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Neurocritical Care
Published in: Neurocritical Care 2/2015

01-12-2015 | Review Article

Emergency Neurological Life Support: Pharmacotherapy

Authors: Gretchen M. Brophy, Theresa Human, Lori Shutter

Published in: Neurocritical Care | Special Issue 2/2015

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Abstract

The appropriate use of medications during Emergency Neurological Life Support (ENLS) is essential to optimize patient care. Important considerations when choosing the appropriate agent include the patient’s organ function and medication allergies, potential adverse drug effects, drug interactions, and critical illness and aging pathophysiologic changes. Critical medications used during ENLS include hyperosmolar therapy, anticonvulsants, antithrombotics, anticoagulant reversal and hemostatic agents, anti-shivering agents, neuromuscular blockers, antihypertensive agents, sedatives, vasopressors and inotropes, and antimicrobials. This article focuses on the important pharmacokinetic and pharmacodynamics characteristics, advantages and disadvantages, and clinical pearls of these therapies, providing practitioners with essential drug information to optimize pharmacotherapy in acutely ill neurocritical care patients.
Literature
1.
Kamel H, Cornes SB, Hegde M, Hall SE, Josephson SA. Electroconvulsive therapy for refractory status epilepticus: a case series. Neurocrit Care. 2010;12(2):204–10.CrossRefPubMed
2.
Hays AN, Lazaridis C, Neyens R, Nicholas J, Gay S, Chalela JA. Osmotherapy: use among neurointensivists. Neurocrit Care. 2011;14(2):222–8.CrossRefPubMed
3.
Perez-Perez AJ, Pazos B, Sobrado J, Gonzalez L, Gandara A. Acute renal failure following massive mannitol infusion. Am J Nephrol. 2002;22(5–6):573–5.PubMed
4.
Gadallah MF, Lynn M, Work J. Case report: mannitol nephrotoxicity syndrome: role of hemodialysis and postulate of mechanisms. Am J Med Sci. 1995;309(4):219–22.CrossRefPubMed
5.
Dorman HR, Sondheimer JH, Cadnapaphornchai P. Mannitol-induced acute renal failure. Medicine. 1990;69(3):153–9.CrossRefPubMed
6.
Gondim Fde A, Aiyagari V, Shackleford A, Diringer MN. Osmolality not predictive of mannitol-induced acute renal insufficiency. J Neurosurg. 2005;103(3):444–7.CrossRefPubMed
7.
Rudehill A, Gordon E, Ohman G, Lindqvist C, Andersson P. Pharmacokinetics and effects of mannitol on hemodynamics, blood and cerebrospinal fluid electrolytes, and osmolality during intracranial surgery. J Neurosurg Anesthesiol. 1993;5(1):4–12.CrossRefPubMed
8.
Palma L, Bruni G, Fiaschi AI, Mariottini A. Passage of mannitol into the brain around gliomas: a potential cause of rebound phenomenon. A study on 21 patients. J Neurosurg Sci. 2006;50(3):63–6.PubMed
9.
Kheirbek T, Pascual JL. Hypertonic saline for the treatment of intracranial hypertension. Curr Neurol Neurosci Rep. 2014;14(9):482.CrossRefPubMed
10.
Forsyth LL, Liu-DeRyke X, Parker D Jr, Rhoney DH. Role of hypertonic saline for the management of intracranial hypertension after stroke and traumatic brain injury. Pharmacotherapy. 2008;28(4):469–84.CrossRefPubMed
11.
Papangelou A, Lewin JJ 3rd, Mirski MA, Stevens RD. Pharmacologic management of brain edema. Curr Treat Options Neurol. 2009;11(1):64–73.CrossRefPubMed
12.
Roquilly A, Mahe PJ, Latte DD, Loutrel O, Champin P, Di Falco C, et al. Continuous controlled-infusion of hypertonic saline solution in traumatic brain-injured patients: a 9-year retrospective study. Crit Care. 2011;15(5):R260.PubMedCentralCrossRefPubMed
13.
Brophy GM, Bell R, Claassen J, Alldredge B, Bleck TP, Glauser T, et al. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care. 2012;17(1):3–23.CrossRefPubMed
14.
15.
Ubogu EE, Sagar SM, Lerner AJ, Maddux BN, Suarez JI, Werz MA. Ketamine for refractory status epilepticus: a case of possible ketamine-induced neurotoxicity. Epilepsy Behav. 2003;4(1):70–5.CrossRefPubMed
16.
Furie KL, Kasner SE, Adams RJ, Albers GW, Bush RL, Fagan SC, et al. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the american heart association/american stroke association. Stroke. 2011;42(1):227–76.CrossRefPubMed
17.
Serebruany VL, Steinhubl SR, Berger PB, Malinin AI, Bhatt DL, Topol EJ. Variability in platelet responsiveness to clopidogrel among 544 individuals. J Am Coll Cardiol. 2005;45(2):246–51.CrossRefPubMed
18.
Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, et al. 2011 ACCF/AHA/SCAI Guideline for percutaneous coronary intervention. A report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines and the society for cardiovascular angiography and interventions. J Am Coll Cardiol. 2011;58(24):e44–122.CrossRefPubMed
19.
20.
Lier H, Krep H, Schroeder S, Stuber F. Preconditions of hemostasis in trauma: a review. The influence of acidosis, hypocalcemia, anemia, and hypothermia on functional hemostasis in trauma. J Trauma. 2008;65(4):951–60.CrossRefPubMed
21.
Crowther MA, Warkentin TE. Managing bleeding in anticoagulated patients with a focus on novel therapeutic agents. J Thromb Haemost. 2009;7(Suppl 1):107–10.CrossRefPubMed
22.
Leissinger CA, Blatt PM, Hoots WK, Ewenstein B. Role of prothrombin complex concentrates in reversing warfarin anticoagulation: a review of the literature. Am J Hematol. 2008;83(2):137–43.CrossRefPubMed
23.
Tran H, Collecutt M, Whitehead S, Salem HH. Prothrombin complex concentrates used alone in urgent reversal of warfarin anticoagulation. Intern Med J. 2011;41(4):337–43.CrossRefPubMed
24.
van Aart L, Eijkhout HW, Kamphuis JS, Dam M, Schattenkerk ME, Schouten TJ, et al. Individualized dosing regimen for prothrombin complex concentrate more effective than standard treatment in the reversal of oral anticoagulant therapy: an open, prospective randomized controlled trial. Thromb Res. 2006;118(3):313–20.CrossRefPubMed
25.
Crawford JH, Augustson BM. Prothrombinex use for the reversal of warfarin: is fresh frozen plasma needed? Med J Aust. 2006;184(7):365–6.PubMed
26.
Weibert RT, Le DT, Kayser SR, Rapaport SI. Correction of excessive anticoagulation with low-dose oral vitamin K1. Ann Intern Med. 1997;126(12):959–62.CrossRefPubMed
27.
Brophy MT, Fiore LD, Deykin D. Low-dose vitamin K therapy in excessively anticoagulated patients: a dose-finding study. J Thromb Thrombolysis. 1997;4(2):289–92.CrossRefPubMed
28.
Lubetsky A, Yonath H, Olchovsky D, Loebstein R, Halkin H, Ezra D. Comparison of oral vs intravenous phytonadione (vitamin K1) in patients with excessive anticoagulation: a prospective randomized controlled study. Arch Intern Med. 2003;163(20):2469–73.CrossRefPubMed
29.
Nee R, Doppenschmidt D, Donovan DJ, Andrews TC. Intravenous versus subcutaneous vitamin K1 in reversing excessive oral anticoagulation. Am J Cardiol. 1999;83(2):286–8 A6-7.CrossRefPubMed
30.
Eerenberg ES, Kamphuisen PW, Sijpkens MK, Meijers JC, Buller HR, Levi M. Reversal of rivaroxaban and dabigatran by prothrombin complex concentrate: a randomized, placebo-controlled, crossover study in healthy subjects. Circulation. 2011;124(14):1573–9.CrossRefPubMed
31.
Wanek MR, Horn ET, Elapavaluru S, Baroody SC, Sokos G. Safe use of hemodialysis for dabigatran removal before cardiac surgery. Ann Pharmacother. 2012;46(9):e21.CrossRefPubMed
32.
van Ryn J, Stangier J, Haertter S, Liesenfeld KH, Wienen W, Feuring M, et al. Dabigatran etexilate-a novel, reversible, oral direct thrombin inhibitor: interpretation of coagulation assays and reversal of anticoagulant activity. Thromb Haemost. 2010;103(6):1116–27.CrossRefPubMed
33.
Dager WE. Using prothrombin complex concentrates to rapidly reverse oral anticoagulant effects. Ann Pharmacother. 2011;45(7–8):1016–20.CrossRefPubMed
34.
Bershad EM, Suarez JI. Prothrombin complex concentrates for oral anticoagulant therapy-related intracranial hemorrhage: a review of the literature. Neurocrit Care. 2010;12(3):403–13.CrossRefPubMed
35.
Holland L, Warkentin TE, Refaai M, Crowther MA, Johnston MA, Sarode R. Suboptimal effect of a three-factor prothrombin complex concentrate (Profilnine-SD) in correcting supratherapeutic international normalized ratio due to warfarin overdose. Transfusion. 2009;49(6):1171–7.CrossRefPubMed
36.
Goldstein JN, Refaai MA, Milling TJ Jr, Lewis B, Goldberg-Alberts R, Hug BA, et al. Four-factor prothrombin complex concentrate versus plasma for rapid vitamin K antagonist reversal in patients needing urgent surgical or invasive interventions: a phase 3b, open-label, non-inferiority, randomised trial. Lancet. 2015;385:2077–87.CrossRefPubMed
37.
Monte AA, Bodmer M, Schaeffer TH. Low-molecular-weight heparin overdose: management by observation. Ann Pharmacother. 2010;44(11):1836–9.CrossRefPubMed
38.
Bordes J, Asencio Y, Kenane N, Fesselet J, Meaudre E, Goutorbe P. Recombinant activated factor VII for acute subdural haematoma in an elderly patient taking fondaparinux. Br J Anaesth. 2008;101(4):575–6.CrossRefPubMed
39.
Mayer SA, Brun NC, Begtrup K, Broderick J, Davis S, Diringer MN, et al. Efficacy and safety of recombinant activated factor VII for acute intracerebral hemorrhage. N Engl J Med. 2008;358(20):2127–37.CrossRefPubMed
40.
Morgenstern LB, Hemphill JC 3rd, Anderson C, Becker K, Broderick JP, Connolly ES Jr, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2010;41(9):2108–29.PubMedCentralCrossRefPubMed
41.
Holbrook A, Schulman S, Witt DM, Vandvik PO, Fish J, Kovacs MJ, et al. Evidence-based management of anticoagulant therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e152S–84S.PubMedCentralPubMed
42.
Baglin TP, Keeling DM, Watson HG. Guidelines on oral anticoagulation (warfarin): third edition-2005 update. Br J Haematol. 2006;132(3):277–85.CrossRefPubMed
43.
Harrigan MR, Rajneesh KF, Ardelt AA, Fisher WS 3rd. Short-term antifibrinolytic therapy before early aneurysm treatment in subarachnoid hemorrhage: effects on rehemorrhage, cerebral ischemia, and hydrocephalus. Neurosurgery. 2010;67(4):935–9.CrossRefPubMed
44.
Schuette AJ, Hui FK, Obuchowski NA, Walkup RR, Cawley CM, Barrow DL, et al. An examination of aneurysm rerupture rates with epsilon aminocaproic acid. Neurocrit Care. 2013;19(1):48–55.CrossRefPubMed
45.
Starke RM, Kim GH, Fernandez A, Komotar RJ, Hickman ZL, Otten ML, et al. Impact of a protocol for acute antifibrinolytic therapy on aneurysm rebleeding after subarachnoid hemorrhage. Stroke. 2008;39(9):2617–21.CrossRefPubMed
46.
Kurz A, Plattner O, Sessler DI, Huemer G, Redl G, Lackner F. The threshold for thermoregulatory vasoconstriction during nitrous oxide/isoflurane anesthesia is lower in elderly than in young patients. Anesthesiology. 1993;79(3):465–9.CrossRefPubMed
47.
Badjatia N, Strongilis E, Gordon E, Prescutti M, Fernandez L, Fernandez A, et al. Metabolic impact of shivering during therapeutic temperature modulation: the bedside shivering assessment scale. Stroke. 2008;39(12):3242–7.CrossRefPubMed
48.
Mokhtarani M, Mahgoub AN, Morioka N, Doufas AG, Dae M, Shaughnessy TE, et al. Buspirone and meperidine synergistically reduce the shivering threshold. Anesth Analg. 2001;93(5):1233–9.CrossRefPubMed
49.
Talke P, Tayefeh F, Sessler DI, Jeffrey R, Noursalehi M, Richardson C. Dexmedetomidine does not alter the sweating threshold, but comparably and linearly decreases the vasoconstriction and shivering thresholds. Anesthesiology. 1997;87(4):835–41.CrossRefPubMed
50.
Lysakowski C, Dumont L, Czarnetzki C, Tramer MR. Magnesium as an adjuvant to postoperative analgesia: a systematic review of randomized trials. Anesth Analg. 2007;104(6):1532–9.CrossRefPubMed
51.
Badjatia N, Kowalski RG, Schmidt JM, Voorhees ME, Claassen J, Ostapkovich ND, et al. Predictors and clinical implications of shivering during therapeutic normothermia. Neurocrit Care. 2007;6(3):186–91.CrossRefPubMed
52.
Mullner M, Urbanek B, Havel C, Losert H, Waechter F, Gamper G. Vasopressors for shock. Cochrane Database Syst Rev. 2004;(3):CD003709.
53.
Sookplung P, Siriussawakul A, Malakouti A, Sharma D, Wang J, Souter MJ, et al. Vasopressor use and effect on blood pressure after severe adult traumatic brain injury. Neurocrit Care. 2011;15(1):46–54.PubMedCentralCrossRefPubMed
54.
van de Beek D, de Gans J, McIntyre P, Prasad K. Corticosteroids for acute bacterial meningitis. The Cochrane database of systematic reviews. 2007;(1):CD004405.
55.
van de Beek D, Drake JM, Tunkel AR. Nosocomial bacterial meningitis. N Engl J Med. 2010;362(2):146–54.CrossRefPubMed
Metadata
Title
Emergency Neurological Life Support: Pharmacotherapy
Authors
Gretchen M. Brophy
Theresa Human
Lori Shutter
Publication date
01-12-2015
Publisher
Springer US
Published in
Neurocritical Care / Issue Special Issue 2/2015
Print ISSN: 1541-6933
Electronic ISSN: 1556-0961
DOI
https://doi.org/10.1007/s12028-015-0158-1

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