Camille Casillas, a PGY2 Critical Care Pharmacy resident at MD Anderson, and Sarah Sindelar, also a PGY2 at Nebraska Medicine and an active voice on Twitter, dive into vital literature from July 2024. They discuss the TRACE III trial's impact on stroke protocols and innovative anticoagulation practices. The conversation shifts to the management of opioid-induced constipation with naloxegol versus methyl naltrexone. With a light-hearted mention of college football loyalty, they weave critical care insights into an engaging narrative.
The TRACE-3 trial indicates that administering tenecteplase within a 4 to 24-hour window significantly improves outcomes for acute ischemic stroke patients without access to thrombectomy.
Results from the CONVINCE trial showed low-dose colchicine did not significantly affect stroke outcomes, yet it reduced C-reactive protein levels, hinting at possible anti-inflammatory properties.
Early pharmacist intervention in anticoagulant therapy significantly increased guideline-recommended use, demonstrating the critical role pharmacists play in optimizing patient medication management.
Deep dives
Extended Treatment Windows for Acute Ischemic Stroke
Intravenous thrombolytic treatment, specifically with tenecteplase, is explored for acute ischemic strokes beyond the traditionally accepted treatment window of 4.5 hours. The TRACE-3 trial focused on administering tenecteplase within a 4 to 24-hour window for patients without access to mechanical thrombectomy. Results showed a significant increase in the absence of disability at 90 days among patients treated with tenecteplase compared to standard therapy. This trial highlights the need for further research into the efficacy of extended window treatments for large vessel occlusion strokes, particularly in populations lacking access to timely interventional procedures.
Colchicine's Role in Stroke Management
The CONVINCE trial evaluated the use of low-dose colchicine in patients with transient ischemic attacks or non-severe strokes, aiming to see if it could reduce composite cardiovascular events. Enrolled participants received either colchicine combined with usual care or just the usual care alone. Despite the anticipated benefits, the trial found no significant difference in the primary outcomes between both groups. However, a notable finding was the reduction in C-reactive protein levels with colchicine treatment, suggesting potential anti-inflammatory benefits that warrant further exploration in future studies.
Pharmacist Interventions in Anticoagulation Therapy
Research from Canada assessed early versus delayed pharmacist intervention in optimizing oral anticoagulant therapy for stroke prevention in patients with atrial fibrillation. The study highlighted significant increases in guideline-recommended anticoagulation use when pharmacists were involved early in the treatment process. Despite COVID-19-induced recruitment challenges, the trial's findings showed early pharmacist intervention effectively led to increased appropriate anticoagulant initiation. This suggests the potential of enhanced pharmacist roles in improving patient outcomes through timely medication management.
Optimizing Seizure Prophylaxis in Traumatic Brain Injury
In a study evaluating levetiracetam dosing regimens for patients with traumatic brain injury, variations in pharmacokinetics necessitated reassessing standard dosing recommendations. The research indicated that common dosing strategies might not achieve adequate serum levels in patients experiencing augmented renal clearance. Results showed that patients given aggressive dosing of levetiracetam exhibited significantly higher trough concentrations, indicating a need for reevaluation of seizure prophylaxis approaches in this population. This study provides valuable insights into tailoring medication regimens for patients with unique pharmacokinetic profiles.
Impact of Sedation Practices in Critical Care
The role of sedation in the ICU setting took a new turn with findings suggesting increased rates of deep sedation during the pandemic. A retrospective study indicated that not only did deep sedation practices persist, but they escalated in later phases of the pandemic, raising concerns about potential oversedation in critical patients. Although previous guidelines leaned toward lighter sedation, the shift observed in this research indicates the need for ongoing reassessment of sedation protocols and practices to align with patient safety standards. The findings emphasize the delicate balance between adequate sedation for patient comfort and the risk of adverse outcomes associated with deeper sedation.
Addressing Constipation in Opioid Use
A retrospective study compared two peripheral mu-opioid receptor antagonists, naloxagol and methyl naltrexone, for treating opioid-induced constipation in ICU patients. Results demonstrated that naloxagol provided comparable time-to-bowel movement outcomes while being more cost-effective compared to methyl naltrexone. The study affirmed that both agents are effective in managing constipation, but naloxagol's lower cost presents a practical advantage for use in clinical settings. These findings highlight the importance of addressing opioid-induced constipation proactively to improve patient outcomes in critical care environments.
