Trev J RN

ICU RN, Gamer, Father

[Trev J RN @TrevorJ37]

The very restricted access to @mlb viewing and @MLBTV puts out such a horrific product. The app is garbage, the feed is always lagging and slow. Need to be reimbursed for the lack of ability to view what I paid for

[Trev J RN @TrevorJ37]

@Castellani2014 Yesterday ❤️

[Trev J RN @TrevorJ37]

@Castellani2014 Undefeated with me in attendance 👀

[Trev J RN @TrevorJ37]

@Castellani2014 I bought tickets for tomorrow’s game before the Yankees series because I knew we caught them at the right time and still couldn’t beat them and now after tonight I don’t even want to go. It’s literally a 3 hr drive and I know it doesn’t even matter. This team sucks

[Trev J RN @TrevorJ37]

@Castellani2014 Didn’t add any power to this lineup and the overachievers from last year are underperforming this year

[Trev J RN @TrevorJ37]

@Castellani2014 WHAT ARE THOSE SWINGS!!!

[Trev J RN @TrevorJ37]

@cmccosky Who’s on track to start Friday then? Melton? Going to the game and have already seen Keider throw against KC.

[Trev J RN @TrevorJ37]

@TigersJUK Don’t lie to me 🥺

[Trev J RN @TrevorJ37]

McKinstry just not going to swing lololol

[Detroit Tigers @tigers]

WALK IT OFF KID

[Trev J RN @TrevorJ37]

@Castellani2014 Honestly believe he has to make all those diving plays because he’s so slow. And his a bottom 5% arm. Hes an awful fielder.

[Trev J RN @TrevorJ37]

@Castellani2014 So freaking bad man. Yesterday was brutal though too.

[Trev J RN @TrevorJ37]

@tigers W post tho. 🤷🏽‍♂️

[Trev J RN @TrevorJ37]

@totalwarsam242 @TigersJUK I know I just hate it. And of course short has a good game. 🤣

[Trev J RN @TrevorJ37]

@Castellani2014 Same for pretzel. Although I think pitch call was bad, but he made them pay 🤷🏽‍♂️

[Josh Farkas MD 💊 @PulmCrit]

Valproic acid is great for refractory agitated delirium.

🏆 Especially useful in patients with explosive/aggressive behavior in the context of a personality disorder (often exacerbated by delirium).

Candidates for VPA:
✅ Not pregnant
✅ No severe liver dz or history of hyperammonemia
✅ No major drug-drug interactions with VPA
✅ Didn't respond to antipsychotics +/- alpha-2 agonists (dexmedetomidine). This isn't a hard requirement, but generally VPA isn't usually a front-line agent.

Advantages of VPA:
👍 Cardiovascular stability
👍 Low risk of airway compromise (only mildly sedating)
👍 Antiseizure activity (e.g., can be used for sz prophylaxis in an agitated patient)
👍 Can be given IV or PO (1:1 conversion with immediate-release formulations)
👍 EM/ICU folks should be knowledgable and comfortable within it already

Disadvantages of VPA:
👎 Dosing requires a little more thought than most agents. For patients on this for more than a few days you want to check a VPA trough and adjust it using the Fraser equation (to account for albumin).
👎 Can cause a lot of side-effects (but most of these are due to *chronic* VPA, rather than just a few days of therapy)

Dosing
🎯 My preference is to use the same dosing regimen as for status epilepticus (40 mg/kg load max 3 grams, then 15 mg/kg/day in divided doses). You can up-titrate as needed while following VPA troughs if ineffective (max dose of 45 mg/kg/day).
🎯 Many studies have reported starting lower and up-titrating, but this delays its efficacy for 2-3 days.
🎯 Using more frequent doses (e.g., q6hr rather than q8hr) may avoid toxic peak levels while maintaining adequate trough levels.

This isn't an option I use a ton, but it's a terrific tool to have in your toolbox for agitated delirium that isn't responding to usual front-line treatments.

⚠️ VPA should be weaned off prior to hospital discharge (unless the patient is seen by psychiatry and they are intentionally recommending VPA as chronic outpatient therapy for bipolar disorder etc - which would be uncommon).

(more discussion on VPA pharmacology in the IBCC chapter on status epilepticus)

Recent article on this in NeuroCritical care here:

[Trev J RN @TrevorJ37]

@aaronemerson09 @TigersJUK Either way it’s crazy

[Trev J RN @TrevorJ37]

@aaronemerson09 @TigersJUK I mean I don’t disagree but I would think call up and send downs would be more gm based. Unless hinch tells him what to do. 🤷🏽‍♂️

[Trev J RN @TrevorJ37]

@TigersJUK Sent him down but kept short? What kind of fucking blackmail does that guy have on Scott Harris

[Trev J RN @TrevorJ37]

@DanielleKaatz I’m sure they will come out of it eventually 🤣