45 Questions
What are the two primary objectives of therapeutic intervention in neurocritical care patients?
Identifying pertinent pathophysiologic and laboratory changes, and developing an evidence-based treatment strategy.
What is the primary goal of monitoring devices used in neurocritical care patients?
To develop and optimize treatment strategies.
What is the significance of a serum sodium level of 128 mmol/L in a neurocritical care patient?
It indicates hyponatremia, which may require therapeutic intervention.
What is the primary complication of acute aneurysmal subarachnoid hemorrhage (SAH) that requires close monitoring?
Hyponatremia and other electrolyte imbalances.
What is the role of the pharmacist in neurocritical care?
To develop and implement evidence-based treatment strategies.
What laboratory values are critical to monitor in neurocritical care patients?
Serum sodium, among other electrolyte and biomarker levels.
What is the significance of hospital day 4 in a neurocritical care patient?
It indicates the patient is in the acute phase of recovery and requires close monitoring.
What is the primary goal of therapeutic intervention in neurocritical care patients?
To prevent further injury and optimize patient outcomes.
What is the recommended limit for sodium increase in the first 24 hours to avoid osmotic demyelination syndrome?
No more than 12 mEq/L
What percentage of patients with subarachnoid hemorrhage (SAH) are prone to hypernatremia?
Up to 22%
What is the role of monitoring devices in developing an evidence-based treatment strategy?
They provide critical data to inform treatment decisions.
What is a potential complication of hypernatremia and hyperchloremia?
Acute kidney injury
What is the primary laboratory test used to diagnose hypernatremia?
Serum sodium
What is the primary characteristic of diabetes insipidus?
Decreased secretion of ADH or vasopressin
What is the typical urinary output in diabetes insipidus?
Voluminous (greater than 250 mL/hour), dilute
What is the primary goal of hypotonic solution therapy in hypernatremia treatment?
Free-water replacement
What is the role of vasopressin analogs in hypernatremia treatment?
Supplementation of ADH to normal functional concentrations
What is the endpoint for titrating vasopressin analog therapy in hypernatremia treatment?
Normalized urinary output, serum sodium, and urine specific gravity
What is the main difference in the success of ketogenic diet in pediatric patients versus adult patients?
Difficulty achieving ketosis in adults
What is the proposed mechanism of action of ketogenic diet in reducing seizures?
Increase sequestration of glutamate and decrease reactive oxygen species
What is the typical time frame for benefits to occur with ketogenic diet?
Within 1-3 months
What is the required ratio of fat to carbohydrate plus protein in ketogenic diet?
4:1 or 3:1 ratio
What is the purpose of continuous EEG monitoring in status epilepticus and RSE?
Necessary for status epilepticus and RSE
Why is it important to proactively monitor serum concentrations of certain agents?
To ensure adequate concentrations and mitigate the risk of toxicity
What is the purpose of vagus nerve stimulation in nonpharmacologic therapies?
As a nonpharmacologic therapy for seizures
What is the role of hypothermia in nonpharmacologic therapies?
As a nonpharmacologic therapy for seizures
What is the significance of surgical management in nonpharmacologic therapies?
As a last resort option when medical therapy fails
What is the primary trigger for muscle rigidity in patients with paroxysmal sympathetic hyperactivity (PSH)?
Pain
What is thought to be the primary cause of paroxysmal sympathetic hyperactivity (PSH) after brain injury?
Somatosympathetic activation and heightened activity of brain stem
What is the name of the tool used to determine the possibility of paroxysmal sympathetic hyperactivity (PSH) at a specific time?
PSH Assessment Measure
What is the primary function of baclofen IT in the treatment of paroxysmal sympathetic hyperactivity (PSH)?
Preventive therapy
What is the dose range of dexmedetomidine IV used as an abortive therapy for paroxysmal sympathetic hyperactivity (PSH)?
0.2-1.5 mcg/kg/hr
What is the primary mechanism of bromocriptine in the treatment of paroxysmal sympathetic hyperactivity (PSH)?
Preventive therapy
What is the dose range of gabapentin used in the treatment of paroxysmal sympathetic hyperactivity (PSH)?
100-300 mg three times daily up to 4800 mg/day
What is the primary mechanism of propranolol in the treatment of paroxysmal sympathetic hyperactivity (PSH)?
Preventive therapy
What is the primary goal of using dantrolene in the treatment of paroxysmal sympathetic hyperactivity (PSH)?
Abortive therapy
What is the approximate osmolality of Gentamicin when administered intraventricularly?
293 mOsm/kg
What is the common adverse effect of intraventricular administration of Amikacin?
Seizures
What is the daily dose of Vancomycin administered intraventricularly in adults?
10-20 mg
What is the volume of sterile water for injection used to administer Amphotericin B deoxycholate intraventricularly?
3 mL
What is the approximate osmolality of Polymyxin B when administered intraventricularly?
10 mOsm/kg
What is the common adverse effect of intraventricular administration of Colistimethate?
Meningeal inflammation
What is the daily dose of Daptomycin administered intraventricularly in adults?
5 mg
What is the common adverse effect of intraventricular administration of Tobramycin?
Seizures
What is the volume of normal saline used to administer Gentamicin intraventricularly?
1 mL
Study Notes
Neurocritical Care
- Neurocritical care patients require therapeutic intervention for acutely occurring pathophysiologic and laboratory changes after neurologic injuries.
- Monitoring devices are used to develop and optimize treatment strategies.
Hyponatremia
- Hyponatremia (serum sodium < 128 mmol/L) can occur after neurologic injuries and requires careful correction to avoid osmotic demyelination syndrome.
- Serum sodium correction should be limited to 12 mEq/L in the first 24 hours or less than 18 mEq/L in the first 48 hours.
Hypernatremia
- Hypernatremia (serum sodium > 150 mmol/L) is common in patients with neurologic injury, particularly in SAH (up to 22%) and TBI (up to 21%).
- Hypernatremia and hyperchloremia are associated with an increased risk of acute kidney injury.
- Diagnosis involves laboratory tests, including serum sodium, urine sodium, urine osmolality, urine specific gravity, and urine volume.
Treatment of Hypernatremia
- Hypotonic solutions for free-water replacement, such as dextrose 5% in water or 0.45% sodium chloride, are used to correct hypernatremia.
- Vasopressin analogs, like desmopressin, can be used to supplement ADH and normalize urinary output and serum sodium.
Monitoring
- Continuous EEG monitoring is necessary for status epilepticus and RSE.
- Proactive monitoring of serum concentrations is essential for agents like phenytoin and valproic acid to ensure adequate concentrations and mitigate toxicity risk.
Intraventricular Administration of Antimicrobials
- Various antimicrobials, such as vancomycin, gentamicin, tobramycin, amikacin, polymyxin B, colistimethate, and amphotericin B, can be administered intraventricularly.
- Each antimicrobial has a specific daily dose and osmolality.
Paroxysmal Sympathetic Hyperactivity (PSH)
- PSH is characterized by episodic increases in sympathetic nervous system activity, often triggered by pain, bladder distension, turning, tracheal suctioning, or unprovoked events.
- The pathophysiology of PSH is largely unknown but thought to be caused by somatosympathetic activation and heightened brain stem activity after brain injury.
- The PSH Assessment Measure is a tool used to determine the possibility of PSH at a specific time, consisting of the Diagnosis Likelihood Tool and Clinical Feature Scale.
Preventive and Abortive Therapies for Paroxysmal Sympathetic Hyperactivity
- Preventive therapies include baclofen IT, bromocriptine, clonidine, gabapentin, and propranolol.
- Abortive therapies include baclofen IT, dantrolene, dexmedetomidine, diazepam, fentanyl, morphine, and propranolol.
This quiz covers the concepts of neurocritical care, a specialized field of medicine that deals with the management of critically ill patients with life-threatening neurological injuries or diseases. It is suitable for medical students, pharmacists, and healthcare professionals.
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