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Episode 100: INSIGHTS - Analgesia & Sedation

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Description

Listen to the next episode of NCS' INSIGHTS series, this time on Analgesia and Sedation. 

The INSIGHTS series is hosted by Casey Albin, MD and Salia Farrokh, PharmD, and covers different topics from Neurocritical Care ON CALL®, the only up-to-date, comprehensive resource to offer content exclusively dedicated to the practice of neurocritical care. Learn more about ON CALL®.

This episode is sponsored by ceribell.

Time is brain when it comes to seizures. Ceribell Point of Care EEG empowers the bedside team to detect or rule out seizure activity in minutes. To learn more, visit ceribell.com.

The NCS Podcast is the official podcast of the Neurocritical Care Society.

Contributors

  • Salia Farrokh, Pharm.D., BCPS, BCCCP

    Salia Farrokh, PharmD, BCPS, BCCCP is a neuro ICU clinical pharmacist specialist at Johns Hopkins Hospital. Dr. Farrokh received her PharmD degree from Saint John Fisher College, Wegmans School of Pharmacy in Rochester, NY. Her postgraduate training includes residencies in Critical Care and Pharmacy Practice at Yale-New Haven Hospital. Dr. Farrokh’s research interests include effective antiplatelet therapy in neuro intervention patients, optimal pain management in neuro ICU patients, and use of neurostimulants in this setting. Dr. Farrokh is passionate about training and precepting students and residents and is a certified ENLS trainer.

  • Casey Albin, MD

    Casey Albin, MD is an Assistant Professor at Emory University School of Medicine where she is a member of the department of Neurocritical Care. She completed both her neurology residency and a fellowship in Medical Simulation at Harvard Medical School/BWH/MGH. She completed Neurocritical Care fellowship at Emory. Dr. Albin’s research interests focus on educational innovations in acute neurologic emergencies and neurocritical care. In addition to running simulation courses, she is the editor of a best-selling textbook The Acute Neurology Survival Guide and is passionate about open access neurologic education through Twitter, blogs, and podcasts. She serves on the Education Committee of the Neurocritical Care Foundation.

  1. 00:00:19
    All right, well, welcome back,
  2. 00:00:20
    everybody, as a reminder, this is the
  3. 00:00:22
    Insights podcast. Insights is a podcast
  4. 00:00:25
    that's based on the on-call content
  5. 00:00:27
    that's published through neurocritical
  6. 00:00:29
    care society. It's available on the
  7. 00:00:31
    website to subscribers. We are only
  8. 00:00:34
    going to focus on just a couple of the
  9. 00:00:35
    updates from these awesome chapters, so
  10. 00:00:37
    we really invite all of the listeners to
  11. 00:00:40
    check out the full chapters, which have
  12. 00:00:42
    a much more depth coverage We are
  13. 00:00:45
    sponsored by Biogen and Sarah Bell, and
  14. 00:00:47
    now a word from our sponsor. Time is
  15. 00:00:49
    brain when it comes to seizures. Sarah
  16. 00:00:51
    Bell point of care EEG empowers the
  17. 00:00:54
    bedside team to detect or rule out
  18. 00:00:56
    seizure activity in minutes. To learn
  19. 00:00:59
    more, visit sarahbellcom.
  20. 00:01:01
    All right, Celia, let's dive right in.
  21. 00:01:03
    This is like a little bit of a different
  22. 00:01:05
    podcast. Normally we do one sort of
  23. 00:01:07
    neurologic disease condition, and we
  24. 00:01:10
    have dived into acute ischemic stroke
  25. 00:01:12
    and status of lepticus and ICP
  26. 00:01:16
    management and I And we're going to do a
  27. 00:01:18
    little bit of a different thing here in
  28. 00:01:20
    which we're going to think about
  29. 00:01:22
    something that affects a lot of our
  30. 00:01:24
    patients in the neuro ICU, which is
  31. 00:01:26
    management of sedation and analgesia And
  32. 00:01:28
    I think what's really unique is that our
  33. 00:01:30
    neuro patients often end up on much
  34. 00:01:33
    higher doses than the typical patient
  35. 00:01:36
    who needs sedation just for synchrony or
  36. 00:01:40
    for comfort.
  37. 00:01:43
    And so, I wanted to kind of just dive
  38. 00:01:46
    right in. You're an author on this
  39. 00:01:47
    chapter and it's really awesome And
  40. 00:01:50
    let's think about two specific disease
  41. 00:01:52
    states that we commonly encounter in the
  42. 00:01:55
    neuro ICU, which is ICP crisis and
  43. 00:02:00
    seizures oppression. Yeah, hi Casey.
  44. 00:02:03
    Good to be back. Absolutely. I love
  45. 00:02:05
    this chapter. I think this is, as you
  46. 00:02:07
    said, very generic to a lot of intense
  47. 00:02:11
    of us, but I think for people that
  48. 00:02:13
    practice in the neuro critical care unit,
  49. 00:02:14
    this is even more important because of
  50. 00:02:16
    some very unique. that we talked about.
  51. 00:02:18
    So we talked about some of this, I
  52. 00:02:21
    think, in our very specific podcast
  53. 00:02:25
    episodes for our ICP crisis and a set of
  54. 00:02:27
    simple objectives. But I think this is
  55. 00:02:28
    really cool now to bring it back here
  56. 00:02:30
    and kind of close the loop. There are,
  57. 00:02:33
    I think, a few agents that are worth on
  58. 00:02:36
    discussing. Printful is the one that I
  59. 00:02:38
    really wanted to kind of talk about more.
  60. 00:02:42
    As you mentioned, let's say if you have
  61. 00:02:44
    a patient in the NICU that you're trying
  62. 00:02:47
    to just provide sedation for intubation
  63. 00:02:50
    purposes. When we talk about our
  64. 00:02:52
    patients with ICP crisis or status
  65. 00:02:54
    epilepticus, we typically talk about
  66. 00:02:57
    the fact that in these cases, you
  67. 00:02:59
    absolutely want to bolus your patient
  68. 00:03:01
    with, you know, purple fall, which,
  69. 00:03:03
    again, is not commonly done if it's
  70. 00:03:05
    used for, you know, sedation or a
  71. 00:03:08
    little bit of comfort during the
  72. 00:03:09
    procedure. When we talk about, again,
  73. 00:03:12
    these indications, be bolus with high
  74. 00:03:14
    doses, which will basically mean
  75. 00:03:17
    hemodynamic compromise, right? So
  76. 00:03:19
    these people can end up with a lot of
  77. 00:03:21
    hypertension, a lot of bradycardia and
  78. 00:03:22
    things like that. And that's why we
  79. 00:03:25
    think about, you know, having
  80. 00:03:26
    norepinephrine or ureasal active agents
  81. 00:03:29
    available proactively with the
  82. 00:03:32
    disclaimer that they are gonna have
  83. 00:03:34
    hemodynamic basically instability. But
  84. 00:03:37
    purplefall, what is unique also is that
  85. 00:03:40
    when you have a trauma patient
  86. 00:03:42
    specifically, younger patients who are
  87. 00:03:45
    getting very, very high doses,
  88. 00:03:47
    purplefall related infusion syndrome or
  89. 00:03:49
    press should be on everyone's radar.
  90. 00:03:52
    And what press says is that we don't
  91. 00:03:54
    really know exactly why it happens. We
  92. 00:03:57
    think there is some sort of impairment
  93. 00:03:59
    in the mitochondrial chain. And that's
  94. 00:04:01
    leading to this really terrifying and
  95. 00:04:06
    life threatening, really syndrome where,
  96. 00:04:08
    you know, you see this manifestation of
  97. 00:04:11
    hyperkalemia, rhabdomyolysis,
  98. 00:04:14
    metabolic acidosis, and then eventually,
  99. 00:04:17
    the strykmias and that can lead into
  100. 00:04:19
    death. It's almost always irreversible,
  101. 00:04:22
    unfortunately. So because of that, we
  102. 00:04:25
    really emphasize on monitoring labs that
  103. 00:04:28
    could potentially help identify this
  104. 00:04:30
    before it happens. So what I mean by
  105. 00:04:33
    these labs, I'm sure a lot of people
  106. 00:04:35
    maybe are use their pharmacists asking
  107. 00:04:38
    for purple fall labs. Did you send for
  108. 00:04:40
    purple fall labs? And what they mean by
  109. 00:04:42
    that is that if you send for CK or
  110. 00:04:44
    crowning kinase, lactate, potassium,
  111. 00:04:49
    triglycerides. So those labs are very
  112. 00:04:52
    much important for proactively kind of
  113. 00:04:57
    seeing if process happening or not. You
  114. 00:05:00
    may also hear that people ask for
  115. 00:05:03
    amylase and lipase. That's really for a
  116. 00:05:06
    separate side effect of purple fall,
  117. 00:05:07
    which is pancreatitis. But just to
  118. 00:05:10
    close the loop on that in these patients
  119. 00:05:12
    that are getting high, high doses,
  120. 00:05:14
    press something to think about. Again,
  121. 00:05:17
    I quickly talked about this in the
  122. 00:05:19
    literature. It's been stated that
  123. 00:05:20
    younger patients, African Americans,
  124. 00:05:23
    trauma patients, patients who are
  125. 00:05:25
    invasive active drugs, patients who are
  126. 00:05:27
    getting corticosteroids at a high risk,
  127. 00:05:29
    but it's something, again, you have to
  128. 00:05:31
    kind of think about it. Even if your
  129. 00:05:33
    patient doesn't have these risk factors,
  130. 00:05:35
    you have to be on top of these labs, so
  131. 00:05:38
    you don't miss them.
  132. 00:05:47
    I think another agent that we see
  133. 00:05:50
    commonly in the neurocritical unit or
  134. 00:05:53
    maybe in a mixed unit when you're taking
  135. 00:05:55
    care of a neuropatient is pentobarb.
  136. 00:05:58
    Again, with pentobarb, you are using a
  137. 00:06:01
    much higher dose. You are bolicing.
  138. 00:06:06
    Cardiac compromise obviously is always
  139. 00:06:08
    something to think about. You
  140. 00:06:10
    absolutely have to have norepinephrine
  141. 00:06:11
    in the room if you're committing someone
  142. 00:06:13
    to a pentobarb coma. A lot of side
  143. 00:06:16
    effects of pentobarb, just like other
  144. 00:06:18
    barbiturates is slowing them down the GI
  145. 00:06:21
    tract. So, Ilius is something that we
  146. 00:06:23
    are almost always honestly certain that
  147. 00:06:25
    it's going to happen with these doses.
  148. 00:06:26
    If you are suspecting Ilius, we have to
  149. 00:06:29
    think about pausing two feeds and such.
  150. 00:06:32
    There's a lot of drug, drug, and
  151. 00:06:33
    interactions. Remember that SIP,
  152. 00:06:36
    barbiturates are SIP-and-ducer, so
  153. 00:06:37
    that's something to keep in mind.
  154. 00:06:40
    Sepsis, immunomodulation, all of that
  155. 00:06:44
    I think should be in our radar
  156. 00:06:48
    I think benzodiazepines, a lot of
  157. 00:06:50
    people are probably a little bit more
  158. 00:06:51
    comfortable with benzodiazepines because
  159. 00:06:53
    we see that in other situations, but
  160. 00:06:56
    again not maybe to these significant
  161. 00:06:58
    doses that we use in a neuropatients. I
  162. 00:07:02
    hope that laurie zapam infuses are not
  163. 00:07:04
    used for these cases because as you know
  164. 00:07:04
    it, laurie zapam has a lot of purple
  165. 00:07:04
    and glycol in the
  166. 00:07:12
    IV formulation that can cause purple and
  167. 00:07:14
    glycol acidity, which can lead into AKI
  168. 00:07:18
    of rhabdominabolic acidosis and
  169. 00:07:19
    significant complications of renal
  170. 00:07:20
    failure. Typically, in those cases,
  171. 00:07:23
    we try to use medazolam so that we can
  172. 00:07:25
    keep the confusion and we keep going up
  173. 00:07:27
    on the dose. I can remember that
  174. 00:07:29
    medazolam can accumulate in renal
  175. 00:07:32
    failure and that's something to keep in
  176. 00:07:33
    mind. But as a general rule, as the
  177. 00:07:36
    safest infusion that we can give without
  178. 00:07:39
    any purple and glycol in it, that's
  179. 00:07:42
    just like another reminder for everyone
  180. 00:07:44
    out there there. But those are I think
  181. 00:07:46
    some of the highlights. to think about
  182. 00:07:48
    and just to remember
  183. 00:07:59
    Got it. So, probe will fall when we're
  184. 00:08:00
    thinking about, thinking about, you
  185. 00:08:02
    know, these doses of 50 to 80, you
  186. 00:08:05
    know, for extended periods of time,
  187. 00:08:07
    thinking about triglycerides, thinking
  188. 00:08:08
    about CK, thinking about hyperclaemia,
  189. 00:08:11
    and being really mindful of monitoring
  190. 00:08:13
    for those, those lab and those
  191. 00:08:15
    metabolic complications, knowing that
  192. 00:08:17
    it can cause lactose acidosis and muscle
  193. 00:08:19
    breakdown, and this kind of rare
  194. 00:08:21
    syndrome. And then, pint of arb, drug
  195. 00:08:24
    drug interactions, ilius, it's going
  196. 00:08:26
    to be a problem. And then, finally,
  197. 00:08:28
    no out-of-hand infusions because that's
  198. 00:08:30
    just going to cause AKA. All right,
  199. 00:08:32
    got it. All right, the other thing I
  200. 00:08:34
    really, really liked about this chapter
  201. 00:08:36
    is that even though we are moving away
  202. 00:08:38
    from deep hypothermia for just your
  203. 00:08:40
    routine cardiac arrest patient, we
  204. 00:08:43
    still are using deep hypothermia in some
  205. 00:08:45
    cases. And even with more moderate
  206. 00:08:48
    hyper, hyperthermia and even just
  207. 00:08:51
    beaver prevention, we still have
  208. 00:08:54
    patients that have shivering. And so,
  209. 00:08:56
    Salia, I was hoping you could walk us
  210. 00:08:57
    through. like what should we do for our
  211. 00:08:59
    approach to shivering in our
  212. 00:09:01
    neuropatients? Yes, absolutely. I
  213. 00:09:04
    think it's important to talk about this
  214. 00:09:07
    bedside shivering scoring tool that,
  215. 00:09:10
    you know, kind of allows our nurses and
  216. 00:09:12
    our clinicians to assess the degree of
  217. 00:09:16
    shivering the bedside. It goes from
  218. 00:09:17
    zero to three, so zero means no
  219. 00:09:21
    shivering at all and three is the worst
  220. 00:09:22
    shivering that you can have. And the
  221. 00:09:26
    idea behind, you know, cinnatives and
  222. 00:09:29
    painkillers is that obviously it can
  223. 00:09:32
    technically help with changing the
  224. 00:09:37
    threshold of shivering, meaning that
  225. 00:09:39
    you basically will start shivering at a
  226. 00:09:41
    lower temperature, which I thought was
  227. 00:09:44
    fascinating. Now, why is it a scoring
  228. 00:09:46
    this scoring tool important and helpful?
  229. 00:09:48
    It's important because when you have a
  230. 00:09:51
    lower degree or a milder degree of
  231. 00:09:54
    shivering, you can give a drug that
  232. 00:09:56
    correlates. that degree of shivering,
  233. 00:09:57
    for example, in the bookshop that we
  234. 00:10:00
    have, and also in the Columbia Protocol,
  235. 00:10:01
    which I think is really the bible of,
  236. 00:10:04
    you know, treatment of shivering. We
  237. 00:10:06
    talk about how acetaminophen can be
  238. 00:10:07
    given, in my own cases. Something I
  239. 00:10:10
    feel like we don't talk about as much
  240. 00:10:12
    use for own is also listed, and
  241. 00:10:16
    something that I see quite often is that
  242. 00:10:18
    people order just a normal ten
  243. 00:10:21
    milligrams to eight hour dosing. It's
  244. 00:10:23
    important to note that the dosing for
  245. 00:10:25
    shivering is a higher dosing. We
  246. 00:10:26
    typically talk about 30 milligrams Q8
  247. 00:10:28
    for this indication, and then when you
  248. 00:10:30
    get to mild to moderate cases of
  249. 00:10:32
    shivering, opioids are actually very
  250. 00:10:34
    effective, and also dexmatomidine and
  251. 00:10:38
    presidex. Now, one surprise when I
  252. 00:10:41
    actually was doing some research about
  253. 00:10:43
    this is that miperidine, which is not
  254. 00:10:45
    an opiate that we commonly use, is the
  255. 00:10:47
    most effective opiate when it comes to
  256. 00:10:49
    shivering. It can actually reduce your
  257. 00:10:52
    shivering threshold by two degrees of of,
  258. 00:10:55
    um, that I agree. So, which is huge,
  259. 00:10:58
    and I have to admit, in our institution,
  260. 00:11:01
    we don't use that agent that much. We
  261. 00:11:03
    don't like to use it as much because it
  262. 00:11:05
    can cause, you know, neurotoxicity,
  263. 00:11:07
    especially invasive renal failure. But
  264. 00:11:09
    if you have someone with a normal renal
  265. 00:11:13
    function, it's worth probably trying.
  266. 00:11:15
    And again, especially if you have a
  267. 00:11:17
    patient that they're not, you know,
  268. 00:11:20
    neuro is not their main problem They,
  269. 00:11:22
    you know, you're doing TTM for other
  270. 00:11:24
    indications, which it ultimately ends
  271. 00:11:27
    up to be neuroprotection, but just the,
  272. 00:11:30
    just the site note that the pheridine is
  273. 00:11:33
    pretty effective. And then when you get
  274. 00:11:38
    to more severe cases, as we talked
  275. 00:11:39
    about with the shivering score, is that
  276. 00:11:42
    you could actually use agents like
  277. 00:11:44
    purple fall. Obviously at that point,
  278. 00:11:46
    your patient will be intubated. They're
  279. 00:11:48
    in the ICU setting and things like that
  280. 00:11:51
    But if you really want to get to, you
  281. 00:11:53
    know, more significant cases where you
  282. 00:11:56
    need to Obviously, you can paralyze and
  283. 00:11:59
    I'll always remember that when you're
  284. 00:12:01
    paralyzing, you have to make sure
  285. 00:12:02
    enough pain and sedation management is
  286. 00:12:05
    on board and we talked about, you know,
  287. 00:12:06
    lower rascals so make sure that patients
  288. 00:12:09
    are not aware of their surroundings.
  289. 00:12:11
    People are, you know, deeply sedated.
  290. 00:12:13
    They're not in pain. They don't
  291. 00:12:15
    remember things because that has been
  292. 00:12:17
    associated with PTSD Depending on the
  293. 00:12:21
    degree of shivering and the score that
  294. 00:12:23
    they get, they could get anything from
  295. 00:12:25
    acetaminophen all the way to purple fall,
  296. 00:12:28
    but it's, it's nice because if you
  297. 00:12:29
    objectively assess them, then you can
  298. 00:12:31
    give them the agent that they need The
  299. 00:12:34
    paradigm is an effective opioid that can
  300. 00:12:37
    reduce your shivering threshold by two
  301. 00:12:39
    degrees of study grade.
  302. 00:12:50
    That's awesome. I think that this is a
  303. 00:12:52
    commonly encountered problem and it is
  304. 00:12:54
    really nice to use that stepwise
  305. 00:12:55
    approach and objective scoring criteria.
  306. 00:12:58
    The final thing that we're going to just
  307. 00:12:59
    do, you know, maybe just one sort of
  308. 00:13:01
    rapid fire purl for is that many, many
  309. 00:13:04
    of our patients in the neuro ICU and in
  310. 00:13:07
    critical care in general end up totally
  311. 00:13:10
    delirious, right? And agitation is a
  312. 00:13:12
    major problem. This chapter provides a
  313. 00:13:15
    really nice summary of some of the
  314. 00:13:18
    agents that can be used to combat ICU
  315. 00:13:20
    delirium or agitation, including
  316. 00:13:22
    presidex, valproic acid, and
  317. 00:13:25
    propranolol. And so maybe just kind of
  318. 00:13:28
    one sort of purl to take with each of
  319. 00:13:30
    those agents, why you like it, what
  320. 00:13:33
    you should look out for. I think if you
  321. 00:13:36
    need to extipate people that are
  322. 00:13:38
    agitated and you really can't have your,
  323. 00:13:41
    you know, fentanyl or other sedating,
  324. 00:13:45
    deeply sedating is on board, obviously
  325. 00:13:47
    because you're afraid of actually. on
  326. 00:13:49
    that. I think prosthetics multiple
  327. 00:13:52
    times has shown that people who are
  328. 00:13:54
    agitated, and they're very close to
  329. 00:13:56
    being extubated, meaning, you know,
  330. 00:13:58
    respiratory-wise, mentally, everything,
  331. 00:14:00
    like they are ready to be extubated.
  332. 00:14:02
    But agitation is the reason for not
  333. 00:14:04
    getting them extubated. Bingo,
  334. 00:14:06
    prosthetics or dexmatomatine will save
  335. 00:14:09
    you and will help you, um, extubate
  336. 00:14:12
    those patients. So that's what I think
  337. 00:14:13
    about prosthetics or dexmatomatine, I
  338. 00:14:15
    should say
  339. 00:14:18
    I see you studying, do not bolus
  340. 00:14:20
    dexmatomatine or prosthetics. And if
  341. 00:14:22
    you do that in the OR, that's, that's
  342. 00:14:24
    fine. I just, something that I feel
  343. 00:14:27
    like I have to keep saying because not
  344. 00:14:30
    only you get the hypertension, but you
  345. 00:14:31
    can basically saturate all your
  346. 00:14:33
    apotonegus and then you can cause this
  347. 00:14:35
    hypertension because now you're actually
  348. 00:14:37
    acting on your apple wandersceptors.
  349. 00:14:39
    And again, like fat things can happen
  350. 00:14:41
    with bolus saying dexmatomatine outside
  351. 00:14:43
    of the OLR, so please don't do that. I
  352. 00:14:46
    suppose well, peroic acid. I honestly
  353. 00:14:49
    am a fan because I think you could have
  354. 00:14:51
    all perc acid for someone who's not
  355. 00:14:52
    intubated. You could possibly prevent
  356. 00:14:54
    someone from getting intubated if
  357. 00:14:55
    they're very agitated. The way I like
  358. 00:14:58
    to dose it, I think, and we have it in
  359. 00:15:00
    the chapter initially, you need a
  360. 00:15:01
    loading dose, especially if someone's
  361. 00:15:03
    very agitated, 20 to 30 make per kick
  362. 00:15:05
    is what we think about. And you heard
  363. 00:15:06
    that right. It's really kind of close
  364. 00:15:08
    to seizure and status, you know,
  365. 00:15:10
    loading doses. And then you could start
  366. 00:15:12
    anywhere from 250 to 500
  367. 00:15:15
    Q8. Obviously, you have to make sure
  368. 00:15:16
    if there aren't a set of penis, not a
  369. 00:15:17
    problem Hyperiminemia may be
  370. 00:15:20
    an issue. But again, if your patient's
  371. 00:15:23
    mental synthesis and very altered, I
  372. 00:15:24
    wouldn't chase that. Do not send for a
  373. 00:15:27
    serial ammonia levels. And remember,
  374. 00:15:29
    usually these patients, when they end
  375. 00:15:31
    up on vial peric acid, they're not
  376. 00:15:33
    gonna be like seizures patients that you
  377. 00:15:34
    are gonna keep them on it. You know,
  378. 00:15:37
    studies that we looked at and what we
  379. 00:15:38
    put in our chapter, we talk about three
  380. 00:15:41
    to seven days. So these are short-term
  381. 00:15:43
    kind of getting them through this, you
  382. 00:15:45
    know, acute phase that they have,
  383. 00:15:47
    delirum, they're agitated because
  384. 00:15:48
    they're, you know, they have all these
  385. 00:15:49
    other things happening to them. So
  386. 00:15:51
    that's just one thing to keep in mind.
  387. 00:15:57
    Propranolol is, I think, a very
  388. 00:15:58
    interesting idea. I think it's because
  389. 00:16:00
    it's so lipophilic, it crosses the
  390. 00:16:02
    blood brain barrier, you know, it can
  391. 00:16:03
    be helpful with reducing norepinephrine,
  392. 00:16:05
    central kind of
  393. 00:16:08
    secretion, and that can help with, you
  394. 00:16:10
    know, kind of getting that edge off So
  395. 00:16:13
    it's been nice. I think it has its
  396. 00:16:16
    utility. Obviously, you have to make
  397. 00:16:18
    sure your patient hemodynamically can
  398. 00:16:21
    tolerate that because it can cause
  399. 00:16:23
    hypertension and bradycardia. I really
  400. 00:16:25
    like it in people that are also
  401. 00:16:27
    qualified for a beta blocker at baseline.
  402. 00:16:29
    I kind of want to switch, you know,
  403. 00:16:30
    their actual beta blocker will perform
  404. 00:16:32
    all for that timeframe. There is no
  405. 00:16:34
    specific dose that I could recommend for
  406. 00:16:36
    this specific indication. I think you,
  407. 00:16:39
    what we have in the chapters, 10
  408. 00:16:41
    milligrams QA, and you kind of see how
  409. 00:16:42
    they tolerate it. You can obviously
  410. 00:16:44
    always add more of a work rate of
  411. 00:16:45
    starting high and kind of. causing
  412. 00:16:47
    issues with high doses initially. But I
  413. 00:16:50
    think again, this is a very helpful,
  414. 00:16:52
    especially in trauma patients, if
  415. 00:16:54
    you're also worried about personal, you
  416. 00:16:56
    know, hypersynthetic activity, where
  417. 00:16:58
    we know that beta blockers may also have
  418. 00:17:00
    a role in reducing mortality. So I
  419. 00:17:02
    think this population specifically
  420. 00:17:04
    trauma patients may really be the
  421. 00:17:07
    perfect population to trial this beta
  422. 00:17:11
    blocker in.
  423. 00:17:13
    That's awesome. Okay. So this was a
  424. 00:17:15
    whirlwind chapter And I really invite
  425. 00:17:18
    everyone who's listening to actually go
  426. 00:17:19
    and read the chapter. There's some
  427. 00:17:20
    incredible tables in there. And I think
  428. 00:17:23
    it's a very useful just overview for how
  429. 00:17:26
    we can best manage these patients and
  430. 00:17:28
    the complications to expect and to try
  431. 00:17:30
    to prevent as you're using these
  432. 00:17:33
    different pharmacological agents. With
  433. 00:17:35
    that, any final takeaway pearls?
  434. 00:17:39
    I think we covered it all. I wanted to
  435. 00:17:41
    kind of echo your
  436. 00:17:44
    emphasis here chapter I think is going
  437. 00:17:47
    to be really helpful. There's a lot of
  438. 00:17:48
    agents we didn't talk about today, you
  439. 00:17:50
    know, ketamine, other agents, all
  440. 00:17:52
    different types of benzodiazepines,
  441. 00:17:54
    such as clobazam. So I think if you
  442. 00:17:57
    want more, please go back to the
  443. 00:17:58
    chapter and take a look at it.