In this episode I’ll:
1. Discuss an article about using propofol for toxin-related seizures.
2. Answer the drug information question “Should SSRIs be stopped in a patient with GI bleeding?”
3. Share a resource for critical care related information.
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Article
Propofol Use for Toxin-Related Seizures
Lead author: F. Lee Cantrell
Published in Pharmacotherapy June 2016
Background
This article is a review of records from a poison control center. For some reason I’ve been finding a lot of these articles lately. I think this type of article is a great way to publish real world experience to help inform clinicians in areas that are not well studied.
Propofol is FDA approved for use as a sedative, but it also has anticonvulsant properties. Whether propofol is effective as treatment for toxin-induced seizures is unknown.
Purpose
The authors sought to characterize the use of propofol for toxin-related seizures as reported to a statewide poison system.
Method
The study was a retrospective review of the electronic records from the California Poison Control System from 2009 to 2012. Patients were included if they were ≥ 18 yrs, and their record was coded with “seizure” and contained the term “propofol.” The authors collected patient age, sex, reported toxin(s) involved, recurrence of seizure activity following/during propofol use, and mortality data.
Result
235 poisoned patients who received adjunctive propofol therapy were included in the review. The age range was 18–82 years and 53% of the patients were female. A total of 155 different toxins were reported. Recurrent seizures occurred in 15.7% of cases following propofol administration. The mortality rate was 6.8% in cases with known outcomes.
Conclusion
The authors concluded that:
Propofol is being used as an anticonvulsant in poisoned patients and appears to have some utility as an adjunct in terminating toxin-related seizures once airway control has been established. Less clear, however, is at what point propofol therapy should be initiated. Prospective controlled studies are warranted to identify the role of propofol in controlling toxin-induced seizures.
Discussion
Several case reports of successful propofol use for toxin-related seizures are referenced within the article. It should be noted that with all patients in this study, propofol was never used as monotherapy for seizure; it was always an adjunctive therapy. Also, all but 1 of the 235 patients was intubated at the time propofol therapy was initiated.
Curiously absent from the study was any speculation that the lipid emulsion vehicle that propofol is delivered in might have played a part in the 84% efficacy rate. Lipid emulsion does reverse the cardiac and CNS effects of local anesthetic systemic toxicity. The most common toxin in the study population was bupropion which was the toxin in the first non-anesthetic case report of lipid emulsion for cardiac toxicity.
Drug information question
Q: Should SSRIs be stopped in a patient with GI bleeding?
A: Maybe if they are still bleeding.
This is a recent question I had & posed in the Pharmacy Nation Slack group…So shout out to me for the question and Pharmacy Pamela, Pharmacy Rene & Pharmacy Aaron for the answers!
I encountered a patient with a GI bleed on hospital day 2. They were on clopidogrel and escitalopram at home. The clopidogrel was held on admission, but the escitalopram was given on hospital day 1 (for an unknown reason the patient was not made NPO). On hospital day 2 the patient was having continued GI bleeding.
The discussion in the Slack group involved whether it was worth causing withdrawal by stopping the SSRI, if the bleeding was recurrent, & whether to switch off of escitalopram after the patient stabilized. Pharmacy Aaron provided a great article relevant to the discussion from 2007 titled: Influence of antidepressants on hemostasis.
Resource
Life In The Fast Lane’s Critical Care Compendium is a comprehensive collection of pages concisely covering the core topics and controversies of critical care.
At the LITFL website there is a searchable index of the compendium of critical care topics. Each page has references linked and a “Reviewed and revised” date so you can get a sense of how current the information might be.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
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