Pharmacological Challenges in Neurocritical Care

Neurointensivists often face the challenge of providing care for critically ill patients with complicated medical conditions. Many pharmacological agents such as anticonvulsants, antimicrobials, anticoagulants, antiplatelets, sedatives, analgesics, hyperosmolar therapy, and neuromuscular blocking agents may need to be initiated or resumed in this setting. The already altered physiology of critically ill patients combined with factors such as obesity as well as interventions such as renal replacement therapy (RRT), extracorporeal membrane oxygenation (ECMO), and plasma exchange (PLEX) may lead to therapeutic failure or toxicity. It is therefore crucial for neurocritical care providers to be familiar with the pharmacokinetic and pharmacodynamic changes of commonly used medications in the neurocritical care setting and apply these principles to clinical practice. It is clear that optimal management of pharmacological agents in neurocritical care is challenging given altered physiology and non-pharmacological interventions listed above. Providing education on such topics and approaching patient care in a multi-disciplinary fashion where clinical pharmacists are actively involved is invaluable.