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Almohaish S, Cook AM, Brophy GM, Rhoney DH. Personalized antiseizure medication therapy in critically ill adult patients. Pharmacotherapy 2023; 43:1166-1181. [PMID: 36999346 DOI: 10.1002/phar.2797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/01/2023] [Accepted: 03/08/2023] [Indexed: 04/01/2023]
Abstract
Precision medicine has the potential to have a significant impact on both drug development and patient care. It is crucial to not only provide prompt effective antiseizure treatment for critically ill patients after seizures start but also have a proactive mindset and concentrate on epileptogenesis and the underlying cause of the seizures or seizure disorders. Critical illness presents different treatment issues compared with the ambulatory population, which makes it challenging to choose the best antiseizure medications and to administer them at the right time and at the right dose. Since there is a paucity of information available on antiseizure medication dosing in critically ill patients, therapeutic drug monitoring is a useful tool for defining each patient's personal therapeutic range and assisting clinicians in decision-making. Use of pharmacogenomic information relating to pharmacokinetics, hepatic metabolism, and seizure etiology may improve safety and efficacy by individualizing therapy. Studies evaluating the clinical implementation of pharmacogenomic information at the point-of-care and identification of biomarkers are also needed. These studies may make it possible to avoid adverse drug reactions, maximize drug efficacy, reduce drug-drug interactions, and optimize medications for each individual patient. This review will discuss the available literature and provide future insights on precision medicine use with antiseizure therapy in critically ill adult patients.
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Affiliation(s)
- Sulaiman Almohaish
- Department of Pharmacotherapy & Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia, USA
- Department of Pharmacy Practice, Clinical Pharmacy College, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Aaron M Cook
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, Kentucky, USA
| | - Gretchen M Brophy
- Department of Pharmacotherapy & Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Denise H Rhoney
- Division of Practice Advancement and Clinical Education, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
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Piwowarczyk L, Tomczak S, Antkowiak P, Jelińska A, Stawny M. Sodium Valproate Incompatibility with Parenteral Nutrition Admixtures—A Risk to Patient Safety: An In Vitro Evaluation Study. Pharmaceutics 2022; 14:pharmaceutics14020371. [PMID: 35214103 PMCID: PMC8876349 DOI: 10.3390/pharmaceutics14020371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 01/28/2022] [Accepted: 02/02/2022] [Indexed: 11/16/2022] Open
Abstract
Epilepsy is defined as a group of concerning problems related to the nervous system; its defining feature is a predisposition to epileptic seizures. The frequency of seizures in intensive care units (ICU) ranges from 3.3% to 34%, and ICU antiepileptic treatment is routine practice. The administration of drugs through the same infusion line is not recommended but is common clinical practice, especially in ICU. Incompatibilities between parenteral drugs and between drugs and parenteral nutrition admixtures (PNAs) are common medical errors and pose risks to patient safety. The co-administration of drugs must always be confirmed and clearly defined. The simultaneous infusion of sodium valproate (VPA, drug used to treat seizures and epilepsy) with parenteral PNAs has not yet been studied. During the experiment reported in this study, a visual control, pH, osmolality, zeta potential, particle size, polydispersity index, and turbidity were measured. The conducted research shows that the lipid emulsion composition has a significant influence on drug–PN (drug–parenteral nutrition) compatibility. The acceptance criteria were met only for PNs containing omega-3-acid-triglycerides (Omegaflex special and peri). The second fraction of particles above 1000 nm was observed for most of the tested PNAs (Lipoflex special, Lipoflex peri, Kabiven, SmofKabiven, Kabiven Peripheral, and Olimel Peri N4E), which disqualifies their simultaneous administration with VPA.
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Brophy GM, Hildebrandt DA, Moore EA, Van de Bussche TJ. Targeted Temperature Management in Nursing Care. Ther Hypothermia Temp Manag 2019; 9:173-176. [PMID: 31436496 DOI: 10.1089/ther.2019.29062.gmb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Gretchen M Brophy
- Department of Pharmacotherapy, Virginia Commonwealth University, Medical College of Virginia, Richmond, Virginia.,Department of Outcomes Sciences Neurosurgery, Virginia Commonwealth University, Medical College of Virginia, Richmond, Virginia
| | | | - Elizabeth A Moore
- Nursing Services, UI Heart and Vascular Center, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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Farrokh S, Tahsili-Fahadan P, Ritzl EK, Lewin JJ, Mirski MA. Antiepileptic drugs in critically ill patients. Crit Care 2018; 22:153. [PMID: 29880020 PMCID: PMC5992651 DOI: 10.1186/s13054-018-2066-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 05/14/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The incidence of seizures in intensive care units ranges from 3.3% to 34%. It is therefore often necessary to initiate or continue anticonvulsant drugs in this setting. When a new anticonvulsant is initiated, drug factors, such as onset of action and side effects, and patient factors, such as age, renal, and hepatic function, should be taken into account. It is important to note that the altered physiology of critically ill patients as well as pharmacological and nonpharmacological interventions such as renal replacement therapy, extracorporeal membrane oxygenation, and target temperature management may lead to therapeutic failure or toxicity. This may be even more challenging with the availability of newer antiepileptics where the evidence for their use in critically ill patients is limited. MAIN BODY This article reviews the pharmacokinetics and pharmacodynamics of antiepileptics as well as application of these principles when dosing antiepileptics and monitoring serum levels in critically ill patients. The selection of the most appropriate anticonvulsant to treat seizure and status epileptics as well as the prophylactic use of these agents in this setting are also discussed. Drug-drug interactions and the effect of nonpharmacological interventions such as renal replacement therapy, plasma exchange, and extracorporeal membrane oxygenation on anticonvulsant removal are also included. CONCLUSION Optimal management of antiepileptic drugs in the intensive care unit is challenging given altered physiology, polypharmacy, and nonpharmacological interventions, and requires a multidisciplinary approach where appropriate and timely assessment, diagnosis, treatment, and monitoring plans are in place.
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Affiliation(s)
- Salia Farrokh
- Department of Pharmacy, The Johns Hopkins Hospital, 600 N. Wolfe Street, Carnegie 180, Baltimore, MD 21287 USA
| | - Pouya Tahsili-Fahadan
- Department of Neurology, The Johns Hopkins Hospital, Baltimore, MD USA
- Department of Medicine, Virginia Commonwealth University School of Medicine, INOVA Campus, Falls Church, VA USA
| | - Eva K. Ritzl
- Department of Neurology, The Johns Hopkins Hospital, Baltimore, MD USA
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD USA
| | - John J. Lewin
- Department of Pharmacy, The Johns Hopkins Hospital, 600 N. Wolfe Street, Carnegie 180, Baltimore, MD 21287 USA
| | - Marek A. Mirski
- Department of Pharmacy, The Johns Hopkins Hospital, 600 N. Wolfe Street, Carnegie 180, Baltimore, MD 21287 USA
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Abstract
Complications involving the central and peripheral nervous system are frequently encountered in critically ill patients. All components of the neuraxis can be involved including the brain, spinal cord, peripheral nerves, neuromuscular junction, and muscles. Neurologic complications adversely impact outcome and length of stay. These complications can be related to underlying critical illness, pre-existing comorbid conditions, and commonly used and life-saving procedures and medications. Familiarity with the myriad neurologic complications that occur in the intensive care unit can facilitate their timely recognition and treatment. Additionally, awareness of treatment-related neurologic complications may inform decision-making, mitigate risk, and improve outcomes.
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Affiliation(s)
- Clio Rubinos
- Department of Neurology, Loyola University Chicago-Stritch School of Medicine, Maywood, IL, 60153, USA
| | - Sean Ruland
- Department of Neurology, Loyola University Chicago-Stritch School of Medicine, Maywood, IL, 60153, USA.
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Lyden P, Brophy GM, Deye N, Horn CM. Temperature Management in Neurological and Neurosurgical Intensive Care Unit. Ther Hypothermia Temp Manag 2016; 6:164-168. [PMID: 27828761 DOI: 10.1089/ther.2016.29020.pjl] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Patrick Lyden
- 1 Department of Neurology, Cedars-Sinai Medical Center , Los Angeles, California
| | - Gretchen M Brophy
- 2 Department of Pharmacotherapy & Outcomes Science and Neurosurgery, Virginia Commonwealth University , Richmond, Virginia
| | - Nicolas Deye
- 3 Reanimation Medicale, Lariboisiere Hospital , Paris, France
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Limpawattana P, Panitchote A, Tangvoraphonkchai K, Suebsoh N, Eamma W, Chanthonglarng B, Tiamkao S. Delirium in critical care: a study of incidence, prevalence, and associated factors in the tertiary care hospital of older Thai adults. Aging Ment Health 2016; 20:74-80. [PMID: 25902330 DOI: 10.1080/13607863.2015.1035695] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Delirium is a common condition in older adults which can have devastating outcomes. The studies about delirium in intensive care units (ICU) are relatively rare compared to studies in the non-ICU setting. This study aimed to study the prevalence, incidence, and risk factors of delirium among older Thai adults in ICU. METHOD Participants were older patients who were admitted to the ICU of Srinagarind Medical School, KhonKaen, Thailand from May 2013 to August 2014. Baseline characteristics were collected. Delirium was rated by trained clinical researchers using the Confusion Assessment Method for the ICU (CAM-ICU). Demographic data were analyzed using descriptive statistics. Regression analyses were used to analyze the outcomes. RESULTS Delirium occurred in 44 of 99 patients (44.4%) with an incidence rate of 22.2% (22/99). The prevalence of delirium in mechanically ventilated patients was 62.5% (30/48). The majority of the patients had delirium within five days of ICU admission. Seven independent predisposing factors were identified using bivariate regressions: age, functional status, disease severity, having pneumonia, cognitive impairment, depression, or previous stroke. Numbers of additional drugs, bed changes, physical restraints, sleep deprivation, use of bladder catheters, and patients with mechanical ventilators were independent precipitating factors. For multivariate regressions, previous stroke, multiple bed changes, and physical restraints were the significant factors. CONCLUSION The prevalence and incidence of delirium of older adults in the ICU setting in this study was high and comparable to prior studies. There are several significant risk factors associated with delirium which could be modified. These factors should be considered when designing effective preventive strategies of delirium.
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Affiliation(s)
- Panita Limpawattana
- a Division of Geriatric Medicine, Department of Internal Medicine, Faculty of Medicine , KhonKaen University , Muang , Thailand
| | - Anupol Panitchote
- b Division of Critical Care, Department of Internal Medicine, Faculty of Medicine , KhonKaen University , Muang , Thailand
| | - Kawin Tangvoraphonkchai
- c Department of Internal Medicine, Faculty of Medicine , KhonKaen University , Muang , Thailand
| | - Naluttaporn Suebsoh
- d Intensive Care Unit of Internal Medicine, Faculty of Medicine , KhonKaen University , Muang , Thailand
| | - Wanaporn Eamma
- d Intensive Care Unit of Internal Medicine, Faculty of Medicine , KhonKaen University , Muang , Thailand
| | - Bunruam Chanthonglarng
- d Intensive Care Unit of Internal Medicine, Faculty of Medicine , KhonKaen University , Muang , Thailand
| | - Somsak Tiamkao
- e Division of Neurology, Department of Internal Medicine, Faculty of Medicine and Northeastern Stroke Research Group , KhonKaen University , Muang , Thailand
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