Seizures are a well-described complication of acute brain injury and neurosurgery. Antiepileptic drugs (AEDs) are frequently utilized for seizure prophylaxis in neurocritical care patients. In this review, the Neurocritical Care Society Pharmacy Section describes the evidence associated with the use of AEDs for seizure prophylaxis in patients with intracerebral tumors, traumatic brain injury, aneurysmal subarachnoid hemorrhage, craniotomy, ischemic stroke, and intracerebral hemorrhage. Clear evidence indicates that the short-term use of AEDs for seizure prophylaxis in patients with traumatic brain injury and aneurysmal subarachnoid hemorrhage may be beneficial; however, evidence to support the use of AEDs in other disease states is less clear.

Empirical dose reductions of VTE prophylaxis are infrequently used in underweight, critically ill patients. Further studies need to be conducted that assess the safety and efficacy of reduced-dose VTE prophylactic regimens in this population to determine if acceptable efficacy can be achieved, with lower risks of bleeding.

OBJECTIVE The inclusion of the pain management domain in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey now ties patients' perceptions of pain and analgesia to financial reimbursement for inpatient stays. Therefore, the authors wanted to determine if a quality improvement initiative centered on a standardized analgesia protocol could significantly reduce postoperative pain among neurosurgery patients. METHODS The authors implemented a 10-month, prospective, interrupted time-series trial of a quality improvement initiative. The intervention consisted of a multimodal, interdepartmental, standardized analgesia protocol with process improvements from preadmission to discharge. All neurosurgical-floor patients participated in the quality improvement intervention, with data collected on a systematically randomly sampled subset of 96 patients for detailed analysis. Patient-reported numeric rating scale pain on the first postoperative day (POD) served as the primary outcome. RESULTS Implementation of the analgesia protocol resulted in improved preoperative and postoperative documentation of pain (p < 0.001) and improved use of multimodal analgesia, including use of NSAIDs (p < 0.009) and gabapentin (p < 0.027). This intervention also correlated with a 32% reduction in reported pain on the 1st POD for all neurosurgical patients (mean pain scale scores 4.31 vs 2.94; p = 0.000) and a 43% reduction among spinal surgery patients (mean pain scale scores 5.45 vs 3.10; p = 0.036). After controlling for covariates, implementation of the protocol was a significant predictor of lowered postoperative pain (p = 0.05) on the 1st POD. This reduction in pain correlated with protocol compliance (p = 0.028), and a significant decrease in the monthly number of naloxone doses suggests improved safety (mean dose ± SD 1.5 ± 1.0 vs 0.33 ± 0.5; p = 0.04). Furthermore, a significant and persistent reduction in the pain management component of the HCAHPS scores suggests a durability of results extending beyond the life of the study (72.1% vs 82.0%; p = 0.033). CONCLUSIONS The implementation of a standardized analgesia protocol can significantly reduce postoperative pain among neurosurgical patients while increasing safety. Given the current climate of patient-centered outcomes, this study has broad implications for the continuum of care model proposed in the Affordable Care Act. Clinical trial registration no.: NCT01693588 ( clincaltrials.gov ).

The aim of the study is to examine the comparative effectiveness of unfractionated heparin 5000 units given subcutaneously two or three times daily and enoxaparin given 30 mg subcutaneously twice daily or 40 mg daily for the prevention of venous thromboembolism in burn patients. This is a retrospective cohort study conducted in adult burn patients admitted between January 1, 1998, and September 30, 2008, who received only one agent for prophylaxis against venous thromboembolism during their admission. The primary outcome was a symptomatic venous thromboembolism, defined as any lower extremity deep venous thrombosis or pulmonary embolism. A total of 1111 patients were included; 600 received heparin and 511 received enoxaparin. Five patients (0.45%) experienced a symptomatic venous thromboembolic event. All five events occurred in the heparin group (P = .07). Heparin patients were older, had a larger TBSA burned, and a longer length of stay. No incidences of heparin-induced thrombocytopenia were identified. In this retrospective study of burned patients, the authors report a low incidence of symptomatic venous thromboembolic events. All events occurred in patients receiving unfractionated heparin as prophylaxis; however, the number of risk factors for venous thromboembolism was also greater in this group. Future prospective studies are needed to determine definitive conclusions regarding appropriate chemical VTE prophylaxis and dosing regimens for burn patients.