Aaron M. Cook

Purpose: Acute stroke patients can demonstrate either augmented renal clearance (ARC) or acute/chronic kidney injury, affecting their clearance of vancomycin. This study assessed the pharmacokinetic parameters of vancomycin in stroke patients. Methods: A single-center retrospective, observational, cohort study was conducted to assess pharmacokinetic parameters of vancomycin in stroke patients from June 2021 through June 2024. Evaluation of population pharmacokinetic parameters was completed using Lixoft Monolix Suite (2024R1). Analyses were performed comparing pharmacokinetic parameters among different stroke types and Augmented Renal Clearance in Trauma Intensive Care (ARCTIC) scores ≥6 vs. <6. Results: There were 95 patients included in this study. Forty-six patients (48.4%) presented with acute ischemic stroke, 49 (51.6%) had hemorrhagic stroke. The total daily dose of vancomycin was 27.2 ± 7.8mg/kg/day. Between ischemic and hemorrhagic stroke, differences were seen in clearance (4.36L/hr vs. 5.30L/hr; p=0.018) and AUC0-24 (518.9µg/mL*hr vs. 454.5µg/mL*hr, p=0.038). Patients with an ARCTIC score ≥ 6 had a significantly higher elimination constant (0.105hr-1 vs. 0.070hr-1, p<0.001), shorter half-life (7.3hr vs. 12.1hr, p<0.001), smaller volume of distribution (0.63L/kg vs. 0.70L/kg, p=0.026), and faster systemic clearance (5.46L/hr vs. 4.10L/hr, p<0.001) than patients with an ARCTIC score <6. Conclusions: In this study, patients with the hemorrhagic stroke subtype had significantly higher clearance and lower AUC0-24 compared to ischemic stroke. While the mean AUC0-24 in both groups was within goal range, likely indicating individualized dosing practices, there was high variability in AUC0-24 in this stroke population. This study demonstrates the need for close TDM of vancomycin in the stroke population.

Antiseizure medications (ASMs) are commonly used in the intensive care unit (ICU) and often exhibit pharmacokinetics that differ substantially from those in healthy volunteers or in the outpatient setting. Organ dysfunction, polypharmacy, exogenous devices, and greater severity of illness all influence ASM pharmacokinetics, dosing decisions, and monitoring parameters. It is essential for critical care clinicians to familiarize themselves with the pharmacokinetics, dosing considerations, effects of exogenous devices, and therapeutic drug monitoring (TDM)-all covered in this narrative review-to incorporate in their approach to ASMs in the critical care setting. We identified relevant literature from MEDLINE from inception to March 2026 related to ASMs in the ICU. Data on pharmacokinetics, dosing in the ICU, the effect of renal replacement therapy, extracorporeal membrane oxygenation (ECMO), and plasmapheresis (PLEX) on ASM exposure, and the role of TDM in the ICU were collected and summarized. Considerations for 15 ASMs (brivaracetam, cannabidiol, carbamazepine, cenobamate, clobazam, lacosamide, lamotrigine, levetiracetam, oxcarbazepine, perampanel, phenobarbital, phenytoin, topiramate, valproate, and zonisamide) were included in the review. Dosing considerations for TDM, including indications and target reference ranges, and specific settings such as organ dysfunction, illness severity, renal replacement therapy, ECMO, and PLEX are discussed. The use of ASMs in the ICU require a distinct approach from outpatient settings. Severity of illness, organ dysfunction and replacement devices, and frequent drug-drug interactions warrant tailored agent selection, dosing, and monitoring.

In 2006, the American College of Clinical Pharmacy (ACCP) issued a position statement recommending residency training as a prerequisite for entering direct patient care activities. Additional recommendations in 2013 added residency training as a prerequisite for providing direct patient care. Over the subsequent 12 years, patient‐level services by pharmacists expanded, and the frequency of team‐based care increased. The Educational Affairs Committee acknowledges these changes in education and clinical pharmacy practice and asserts that postgraduate year one (PGY1) residency training remains a prerequisite to prepare a pharmacist to provide comprehensive clinical pharmacy services. A postgraduate year two (PGY2) residency in specialty care is recommended for the provision of specialty care, recognizing the current system lacks the capacity to provide training for all. The 2025 committee adds the recommendation that completion of residency training is also necessary for the advancement of indirect patient care skills, and all programs should be accredited through standards‐based review. When residency training is not available, the committee recommends resident equivalency be achieved through professional development. The complexities of medication management necessitate residency training; therefore, the pharmacy profession needs to actively expand training programs and establish standards for alternative training models.

Objective: Pharmacists care for patients with intracranial bleeding such as those with subarachnoid hemorrhage (SAH) or subdural hematoma (SDH), although these bleeding events are often generically termed “head bleed.” This over-simplified term refers to a heterogeneous group of life-threatening intracranial hemorrhages, each with a distinctive etiology and treatment paradigm. Data sources: Common intracranial hemorrhage types were reviewed to identify the scope of this narrative review. Study selection and data abstraction: Relevant studies and guidelines pertinent to the selected topic were considered. Data synthesis: Various hemorrhage types such as intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), and SDH fall into the colloquialism of “head bleed.” However, these and other hemorrhage types are radiographically distinct and often require different management strategies. Surgical management is helpful in some of these situations (SDH, SAH) and limited in scope for others (ICH). Pharmacotherapy for reversal of coagulopathy and treatment of elevated intracranial pressure may be considered similar across the spectrum of intracranial bleeding pathologies, while other factors such as seizure prophylaxis and blood pressure control depend on the bleeding type. Relevance to patient care and clinical practice: Differences in the need for surgical intervention, neurologic monitoring, cerebral perfusion changes, risk of seizure, optimal blood pressure, and other clinical characteristics make each type of intracranial bleeding unique. Conclusions: Pharmacists should be aware of the differences in surgical and pharmacotherapy strategies among these intracranial hemorrhages to optimize care for this neurocritical care population.

Traumatic brain injury (TBI) is a prevalent cause of morbidity and mortality worldwide. A focus on neuroprotective agents to prevent the secondary injury cascade that follows moderate-to-severe TBI has informed the field greatly but has not yielded any viable therapeutic options to date. New strategies and pharmacotherapy options for neuroprotection continue to be evaluated, including tranexamic acid, progesterone, cerebrolysin, cyclosporin A, citicholine, memantine, and lactate. Biomarkers of injury that can aid in diagnosis and prognosis have also been elucidated and are incrementally being used in clinical practice. The spectrum of TBI severity has also gained increasing attention as it relates to mild TBI or concussion, blast injury, and subacute or chronic subdural hematomas. In this review, we review the pathophysiology, recent clinical trials, and future directions for acute TBI.

Precision medicine has the potential to have a significant impact on both drug development and patient care. It is crucial to not only provide prompt effective antiseizure treatment for critically ill patients after seizures start but also have a proactive mindset and concentrate on epileptogenesis and the underlying cause of the seizures or seizure disorders. Critical illness presents different treatment issues compared with the ambulatory population, which makes it challenging to choose the best antiseizure medications and to administer them at the right time and at the right dose. Since there is a paucity of information available on antiseizure medication dosing in critically ill patients, therapeutic drug monitoring is a useful tool for defining each patient's personal therapeutic range and assisting clinicians in decision‐making. Use of pharmacogenomic information relating to pharmacokinetics, hepatic metabolism, and seizure etiology may improve safety and efficacy by individualizing therapy. Studies evaluating the clinical implementation of pharmacogenomic information at the point‐of‐care and identification of biomarkers are also needed. These studies may make it possible to avoid adverse drug reactions, maximize drug efficacy, reduce drug–drug interactions, and optimize medications for each individual patient. This review will discuss the available literature and provide future insights on precision medicine use with antiseizure therapy in critically ill adult patients.