Ryan Grant

SICU/Trauma PharmD | 💊🌲☕️🏋🏻‍♂️ | Amateur 👨🏼‍🍳 | Taking risks & learning everyday | On a mission to see the 🌎#growthmindset #FOAMed #TwitteRx #MedTwitter

[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:

[Joanna He, PharmD, BCPS, BCCCP @JoannaHePharmD]

We're hiring an EM pharmacist at Ochsner LSU Health! Message me for more details. Residents graduating soon are welcome to apply as well! #TwitterRx

✅️ AMC
✅️ Level 1 Trauma Center
✅️ Comprehensive Stroke Center
✅️ ECMO Gold Center of Excellence

[MICROBIOLOGÍA - Hospital Clínico de Valencia @MicroClinicoVLC]

🦠Las infecciones por BGN-MDR son una amenaza global.
Revisión en Lancet 2025 actualiza:
🔬Mecanismos de resistencia: ESBL, AmpC, KPC, OXA-48, NDM
⚡Diagnóstico rápido: PCR, MALDI-TOF, genómica
💊Nuevo arsenal: cefta-avi, mero-bavor, imi-rele, cefto-tazo, cefe-enme, cefiderocol

[Ryan Grant @rg_pharmd]

@RaziaAliani I’d like a copy!

[Ryan Grant @rg_pharmd]

@PharmacyAcute C

[American College of Medical Toxicology @acmtmedtox]

Position Statement: ACMT Supports the Safe Use of #Acetaminophen in Pregnancy. Read our full statement here➡️https://t.co/gtZ8zvxLmu

@acog @MySMFM @AmerAcadPeds @SDBPeds

[Reads with Ravi @readswithravi]

A reminder:

[Ryan Grant @rg_pharmd]

Come work in a forward-thinking, fast-paced academic medical center with some great coworkers! Message me or @JoannaHePharmD if you’re interested

[Joanna He, PharmD, BCPS, BCCCP @JoannaHePharmD]

Internal medicine and MICU pharmacist openings at my hospital were just posted! We're an AMC, Level I Trauma Center, Comprehensive Stroke Center, and ECMO Center of Excellence with a PGY-1 pharmacy residency. Links in comments. Message me for details! #TwitteRx #PharmICU

[Joanna He, PharmD, BCPS, BCCCP @JoannaHePharmD]

Internal medicine and MICU pharmacist openings at my hospital were just posted! We're an AMC, Level I Trauma Center, Comprehensive Stroke Center, and ECMO Center of Excellence with a PGY-1 pharmacy residency. Links in comments. Message me for details! #TwitteRx #PharmICU

[Ryan Grant @rg_pharmd]

For all who want some #CE and to learn from some of the best in critical care (and hear my 2 cents on #antibiotics), come join us for the 4th annual SICEMs conference May 3rd! #criticalcare #continuinged #MedEd

[Ryan Grant @rg_pharmd]

@PharmacyToDose Love this series-great reviews! Strong work Nick!

[Ryan Grant @rg_pharmd]

@PharmacyToDose @GilbertPharmD @PCC_PharmD @Miano81 For multi-compartmental ICH, would you consider using andexxa?

[Ryan Grant @rg_pharmd]

Can’t wait to listen!

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

🚨NEW POD ALERT🚨
Rapid Reaction: ANNEXA-I
https://t.co/3zPUDWF38O

Where did hemostatic efficacy definition come from? 🧠
When did they reconstitute andexanet alfa? 💉
Balancing efficacy and safety ⚔️
Summarize protocol amendments (7 pages worth!) 📜
Questions we still need answered 🤔

More to come on this trial, but wanted to record some thoughts after the release

https://t.co/22L2k5pvQh

https://t.co/VKHShWc89G

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

🚨NEW POD ALERT🚨
Rapid Reaction: ANNEXA-I
https://t.co/3zPUDWF38O

Where did hemostatic efficacy definition come from? 🧠
When did they reconstitute andexanet alfa? 💉
Balancing efficacy and safety ⚔️
Summarize protocol amendments (7 pages worth!) 📜
Questions we still need answered 🤔

More to come on this trial, but wanted to record some thoughts after the release

https://t.co/22L2k5pvQh

https://t.co/VKHShWc89G

[Tony Breu @tony_breu]

1/14
How do diuretics lead to metabolic alkalosis?

I often invoke "contraction alkalosis", typically as a hand-wave explanation as patients' bicarbonate increases with diuresis.

Should I continue to wave my hands?

[David Goggins @davidgoggins]

While it is great to have an opinion and stand for something, you best be sure your shit is tight before you verbalize it. The return blows that you will receive might just be a lot more damaging than the ones you threw!

Stay hard!

[𝗥𝗲𝘀𝘂𝘀𝗠𝗲𝗱 @ResusMed]

🚑 Shock Index (SI): A Vital Tool in Critical Care 🚑

1️⃣ Introduction:
The Shock Index is the ratio of heart rate to systolic blood pressure. It's a simple yet powerful tool to identify patients at risk of shock, a life-threatening condition where the body's organs don't receive enough oxygenated blood.

2️⃣ History:
First introduced in 1967, by Allgöwer and Buri, as a quick, noninvasive method to determine the degree of hypovolemia in hemorrhagic shock. It's been validated in various settings, from the battlefield to the emergency room, and has proven to be a reliable predictor of patient outcomes.

3️⃣ Patients & Usage:
Trauma Patients: Quick assessment of blood loss and severity.

Cardiac Patients: Helps in identifying heart-related shock.

Sepsis: Early detection of septic shock.

Pregnancy: Useful in assessing the risk of complications.

Pediatrics: Adapted for use in children with modified values.

4️⃣ How to Calculate:
SI = Heart Rate / Systolic Blood Pressure
Normal SI: 0.5 - 0.7
Elevated SI (>0.9): Increased risk of shock and mortality.

5️⃣ Advantages:
Easy to calculate.
Rapid assessment tool.
Guides resuscitation efforts.

6️⃣ Limitations:
Not a standalone diagnostic tool.
May vary with age, medications, and underlying conditions.

7️⃣ Conclusion:
The Shock Index is an essential part of modern emergency medicine. By providing a quick snapshot of a patient's physiological state, it enables timely intervention and can save lives.

🩺 Share this post with your fellow healthcare professionals to spread awareness about this crucial tool in trauma care! 🩺

[Ryan Grant @rg_pharmd]

“The entire academic medical system is based around not paying people what they’re worth”

[Dr. Glaucomflecken @DGlaucomflecken]

The residents have unionized

[Ryan Grant @rg_pharmd]

@jmwright432 @beth_simas Congrats!

[Ryan Grant @rg_pharmd]

@PlayStation any way I can get someone to chat with me about de-activating 2 step verification for my PS+ account? Your chat bot for support isn’t very helpful in resolving this matter