A. Shaun Rowe

The Insertion and Management of External Ventricular Drains: An Evidence-Based Consensus Statement : A Statement for Healthcare Professionals from the Neurocritical Care Society.

Abstract External ventricular drains (EVDs) are commonly placed to monitor intracranial pressure and manage acute hydrocephalus in patients with a variety of intracranial pathologies. The indications for EVD insertion and their efficacy in the management of these various conditions have been previously addressed in guidelines published by the Brain Trauma Foundation, American Heart Association and combined committees of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons. While it is well recognized that placement of an EVD may be a lifesaving intervention, the benefits can be offset by procedural and catheter-related complications, such as hemorrhage along the catheter tract, catheter malposition, and CSF infection. Despite their widespread use, there are a lack of high-quality data regarding the best methods for placement and management of EVDs to minimize these risks. Existing recommendations are frequently based on observational data from a single center and may be biased to the authors’ view. To address the need for a comprehensive set of evidence-based guidelines for EVD management, the Neurocritical Care Society organized a committee of experts in the fields of neurosurgery, neurology, neuroinfectious disease, critical care, pharmacotherapy, and nursing. The Committee generated clinical questions relevant to EVD placement and management. They developed recommendations based on a thorough literature review using the Grading of Recommendations Assessment, Development, and Evaluation system, with emphasis placed not only on the quality of the evidence, but also on the balance of benefits versus risks, patient values and preferences, and resource considerations.

Seizure Prophylaxis in Neurocritical Care: A Review of Evidence‐Based Support

Seizures are a well‐described complication of acute brain injury and neurosurgery. Antiepileptic drugs (AEDs) are frequently utilized for seizure prophylaxis in neurocritical care patients. In this review, the Neurocritical Care Society Pharmacy Section describes the evidence associated with the use of AEDs for seizure prophylaxis in patients with intracerebral tumors, traumatic brain injury, aneurysmal subarachnoid hemorrhage, craniotomy, ischemic stroke, and intracerebral hemorrhage. Clear evidence indicates that the short‐term use of AEDs for seizure prophylaxis in patients with traumatic brain injury and aneurysmal subarachnoid hemorrhage may be beneficial; however, evidence to support the use of AEDs in other disease states is less clear.

Long-Term Comparison of GOS-E Scores in Patients Treated With Phenytoin or Levetiracetam for Posttraumatic Seizure Prophylaxis After Traumatic Brain Injury

Background: Much debate exists on the optimal medication for posttraumatic seizure prophylaxis after traumatic brain injury (TBI). There is some evidence that levetiracetam (LEV) could be neuroprotective and provide long-term benefits in this patient population. Objective: The primary objective was to compare the Glasgow Outcome Scale–Extended (GOS-E) 6 months or more after severe TBI. Secondary end points were presence of early seizures (0 to 7 days post-TBI) or late seizures (8 days post-TBI to phone interview), use of anticonvulsant medication when interviewed, medication-related hospital complications, and a summary of phenytoin (PHT) and LEV dosing regimens. Methods: This was an IRB-approved, single-center, prospective cohort analysis. Patients were identified by cross-referencing a list of patients receiving LEV or PHT, with a list of patients with ICD-9 code consistent with TBI. After study inclusion, patients were contacted by telephone, and the GOS-E was administered. Data for secondary end points were gathered by retrospective chart review. Results: In all, 19 patients were included in the final analysis. There was no difference in the GOS-E score assessed ≥6 months after injury (5.07 ± 1.69 vs 5.60 ± 2.07, P = 0.58). There was no difference in the secondary end points of early seizures (P = 0.53) or late seizures (P = 0.53). However, the PHT group experienced a higher rate of hospital days with recorded fever (0.20 ± 0.22 vs 0 ± 0; P = 0.014). Conclusions: Long-term functional outcome in patients who experienced a TBI was not affected by treatment with PHT or LEV; however, patients treated with PHT had a higher incidence of fever during hospitalization.

Pharmacy student knowledge retention after completing either a simulated or written patient case

Objective. To determine pharmacy students’ knowledge retention from and comfort level with a patient-case simulation compared with a written patient case. Design. Pharmacy students were randomly assigned to participate in either a written patient case or a simulated patient case in which a high-fidelity mannequin was used to portray a patient experiencing a narcotic and acetaminophen overdose. Assessment. Participants’ responses on a multiple-choice test and a survey instrument administered before the case, immediately after the case, and 25 days later indicated that participation in the simulated patient case did not result in greater knowledge retention or comfort level than participation in the written patient case. Students’ knowledge improved post-intervention regardless of which teaching method was used. Conclusions. Although further research is needed to determine whether the use of simulation in the PharmD curriculum is equivalent or superior to other teaching methods, students’ enthusiasm for learning in a simulated environment where they can safely apply patient care skills make this technology worth exploring.

Risk factors for discharge on a new antipsychotic medication after admission to an intensive care unit

PURPOSE Increased awareness of delirium in the intensive care unit (ICU) has led to higher use of antipsychotic medications for treatment of delirium. These medications are often not discontinued at ICU or hospital discharge, which may increase the risk of inappropriate polypharmacy. Our study sought to identify risk factors for being discharged on a new antipsychotic medication after admission to a trauma-surgical ICU or neurocritical care unit. METHODS This was a retrospective cohort study at an academic medical center and included patients who were admitted to the trauma-surgical ICU or neurocritical care unit and received an antipsychotic medication. Those younger than 18 years, died before hospital discharge, or did not have complete documentation were excluded. RESULTS A total of 341 records were included in the final analysis. Of those, 82 (24%) were discharged on a new antipsychotic and 67% of those patients had no documented indication. Acute Physiology and Chronic Health Evaluation II (odds ratio, 1.030 [95% confidence interval, 1.030-1.110]) and days treated with benzodiazepines (odds ratio, 1.101 [95% confidence interval, 1.060-1.143]) were independently associated with being discharged on a new antipsychotic medication. CONCLUSIONS Those patients with higher Acute Physiology and Chronic Health Evaluation II scores and more benzodiazepine days are at increased odds of being discharged on a new antipsychotic.

Coagulation factor VIIa (recombinant) for warfarin-induced intracranial hemorrhage.

PURPOSE The use of coagulation factor VIIa (recombinant) for the treatment of warfarin-induced intracranial hemorrhage (ICH) is described. SUMMARY ICH is a devastating disorder that can be exacerbated by the use of oral anticoagulation. The treatment of warfarin-associated ICH involves the prompt reversal of anticoagulation to allow for surgical procedures, if necessary. Despite limited labeled indications, factor VIIa (recombinant) has been used to reverse warfarin-induced anticoagulation in patients with active hemorrhage, partly due to the rapid effect of factor VIIa on the International Normalized Ratio and the ability to administer the drug quickly in acute settings. The efficacy of factor VIIa (recombinant) for the reversal of anticoagulation in patients with warfarin-associated ICH has been described in several case reports, case series, and retrospective cohort studies. Based on these reports, the use of factor VIIa (recombinant) for the treatment of warfarin-associated ICH may be a viable alternative or adjunct therapy to standard treatment with fresh-frozen plasma and vitamin K. However, due to the nature of these reports, future controlled trials should be conducted to verify the exact place for factor VIIa (recombinant) for this indication. Thromboembolic complications are rare but serious complications secondary to the use of factor VIIa (recombinant). Though differences exist in the reported rate of thromboembolic complications associated with factor VIIa (recombinant), factor VIIa (recombinant) should be used with caution in patients with a predisposition to thromboembolic complications. CONCLUSION Use of factor VIIa (recombinant) may be considered for reversal of anticoagulation in patients with warfarin-associated ICH. However, patients should be screened for increased risk of thrombosis before administration of the drug.

Management of Apixaban-associated Subdural Hematoma: A Case Report on the Use of Factor Eight Inhibitor Bypassing Activity

Objective:We report a case of a patient receiving apixaban who developed a spontaneous subdural hematoma and declining mental status that improved after administration of a single dose of factor eight inhibitor bypassing activity. Design:Case report. Setting:Comprehensive Stroke Center, Neurocritical Care Unit. Patient:A 76-year-old man presented to an outside facility with a chief complaint of headache and pain behind his right eye. A CT scan of his head revealed a subdural hematoma. The patient was transferred to our facility with worsening clinical status. Interventions:After a confirmatory cranial CT scan revealed a worsening subdural hematoma with midline shift, a single dose of factor VIII inhibitor bypassing activity (25 U/kg) was administered. Measurements and Main Results:Coagulation tests following the administration of factor VIII inhibitor bypassing activity and a follow-up CT scan confirmed hemostasis. The patient was discharged home with no focal deficits. Conclusions:Factor VIII inhibitor bypassing activity may be a viable, nonspecific reversal agent for life-threatening bleeding associated with apixaban.

Key Articles and Guidelines in the Primary Prevention of Ischemic Stroke

Ischemic stroke is a prevalent disease with a large burden on the health system. Preventive strategies, therefore, are paramount. Primary prevention is aimed at reducing the risk of stroke in asymptomatic people. The most effective prevention is through control of modifiable risk factors. Due to the large amount of literature available on this topic, this bibliography (the first of a 2‐part series) aims to provide a comprehensive resource for medical practitioners charged with caring for this population.

Evaluation of the Hemodynamic Effects of Intravenous Amiodarone Formulations During the Maintenance Phase Infusion

Background: Two of the excipients in intravenous formulations of amiodarone, polysorbate 80 and benzyl alcohol, have been shown to cause hypotension. A newer formulation of amiodarone, which contains cyclodextrin, is devoid of these excipients. Objective: To evaluate the change in mean arterial pressure when utilizing 2 intravenous amiodarone formulations. Methods: This was a retrospective cohort analysis conducted at an academic medical center. Patients received intravenous amiodarone containing either polysorbate 80/benzyl alcohol (control) or cyclodextrin (cyclodextrin). Patients received these formulations based on a standard institutional protocol of 1 mg/min for 6 hours, followed by 0.5 mg/min for at least 18 hours or until discontinued by the provider. All data were collected from the medical record and included changes in blood pressures, time to lowest systolic blood pressure, concurrent antihypertensive use, and number of patients requiring treatment for hypotension. Results: A total of 160 patients (120 control, 40 cyclodextrin) were included. There was a statistically significant difference in mean arterial pressure between the groups receiving the control formulation of amiodarone compared with the cyclodextrin formulation across the 24-hour maintenance phase infusion (P < 0.001). There was a significant difference between formulations with regard to the change in mean arterial pressure during the 0- to 6-hour and 12- to 18-hour time blocks. There was a statistically significant difference in the number of patients receiving fluid boluses for treatment of hypotension (P = 0.001). Conclusions: The excipients in the formulation of intravenous amiodarone may have a significant role in the hypotensive effects seen throughout the duration the maintenance phase infusion.

Futility Assessment of Recombinant Factor VII Activated for the Treatment of Hemorrhagic Shock Requiring Massive Transfusion

Objective Recombinant human factor VII activated (rFVIIa) is an adjuvant therapy in patients receiving massive transfusion for hemorrhagic shock. We compared patient characteristics and outcomes to determine futility criteria for the administration of rFVIIa in patients receiving massive transfusion for hemorrhagic shock. Methods This was a retrospective cohort analysis of patients who received both massive transfusion and rFVIIa. Consecutive trauma patients were allocated to 1 of 2 cohorts: survivors and nonsurvivors. Results Seventy-two subjects comprised the study: 27 were survivors and 45 were nonsurvivors. A univariate analysis revealed that nonsurvivors were older and had a more profound coagulopathy as measured by prothrombin time. A stepwise logistic regression revealed an increased odds of death in those patients who were older (odds ratio [OR], 1.048; 95% CI, 1.008 −1.091), had a higher admission prothrombin time (OR, 1.561; 95% CI, 1.152-2.116), and received more fresh frozen plasma (OR, 1.098; 95% CI 1.023-1.179). In addition we saw a protective effect with increased platelet administration (OR, 0.645; 95% CI, 0.446-0.932). Conclusion The use of rFVIIa for massive transfusion in middle-aged patients with moderate coagulopathy experiencing hemorrhagic shock may be considered futile. However, if rFVIIa is to be used as part of a massive transfusion protocol, adequate administration of platelets should be ensured.