Search

The use of intravenous (IV) acetaminophen (APAP) for fever has not been thoroughly studied in neurocritical care (NCC) patients, in whom a temperature of ≥38°C is associated with poor outcomes and treatment to normothermia is common practice. This retrospective study evaluated NCC patients admitted between May 1, 2012, and April 30, 2013, and received at least one dose of IV or oral (PO) APAP for a body temperature of ≥38°C. The primary aim of this study was to compare the reduction in body temperature (RIT) between IV and PO APAP, calculated as the change in temperature before and 0.5, 1, 2, 3, and 6 hours after administration. Descriptive statistics were used to assess use characteristics, and Kruskal-Wallis and Mann-Whitney

Pharmacologic interventions are commonly used to support rehabilitation efforts of patients with disorders of consciousness (DoC). The 2018 practice guidelines recommend amantadine in adults with traumatic DoC to promote functional recovery, though several other stimulants are used off-label in clinical practice and trials, such as methylphenidate, bromocriptine, levodopa, and zolpidem. Differences in the mechanisms of action, adverse effects, pharmacokinetics, and drug–drug interactions should be considered when selecting the best agent for each individual patient. Overall, pharmacologic stimulants may provide a safe and inexpensive pathway to increased functionality and participation in rehabilitation. This article provides a concise summary of scientific evidence supporting the use of pharmacologic therapies to stimulate recovery of consciousness in patients with DoC.

Levetiracetam is an antiseizure medication commonly used in neurocritical care(NCC) patients to prevent or treat seizures. Behavioral adverse events(BAE) have been reported to occur in approximately 10% of patients taking levetiracetam; however, the incidence of these BAEs in NCC patients is unknown. The objective of this study was to identify the incidence of levetiracetam-associated BAEs in NCC patients.Adult NCC patients admitted between November 1, 2014 and October 31, 2018 and diagnosed with traumatic brain injury(TBI), subarachnoid or intracerebral hemorrhage(SAH/ICH), or cerebral infarction(CI) were included in this study. Levetiracetam-associated BAEs were identified by: 1) agitation/restlessness, delirium, or anxiety; 2) administration of haloperidol, quetiapine, ziprasidone, olanzapine, or risperidone; 3) positive CAM-ICU and/or 4) implementation of physical restraints. Patients were considered to have a levetiracetam-associated BAE if one of these criteria were met while receiving levetiracetam.There were 965 patients included; 52% males with a median GCS of 13. Injury types included TBI (43.1%), ICH (21.8%), SAH (20.5%), and CI (14.6%). BAEs were identified in 46% of patients. Of these, 60% had documentation of agitation/restlessness, delirium, or anxiety while receiving levetiracetam, only 25% had a positive CAM-ICU, 13% had restraints ordered, and 42% received antipsychotics. Patients with TBI had the highest incidence of BAEs (52.4%). The median time to initiation of levetiracetam after hospital admission was 6.4 hours and BAEs occurred after 1.3 days of levetiracetam initiation.In this study, we found that almost half of our NCC population experienced levetiracetam associated BAEs which were mostly hyperactive in nature. We believe that the incidence of BAEs in our specific patient population cannot solely be attributed to ICU delirium given the lower risk of developing hyperactive delirium in ICU patients as compared to other subtypes. Therefore, monitoring and determination of the benefit versus risk in those experiencing BAEs is highly encouraged.

Patients with neurological injuries have many complicating factors that may impact outcomes. This includes medications used to treat acute and chronic illnesses that also affect systemic and central vasoactivity and may complicate neurological testing and recovery. Unfortunately, there is a lack of data to help guide clinicians on the cerebrovascular effects of medications. Multimodality monitoring techniques are used for neurocritical care patients, including transcranial Doppler, cerebral blood flow, and intracranial pressure monitoring devices. Some medications may affect cerebral autoregulation and blood flow and cause abrupt hemodynamic changes. Comorbid conditions may also contribute to pharmacokinetic changes for certain medications, causing unwanted effects. The use of monitoring techniques can serve as a tool for determining therapeutic responses to pharmacologic treatments and may be useful for guiding therapy. This chapter will focus on how the use of neurosonographic devices may help guide medication management in neurocritical care patients.