Pharmacy Pearls with Mike Perza

OVERVIEW

Pick up some pharmacy knowledge with host Dustin Slagle, MD, and guest Mike Perza, PharmD, BCPS, a clinical pharmacist in emergency medicine.

Buckle up for an episode packed with pearls on topics ranging from RSI medication management to hydroxocobalamin.

RSI– Rocuronium vs Succinylcholine
Although rocuronium has the benefit of not causing hyperkalemia like a depolarizing paralytic like succinylcholine there are other trade-offs¹:

• Small volume of distribution (drug rapidly reaches peak concentration and stays that way)
• Doses of rocuronium above 0.6-1.0 mg/kg hasten its onset–can be < 1 min
• Higher doses of rocuronium increase its time of action as a paralytic (which means it can be faster than your sedative)
• High doses can extend length of action by 90-120 min, which can be much longer than induction sedation

Intubation pharmacy package does not end at RSI–you need a plan for continued sedation and for possible resultant hypotension. This can be even more important when your paralytic can outlast your induction sedative.

More reading here of the mention PADIS guidelines–pharmacy guidelines for sedation of critically ill patients: https://pubmed.ncbi.nlm.nih.gov/30113371/ 

An Informed Discussion of the Benefits of Lytics in Ischemic Stroke
NINDS is one of the landmark studies informing our practice of using thrombolytics for ischemic stroke.

Read the paper for yourself, but one could highlight that the improvement seen in this study of 13% more good neurologic outcomes (via modified Rankin scale) at 90 days in the thrombolytic group have to be weighed against the increased ~6% increase in intracranial hemorrhage rate.³

Thrombolytics for acute ischemic stroke without contraindications against their use are standard of care, but every patient deserves an informed consent discussion if possible.

KCentra vs Andexanet Alfa for Reversal of Xa Inhibitors
Anexxa-I showed that andexanet alfa when compared to standard of care (85% received 4 factor PCC) had improved hemostatic efficacy (67 vs 53 %) but showed similar proportion of good neurologic outcomes–leaving the question open about when and how andexanet alfa should be used.⁴

A fixed dose of 4 factor PCC may be as effective as a weight based variable dose.⁵

Status Epilepticus Management
This discussion is not evidence based or meant to be guidelines for care, but rather to stimulate thought and conversation. Continue to read and apply physiological principles in an evidenced way.

Thoughts on When and When Not to Use Hydroxocobalamin
Again, a discussion to provoke thought. Look for the physiological evidence of carbon monoxide toxicity when thinking about using carbon monoxide antidotes.

Sources

1. Jain A, Wermuth HR, Dua A, et al. Rocuronium. [Updated 2024 Feb 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls. 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539888/
2. Devlin JW, Skrobik Y, Gélinas C, et al. Executive Summary: Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med. 2018;46(9):1532-1548.
3. National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995 Dec 14;333(24):1581-7.
4. Connolly SJ, Sharma M, Cohen AT, et al. - ANNEXA-I Investigators. Andexanet for Factor Xa Inhibitor-Associated Acute Intracerebral Hemorrhage. N Engl J Med. 2024;390(19):1745-1755.
5. Chiasakul T, Crowther M, Cuker A. Four-factor prothrombin complex concentrate for the treatment of oral factor Xa inhibitor-associated bleeding: a meta-analysis of fixed versus variable dosing. Res Pract Thromb Haemost. 2023;7(2):100107.