NeuroWiseRx

     I had the distinct honor of being invited on to the one and only Pharmacy to Dose podcast last week talking about a topic which is so important to our day to day life in the NeuroICU – acute blood pressure control. Take a listen to the episode whenever you get a chance – we split it up into two parts, the first on the pathophysiology of blood pressure control in neurologic emergencies, and the second on the specific agents we use in this setting, how to dose them, and how to choose between them. It was a blast talking with Nick and I figured I would provide a snapshot of some of the things we talked about on the podcast. Nick nicely outlines the papers I mention in the podcast here , and I’ll give some additional thoughts below. So why do we care about this? Why is it that nearly every patient admitted to the NeuroICU, at least those with a vascular problem, get some strict SBP goal on admission rather than the universal MAP > 65 we usually see in the MICUs...

  I'm sorry to break this to you, but your ICU patient’s valproate (VPA) level may be lying to you. Hidden within the total valproate concentration you checked is the concentration that matters – the free concentration, which is pharmacologically active and primarily responsible for the CNS exposure to VPA 1,2 – but without peeking under the hood and directly measuring that free concentration, it is nearly impossible to predict exactly how much VPA your patient is exposed to. Because of this, dose adjustments made based on total concentrations have the risk of widely missing the mark. While altered protein binding with valproic acid is a well-known phenomenon especially in the setting of drug interactions like co-therapy with phenytoin, the extent to which protein binding can be altered in ICU patients is criminally underrecognized. Here we'll talk a bit about how VPA’s pharmacokinetics are unique, what factors influence its binding to albumin, why those factors matter...