Assessment of Antishivering Medication Requirements During Therapeutic Normothermia: Effect of Cooling Methods.

Shivering during targeted temperature management (TTM) should be minimized because it can cause cerebral and metabolic stress. It has been proposed that surface cooling (SC) may result in more shivering than endovascular cooling (EC) methods. The purpose of this study was to compare antishivering medication requirements and degree of shivering in these groups during TTM to Normothermia (NT). This was a retrospective single-center cohort study of patients treated with protocolized TTM through SC and EC methods to achieve NT (37.0-37.5°C). The number of interventions and daily dose of antishivering medications, per institutional protocol, were compared between the two groups. The intensity of shivering was assessed with the Bedside Shivering Assessment Scale. Patients in the EC group (n = 23) had more antishivering interventions per patient day than those in the SC group (n = 43) (3.28 vs. 2.67, p = 0.002). Acetaminophen (81% vs. 59%, p < 0.001), buspirone (75% vs. 53%, p < 0.001), and magnesium infusions (52% vs. 36%, p = 0.012) were used on more patient days in the EC group. Patients treated with SC required more patient days of propofol (35% vs. 19%, p = 0.006) and higher average dexmedetomidine dosing per patient-day (0.70 vs. 0.56 µg/[kg·h], p = 0.03). Dosing of other medications was similar. There were no observed differences in degree or intensity of shivering. In our cohort, patients in EC group required more antishivering interventions, but less sedation, during TTM than patients in SC group. Optimizing nonsedating medications, such as acetaminophen, buspirone, and magnesium infusions, may decrease the requirement for sedatives to control shivering in both SC and EC.

Dabigatran-Associated Intracranial Hemorrhage: Literature Review and Institutional Experience.

Dabigatran etexilate is an oral direct thrombin inhibitor approved for prevention of stroke and systemic embolization in patients with nonvalvular atrial fibrillation and for the treatment of venous thromboembolism. Although dabigatran has a favorable safety profile, predictable pharmacokinetics, fewer drug interactions than warfarin, and does not require monitoring, clinical data regarding dabigatran reversal are limited. In addition, currently available laboratory assays allow measurement of the presence, but not extent, of dabigatran-associated anticoagulation. Patient age, renal function, weight, concurrent drug therapy, adherence, and concomitant disease states can affect dabigatran's efficacy and safety. Management of dabigatran-related intracranial hemorrhage must be approached on a case-by-case basis and include assessment of degree of anticoagulation, severity of hemorrhage, renal function, timing of last dabigatran dose, and risk of thromboembolic events. Initial management includes dabigatran discontinuation and general supportive measures. Oral activated charcoal should be administered in those who ingested dabigatran within 2 hours. Four-factor prothrombin complex concentrates (4PCCs), activated PCC, or recombinant activated factor VII use may be reasonable but is not evidence based. Reserve fresh frozen plasma for patients with dilutional coagulopathy. If readily available, hemodialysis should be considered, particularly in patients with advanced kidney injury or excessive risk of thromboembolic events. More clinical studies are needed to determine a standardized approach to treating dabigatran-associated intracranial hemorrhage. Institutional protocol development will facilitate safe, efficacious, and timely use of the limited management options.

Alternatives to sodium amobarbital in the Wada test.

OBJECTIVE: To review the literature and identify alternatives to sodium amobarbital for use in the Wada test. DATA SOURCES: A search of PubMed (1960-October 2010) was performed using the following key words alone or in combination: Wada test, intracarotid amobarbital procedure, intracarotid, intraarterial, sodium amobarbital, methohexital, Brevital, pentobarbital, etomidate, propofol, and alternative anesthetics. References of the identified articles were reviewed for relevant information. STUDY SELECTION AND DATA EXTRACTION: All articles in English identified from the data sources were evaluated. Review included comparative, prospective, and retrospective studies along with case series and case reports. DATA SYNTHESIS: Methohexital, pentobarbital, etomidate, and propofol have all been studied as alternatives to sodium amobarbital in the Wada test. Four controlled experimental trials, 1 uncontrolled experimental trial, 6 retrospective chart reviews, and 2 case reports were reviewed. Methohexital, pentobarbital, and propofol required a second injection due to their short duration of action. Etomidate was studied as a bolus injection followed by a continuous infusion until the critical speech and memory tests were administered, which differed from the standard Wada test procedure. Patients had an increased risk of seizures with methohexital, whereas 1 patient developed transient respiratory depression immediately after receiving pentobarbital. Furthermore, propofol caused increased tone with twitching and rhythmic movements, which interfered with the completion of the Wada test for 1 patient. All authors concluded that these agents were equivalent to amobarbital for the Wada test. CONCLUSIONS: Methohexital, pentobarbital, etomidate, and propofol are viable alternatives to sodium amobarbital for use in the Wada test, but each has shortcomings.