside evaluation IV: Intra venous MDT: Multi-discplilinary team NBM: Nil by mouth NGT: Naso-gastric tube rt-PA: Recombinant tissue plasminogen activator

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JCPSLP Volume 16, Number 2 2014

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