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 whom 125 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 posttraumatic 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.

Background: Manufacturers of phenytoin injection recommend that it be given without dilution by direct IV injection. Direct IV injection presents well-recognised side effects which can be minimised by giving phenytoin as an infusion. Aim: To assess the stability of Phenytoin Injection (DBL) in sodium chloride 0.9% prepared for infusion in Viaflex bags and a Buretrol extension set. Method: Admixtures containing 3, 6 and 10 mg/mL of phenytoin were prepared in sodium chloride 0.9% and stored in Viaflex bags, extension sets and beakers exposed to air (controls) for 6 hours. The concentration of phenytoin in the Viaflex bags was measured by UV absorption spectrophotometry. All the admixtures were inspected for microscopic particulate matter and the pH measured at intervals over 6 hours. Results: In the Viaflex bags there were no changes in the phenytoin concentration, minimal change in pH(< 0.1) and no particulate matter over 6 hours. In the extension sets and beakers, particulate matter was minimal at 2 hours and extensive beyond this time. There was an overall decrease of 0.30 and 0.32 pH units in samples from the extension sets and beakers. Conclusion: Phenytoin Injection (DBL) can be given as an IV infusion in sodium chloride 0.9% provided it is prepared in a Viaflex bag and infused within 2 hours of preparation.