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Anti-seizure prophylaxis in critically ill patients with traumatic brain injury in an intensive care unit
K Sundararajan1, D Milne2, S Edwards3
1Staff Specialist, Intensive Care Unit, Royal Adelaide Hospital and Senior Clinical Lecturer, Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia.
Insights
Few traumatic brain injury patients received effective anti-seizure prophylaxis. Phenytoin levels fluctuated, and 18% experienced seizures, suggesting poor guideline adherence and need for improved dosing strategies.
Area of Science:
- Neuroscience
- Critical Care Medicine
- Pharmacology
Background:
- Traumatic brain injury (TBI) poses a significant risk for post-traumatic seizures.
- Effective anti-seizure prophylaxis is crucial for managing TBI patients.
- Current prophylaxis practices and their efficacy in TBI require evaluation.
Purpose of the Study:
- To determine the proportion of TBI patients receiving effective anti-seizure prophylaxis.
- To assess phenytoin level monitoring and therapeutic range achievement in TBI patients.
- To identify the prevalence of post-traumatic seizures in the studied TBI cohort.
Main Methods:
- Prospective observational study in a tertiary ICU.
- Inclusion of 125 TBI patients admitted between February 2012 and August 2013.
- Analysis of anti-seizure prophylaxis administration, phenytoin levels, and seizure occurrence.
Main Results:
- Only 13.6% of TBI patients received anti-seizure prophylaxis.
- Phenytoin levels were inconsistently maintained within the therapeutic range (40-80 µmol/l).
- 18% of TBI patients experienced post-traumatic seizures, indicating a high prevalence.
Conclusions:
- Suboptimal anti-seizure prophylaxis and phenytoin management in TBI patients.
- Poor adherence to guidelines may contribute to high seizure rates.
- Further research on optimal dosing and monitoring of anti-seizure medications in TBI is warranted.
Abstract:
The objectives of this prospective observational study were to determine the proportion of patients with traumatic brain injury who received effective anti-seizure prophylaxis. The study was conducted in a tertiary level ICU of a major trauma referral centre between February 2012 and August 2013. A total of 2361 patients were admitted to the ICU in this study period, of whom125 patients (index) with traumatic head injury were included in this study. The patients had a mean age of 45 years (SD=19), a mean score on the Glasgow Coma Scale of 9 (SD=4), a mean injury severity score of 27 (SD=13) and a mean APACHE III score of 55 (SD=27). Only 13.6 % (17 of 125) of patients were given anti-seizure prophylaxis and phenytoin levels were measured in 9.6% (12 of 125). Although all 12 patients achieved an effective concentration for phenytoin therapy (>40 µmol/l) after the loading dose, no patient had their target concentration consistently maintained in the recommended therapeutic range (40 to 80 µmol/l) throughout the seven-day monitoring period. There was wide fluctuation in phenytoin levels in the patients in this study. Twenty-two (18%) of the index patients had post-traumatic seizures, indicating a high prevalence for this study. Poor compliance with guidelines could possibly explain this phenomenon. Future studies are needed to look at the dosing and monitoring of phenytoin and/or alternative anti-seizure prophylaxis in patients with traumatic brain injury.
