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All right, guys, welcome back. This
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is the Insights Podcast from Neuro
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Critical Care Society. As a reminder,
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the Insights Podcast is based on the
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on-call content, which is published
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online. It's a continually updated
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textbook with experts in the field
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reviewing all of the latest guidelines
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and up-to-date literature, and so we
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really invite you to check this out,
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but we are very, very thankful for our
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sponsors, Biogen and Cerebell, and now
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a word from our sponsor Time is brain
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when it comes to seizures. Cerebell
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Point of Care EEG empowers the bedside
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team to detect or rule out seizure
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activity in minutes. To learn more,
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visit Cerebellcom. All right, well,
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welcome back, Celia. It's been a while.
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Yeah, thanks for having me. Thanks for
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being here. This has been great. I'm
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happy to be back and do all of this
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again and have so much fun with
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neurocritical care. Love it So we left
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off when we were doing a date. a very,
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you know, core topic in neurocritical
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care, which is the management of acute
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ischemic stroke. And today, we're
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going to flip to the other side of the
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stroke coin, the sort of hemorrhagic
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stroke, and kind of go through, you
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know, the clinical approach to when
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this patient walks in the door. And so
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what I really want to emphasize in sort
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of starting out from the clinical
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perspective is that it is impossible to
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tell if a patient is having an ischemic
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stroke or hemorrhagic stroke just by
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looking at the patient. There's been a
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lot of effort to see, you know, is
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there, are there some more telltale
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signs like, are this, you know,
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intercrenal hemorrhage patients, are
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they more hypertensive? Are they
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sleepier? And while that might be true
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in some cases, it's not reliable. So
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again, this patient, like, just as
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you do for any ischemic stroke alert,
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the same principles apply for
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hemorrhagic stroke. And that's when you
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notice that a patient has Bocal deficit
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that you can localize. to one lobe of
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the hemispheres or the cerebellum, you
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really need to get, or brainstem, you
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really need to get that patient to the
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CT scanner to figure out if they are
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having an ischemic event and then
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qualify for all the therapy we talked
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about in the last two episodes, or if
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this is an ICH. And once you make that
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determination, then it becomes kind of
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an algorithm for the management of these
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patients upfront, the big focus being
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ABCs, which for these patients,
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obviously the airway and the breathing.
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But then we're thinking a lot about the
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circulation. And then that, I mean,
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they're blood pressure. And so Celia,
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I was wondering, since blood pressure
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control is really the mainstay of
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treatment for these patients, what are
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some clinical tips to take for the
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bedside when you're thinking about, how
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do I lower the blood pressure? How much
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do I lower the blood pressure? What
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agent is best for lowering the blood
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pressure? Since that's such a big
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decision for this patient population Um,
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There's a lot of debate, probably about
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what is the right target, and we can
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talk about that. I think before we get
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there, the new guidelines, the 2022
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ICH guidelines, talk about the fact
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that the sooner the better, and they
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specifically talk about that within two
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hours of ICH really want to get on the
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blood pressure control, and the idea is
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that you get them within the goal, then
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the first hour of starting your
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anti-hypertensive medication Now, what
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goal do we have in mind? I think not to
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go over all the details, but we have we
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had the ATAC trial and the Interact
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trial. I think there was a lot of
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debate Do. you do less than 180? Do
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you do less than 140? Guess what? The
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guidelines say 130 to 150 now. So I
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think 140 is what we typically kind of
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think about. And you know, there is
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also some discussion that in patients
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with mild to moderate ICH, getting the
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blood pressure less than 130 is going to
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be harmful it's just something to keep
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in mind. 130 to 150 is the goal. If
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they come in with blood pressure within
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150 to 220, I think it's a little bit
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more gray when people come in with blood
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pressure, more than 220, I think
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that's when we talk about do we do
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percentage reduction 10 to 15 from that
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initial presentation? You already know.
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But I think and patients are massive. I
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see it's again, like the evidence is
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gray. They don't have specific
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recommendations for the target. A lot
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of these patients have to go for
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surgical interventions and all that. So
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this is mostly for mild and moderate,
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ICH. Again, they don't come in with
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blood pressure of over 220. The target
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is 130 to 150. And don't get them below
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the 130 because that's harmful.
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And the next question is, okay, what
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agent do you use? I think just like
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anything in critical care, the basic of
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critical care I think management is that
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you want an agent that works really fast,
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that can be given IV and that also is
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easily titrateable, right? You don't
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want to give a drug that stays in the
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system forever and you can't really
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titrate or it's not quick onset. And
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based on that, I think the agents that
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come into mind, the agents that
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typically are used are
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IV neckardipine, which is quick onset,
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you know, it's easily titrateable.
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It's a calcium channel blocker. Another
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calcium channel blocker that some
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institutions may have is clovidipine.
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It's also quick on, actually quicker on,
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quicker off, that may be something that
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is nice about it, but it's expensive.
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Not a lot of institutions have that.
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And honestly, there are some
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retrospective reviews that look at these
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two agents and there is no difference in
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outcomes when they look at ICH expansion
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So if you don't have a clove at a pain,
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do not worry. And that cardopene is
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probably as great and it does the job.
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Um, what are the other agents, um,
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think IV, asthma, if your patient's
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heart rate can tolerate that because,
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you know, it is used for cerebral
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pressure, but it is a, uh, beta
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blocker and it can drop, um, heart
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rate to some degree. It's something to
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keep in mind. I'd be a libadol. If you
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don't have the capacity to do an
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infusion and you just need to use
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interim endoses, I'd be a libadol as a
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good option. Um, lastly, I kind of
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wanted to mention that although we talk
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about IV hydralisine, this is probably
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not the preferred agent end of studying
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You really don't want to use it unless
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you absolutely are out of all the other
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options, just because it is more
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unpredictable as far as the onset and
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the outcomes and the blood pressure
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management. So that's usually a last
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resort. And then something to also
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highlight is that you absolutely don't
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want to use your nitrates into studying
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agents and they can possibly increase
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ICP. I love that. I mean, I just
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would echo. I feel like hydralisine has
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such a, just really unpredictable
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effect and for some patients it drops
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them. much and others it doesn't do
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anything. The other thing I would say
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for these patients is if you have the
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capacity at your shop to put in an
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A-line that's really helpful you know
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most places you can give an A-line in
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really quickly and that allows for like
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the continual monitoring of this it
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makes it easier for the nurses to
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titrate this consistently you know we're
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not having big swings from you know
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taking the blood pressure really high
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and then dropping it too low then
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turning off the infusion and the blood
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pressure rises you know we want to have
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a controlled downslope to that target of
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130 to 150 if your patient is presenting
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with a blood pressure less than 220. I
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got to tell you like a lot of patients
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where I work coming with blood pressures
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way higher than 220 and for them we're
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doing exactly what Sally was saying
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which is just a percentage reduction so
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usually getting them down to like less
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than 180 less than 160 70 again because
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we're gonna harm their kidneys if they
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are just chronically useful. to seeing
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a very high blood pressure. And then we
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just box their kidneys. That leads to
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all sorts of like downstream
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consequences with sort of the AKI.
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And then you have to figure out this
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person and I populate it, right?
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Because the other thing that we can do
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to limit secondary brain injury is make
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sure that we are reversing any
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quagulopathy. So this gets tricky, so
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I'll walk us through one of the
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guidelines, say, how am I going to
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even determine if the patient's on a doe
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act if there's not family around? This
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gets kind of complicated
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If you're right on, it's very
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complicated. I think a few maybe
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principles to think about, and then
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hopefully that can help us. I think
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number one is that if you have any
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suspicion that this patient's on
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anti-regulation, do not wait for any
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levels to come back before reversing
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them. This is true for everything, for
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a boyfriend, doe acts, all the things,
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and we'll go through the specifics of
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all of that if you know when they take
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it that's amazing and you can figure out
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when was the last dose and think about
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did they even you know qualify to be
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reversed. So now walking through how we
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decide where do we go from here again I
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think for the majority of these agents
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something that I keep talking about in
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teaching in our unit is that I go by the
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rule of 48 hour mark meaning 48 hours
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pretty safe to think about these
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patients should be reversed. Again I
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think this is a multidisciplinary
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discussion but I think for the majority
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of agents 48 hours is probably a good
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time frame to have in mind and that's
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really based on three to five half lives
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of these drugs given that the half life
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ranges from 10 to 12 hours for the
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majority of these agents again in a
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patient with normal renal function.
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I wanted to kind of walk us through
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individual agents, so let's start with
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Warfarin maybe. Again, we don't see
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Warfarin as much as we used to, which
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is nice, but I think there's a time
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that evidence really kind of suggests
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that you have to wait for INR to come
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back before you reverse people. There
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is plenty of literature now talking
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about fixed dosing of four factor PCC,
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meaning for IC agencies cases, you can
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just give a fixed dose and you don't
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really have to worry about these people,
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the INR coming back to reverse that.
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Now, the target INR is less than 14,
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so if you're INR still above 14 after
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that fixed dose and you're still
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concerned, you can think about a
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supplemental dose. Again, this could
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be a discussion with the team based on
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risk factors and everything else. So
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again, no need to wait for INR. You
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have that capability to do a fixed dose
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four factor PCC. Now, what about
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Heparin or Lobenox, Prodomenis, the
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agent of choice? I think that one's a
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little bit easier. just because a lot
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of people are familiar with that. And
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then we get to the 10A inhibitors,
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right? It picks a band, right rocks a
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band, docks a band, all those fun
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agents that we see more and more these
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days. So this is where I think it gets
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controversial. And I think this is
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controversial.
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So much controversy. So I can, again,
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I think because the evidence isn't there,
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I'll tell you what I have seen from
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evidence and what we do and all of that
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But again, very controversial, just
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like Casey said, I think you can talk
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to 10 people in one room and everyone
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will give you a different answer. I
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think the evidence, though, is that we
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do not have any head-to-head trials
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looking at these two agents, K-Central,
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which is four-factor PCC and index in it,
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in the same population, the same kind
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of randomized trial. And there is some
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hope that even ongoing trial that is
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gonna get published soon and hopefully
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that will answer some of those questions.
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But we don't have anything yet. Now,
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some institutions have looked at their
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experience, meaning they looked at case
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center alone and they looked at indexing
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it alone. And they published their
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outcomes. And guess what? What we know
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from these, again, retrospective. So
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we have to think about that. What we
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know is that the efficacy is probably
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comparable. Again, I say probably
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because they look at different
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definitions of ICH hemostasis. They had
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different patient populations and all of
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that. And it was not randomized and all
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of that But then one thing that also we
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found out was that quesentra was
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associated with a lower risk of
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thrombosis. So as of now, the
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retrospective studies that are published,
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again, retrospective, that's the key
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here, they saw thrombosis of around 4
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to 5. And then fixed ICH was a big
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study that came from the neurocrotable
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care society. And then for the index
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and the index of thrombosis, or
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actually reported a higher rate, about
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10 risk of thrombosis. So that's just
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something to keep in mind. I think to
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me, whatever you have in your
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institution that is faster, you have a
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protocol for it, you know that you can
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activate that process and you can get
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the approval and you can get that
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situation and that ball rolling fast,
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that's what I would do. And one
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piece of information to also share is
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that people ask about, okay, you are
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saying that do not send for any levels
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before reversing people. I still to
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this date, I believe in that, if your
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suspicion is high, you don't want to
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send 10A levels, you don't want to send
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INR, any of that. People ask about
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what about, especially with indexing,
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if you send 10A levels after, you
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really should not. The idea is that,
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you know, in the annex of four, they
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actually had calibrated 10A levels for
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the agent that they were looking at So
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it picks a band, right rocks a band,
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all of that. And a lot of institutions
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don't have that. And even an exophore
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showed that majority of people's 10A and
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I'm sorry, levels got reduced, but not
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everyone's level got reduced. So the
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idea was that if you achieve hemostasis
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with your ICH and that's confirmed,
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then you're done. Totally, I think
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that's such great advice. Give whatever
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is available fastest, right? If that's
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four factor PCC, just give that. You
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know, the dosing for that, sort of we
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are using 25 to 50 international units
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for KG. Sally, is that what y'all are
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using as well? Are we talking about
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Warfarin Reversal or DOAC reversal?
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Sorry, for DOAC reversal. So we
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actually have a fixed dosing now, which
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is making it really easy. So for
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Warfarin Reversal, we have 1, 500
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units. And for based on body weight,
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obviously, it's a little bit more
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complicated than that, meaning there's
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a threshold of body weight below and
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above, but 1, 500 is universally what
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we eat for typical average people. And
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then for DOA Act related, ICA for use
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2000 units. That's awesome. I think
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whatever we can do to simplify this
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process, the point is don't wait until
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this patient's rolling through the door
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to make a decision about how you're
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going to reverse. Know what your
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hospital's policy is, like from the
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beginning. Know what people are
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comfortable with, what the pharmacist
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is comfortable with, how long it's
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gonna take to get these agents to
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bedside before you're actually in the
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moment dealing with these patients
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All right, so we have, we've
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identified the bleed, we have
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controlled their blood pressure, we
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have addressed whether or not they're
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antifigulated and have appropriately
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reversed them. The final thing to sort
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of think about in the upfront management
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of these ICH patients is whether or not
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there is probable ICP issues or
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hydrocephalus.
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Many of our patients who have deep basal
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ganglia or phthalamic bleeds will also
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have IVH Not every single IVH needs an
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external ventricular drain, but a lot
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of patients do. I think that's when you
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really need close collaboration with a
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neurosurgical colleague. So we know
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that that type of surgical intervention
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really is life-saving for many patients.
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Surgical options beyond just placing an
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EVD for hydrocephalus management,
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that's a little trickier The trials
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really have not been definitive that we
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help people with surgical treatments.
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We keep trying to find who is the right
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patient population? What's the right
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time? What is the right surgical
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technique? How do we make this most
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minimally invasive? Again, work
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closely with your neurosurgical
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colleagues for this patient population.
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We're gonna
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spend a whole episode talking about sort
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of medical management of intracranial
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pressure. So we'll skip that now. Just
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kind of keep in mind, like, does this
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patient look like they're getting sleepy?
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Is there evidence of uncle or
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trans-tentorial herniation? And then
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think about how am I gonna - And write
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that. All right, so yeah, so any like
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parting wisdom in terms of ICH
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management, take away points? I think
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this covered at all. I think just to
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highlight an echo that time is brain
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really, whatever you can do to fastest
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blood pressure management, I think
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reversal into studying of AC related ICH,
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those two really should happen kind of
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hand-in-hand. Just one thing to
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highlight also that and all the studies
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that looked at. I see for versatile
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understanding of anti-quagulation. Not
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a lot of them actually report a blood
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pressure management in that timeframe.
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So that's just one thing to think about
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whenever you're looking at these trials,
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are they reporting blood pressure? What
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was the blood pressure? What was that
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range during that first six hours,
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which is the initial expansion and
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damage happened. So some of those
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pearls, but I think hopefully this can
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help people with their initial
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managementization to ED or other ICUs
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are being neurocritical care unit, if
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you're new and you wanna learn the
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basics and the pearls, I think
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hopefully this is helpful. I love it.
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All right, we'll be back with another
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episode, this time focused on
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intracranial pressure, and so we hope
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you will stick around and join us. And
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again, thanks so much for listening.