Lainie

Butler grad | Critical care pharmacist | Interested in trauma care & neuro 🧠👩🏼‍🔬💊

[Lainie @pharmD_lainie]

Last day at the U 🥹 officially a critical care pharmacist, time for a NAP🥳😴

[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:

[Lainie @pharmD_lainie]

Literally the most fulfilling intervention as a pharmacist is providing a warm blanket to a cold patient, like idec it’s not med related it’s SO wholesome.

Patients be making me BLUSH w their warm blanket praises 🤭

[Lainie @pharmD_lainie]

Had the privilege of presenting my PGY2 research project on VPA for agitation/delirium in neurosurg ICU patients at NCS last week.

Great week of learning and exploring sunny San Diego 😎

[Pharmacy To Dose: The Critical Care Podcast @PharmacyToDose]

🚨NEW POD ALERT🚨
2024 @neurocritical Annual Meeting
Thursday Mini-Recap #NCS2024

Highlighting 16 research posters presented at the conference!
All 16 poster images included in thread below

🟢 https://t.co/4k3MVF3BHg

[Pharmacy To Dose: The Critical Care Podcast @PharmacyToDose]

Research posters highlighted (4/4)

[Wendy Chang @EM_NCC]

Standing room only at #NCS2024 session on @brain_trauma penetrating #TBI guidelines.

Long awaited with useful algorithms including tool for assessing futility. Most importantly, advocates for aggressive surgical treatment and acknowledges challenges with prognostication.

[Nick Mark MD @nickmmark]

Pro-argument:
- better pharmacokinetics (longer acting, self taper) & anti-NMDA effects make PHB superior to BZDs
- less respiratory depression with PHB
- (limited) studies suggest PHB results in fewer additive meds & restraints, as well a 40% reduction in LOS

#CHEST2024

[Lainie @pharmD_lainie]

@cecilia_pharm Trauma season is ending ??

[Lainie @pharmD_lainie]

@cecilia_pharm Manifesting some good ECMO cases for u (& Jimmy) ✨

[Andrew Desio, PharmD BCPS BCCP BCCCP BCIDP @PharmDFarmD]

Underdose the phenobarb > blame the phenobarb for not working

Break the cycle! 10 mg/kg!

[Lainie @pharmD_lainie]

Me waiting for the team to need post paralytic sedation

[Mica Schachter, MD @neurona_critica]

Critical Care of Spinal Cord Injury Infographic

https://t.co/cOpnDcqT5P

@caseyalbin @aartisarwal @almuftifawaz @stephanamayer @rkchoi @DrKentris @gabifpucci @CritCareReviews @neurointensivos @nicuintheD @DanHarrisonMD @JennKimMDPhD #NeuroTwitter #Neurosurgery

[Brent C. Beckner PharmD, BCPS, BCCCP @BCB_PharmD]

What does a pharmacist even do anyways?

[Lainie @pharmD_lainie]

Plssss let today be the last time I take an MPJE for a longggggg time 🥴🙏🏻

[Lainie @pharmD_lainie]

@cecilia_pharm Yeaaaaa girllllll 🤠

[Lainie @pharmD_lainie]

Wydm there are 5 days left of residency

[✨neuron divergent EKG slayer MD✨ @fuqekgs]

What working in medicine is like

[zerotonin @fooshbby]

going to work at the hospital on a nice summery day

[Lainie @pharmD_lainie]

@katie_vanvleet It’s me I’m the hater