Time plays a major role in seizure evaluation and treatment. Acute repetitive seizures and status epilepticus are medical emergencies that require immediate assessment and treatment for optimal therapeutic response. Benzodiazepines are considered the first-line agent for rapid seizure control. Thus, various routes of administration of benzodiazepines have been studied to facilitate a quick, effective, and easy therapy administration. Choosing the right agent may vary based on the drug and route properties, patient’s environment, caregiver’s skills, and drug accessibility. The pharmacokinetic and pharmacodynamic aspects of benzodiazepines are essential in the decision-making process. Ultimately, agents and routes that give the highest bioavailability, fastest absorption, and a modest duration are preferred. In the outpatient setting, intranasal and buccal routes appear to be equally effective and more rapidly administered than rectal diazepam. On the other hand, in the inpatient setting, if available, the IV route is ideal for benzodiazepine administration to avoid any potential absorption delay. In this article, we will provide an overview and comparison of the various routes of benzodiazepine administration for acute control of repetitive seizures and status epilepticus.
BackgroundAntiplatelet therapy is used to prevent stent thrombosis in intracranial stents, but the optimal dose of aspirin is unknown. This study sought to determine whether the degree of platelet inhibition with aspirin is affected by bodyweight as observed through a platelet reactivity assay.MethodsThis is a retrospective review of patients who underwent neurovascular stent placement and had a VerifyNow Aspirin assay result. The primary outcome was the correlation between the VerifyNow Aspirin result, bodyweight, and the initial dose of aspirin. Secondary outcomes included the impact of the VerifyNow P2Y12 result and of weight on the incidence of bleeding or a thrombotic event.ResultsOf the 142 included patients, 62.7% weighed ≥70 kg and 88.7% were initiated on aspirin 300–325 mg daily. 83.8% achieved a therapeutic VerifyNow Aspirin result. There was minimal correlation between the VerifyNow Aspirin result, bodyweight, and aspirin dose (R2=0.02). Between patients who weighed <70 kg versus ≥70 kg, there was no difference in the mean aspirin reaction units (ARU) (449 vs 435, p=0.32) or in the incidence of bleeding (28% vs 17.1%, p=0.14) or a thrombotic event (4% vs 5.3%, p=0.59). No patient experienced stent thrombosis and eight patients experienced in-stent stenosis. In a multivariate analysis, only the VerifyNow P2Y12 result predicted the development of either bleeding or a thrombotic event (p<0.01).ConclusionsBodyweight did not influence the likelihood of obtaining a therapeutic VerifyNow Aspirin result. The clinical utility of obtaining VerifyNow Aspirin assays for this patient population is unknown.
Background: Nimodipine improves outcomes following aneurysmal subarachnoid hemorrhage (aSAH) and current guidelines suggest that patients with aSAH receive nimodipine for 21 days. Patients with no difficulty swallowing will swallow the whole capsules or tablets; otherwise, nimodipine liquid must be drawn from capsules, tablets need to be crushed, or the commercially available liquid product be used to facilitate administration through an enteral feeding tube (FT). It is not clear whether these techniques are equivalent. The goal of the study was to determine if different nimodipine formulations and administration techniques were associated with the safety and effectiveness of nimodipine in aSAH.
Purpose
Evaluation of mechanisms used to cope with an i.v. fluid shortage to determine if prescribing habits were changed and if substitution of an i.v. dose of magnesium with an oral dose impacted patient outcomes.
Methods
A single-center, retrospective analysis of electronic medical record (EMR) alerts and medical records covering 6-month periods before and during an i.v. fluid shortage was conducted. Records of adult medical and surgical inpatients admitted during these periods who had an order for i.v. or oral magnesium were screened for inclusion. The primary outcome of part 1 of the study was the percent acceptance of drug shortage–related EMR alert recommendations associated with i.v. magnesium. The primary outcome of part 2 of the study was the change in serum magnesium concentration (SMC) after an i.v. or oral dose of magnesium was administered.
Results
Of the 7,476 EMR alerts generated during provider ordering of i.v. magnesium products, 4.8% resulted in the provider accepting the recommendation to switch to an oral alternative, 89% resulted in continuation of an i.v. magnesium order, and 6.2% resulted in order cancellation. Among patients who received magnesium doses, SMC values increased by a mean (SD) of 0.135 (0.08) mg/dL per gram of i.v. magnesium sulfate administered (n = 251), compared to an increase of 0.058 (0.08) mg/dL per 400-mg tablet of magnesium oxide administered (n = 42).
Conclusion
Acceptance of the EMR alert recommendations was low. Both i.v. magnesium sulfate and oral magnesium oxide are viable options for increasing SMC.
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