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Bahey AAA, Chughtai T, El-Menyar A, Verma V, Strandvik G, Asim M, Consunji R, Younis B, Parchani A, Rizoli S, Al-Thani H. Seizure Prophylaxis in Young Patients Following Traumatic Brain Injury. J Emerg Trauma Shock 2024; 17:25-32. [PMID: 38681877 PMCID: PMC11044991 DOI: 10.4103/jets.jets_93_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/31/2023] [Accepted: 11/20/2023] [Indexed: 05/01/2024] Open
Abstract
Introduction Phenytoin is one of the commonly used anti.seizure medications in nontraumatic seizures. However, its utility and safety in young patients with traumatic brain injury (TBI) for the prevention of early-onset seizures (EOS) are debatable. We sought to explore the use of phenytoin as a seizure prophylaxis following TBI. We hypothesized that administering phenytoin is not effective in preventing EOS after TBI. Methods This was a retrospective observational study conducted on adult TBI patients. EOS was defined as a witnessed seizure within a week postinjury. Data were compared as phenytoin versus no-phenytoin use, EOS versus no-EOS, and among TBI severity groups. Results During 1 year, 639 TBI patients were included with a mean age of 32 years; of them, 183 received phenytoin as seizure prophylaxis, and 453 received no prophylaxis medication. EOS was documented in 13 (2.0%) patients who received phenytoin, and none had EOS among the nonphenytoin group. The phenytoin group was more likely to have a higher Marshall Score (P = 0.001), lower Glasgow Coma Scale (GCS) (P = 0.001), EOS (P = 0.001), and higher mortality (P = 0.001). Phenytoin was administrated for 15.2%, 43.2%, and 64.5% of mild, moderate, and severe TBI patients, respectively. EOS and no-EOS groups were comparable for age, gender, mechanism of injury, GCS, Marshall Score, serum phenytoin levels, liver function levels, hospital stay, and mortality. Multivariable logistic regression analysis showed that low serum albumin (odds ratio [OR] 0.81; 95% confidence interval [CI] 0.676.0.962) and toxic phenytoin level (OR 43; 95% CI 2.420.780.7) were independent predictors of EOS. Conclusions In this study, the prophylactic use of phenytoin in TBI was ineffective in preventing EOS. Large-scale matched studies and well-defined hospital protocols are needed for the proper utility of phenytoin post-TBI.
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Affiliation(s)
- Ahmed Abdel-Aziz Bahey
- Department of Pharmacy, Clinical Pharmacy, Trauma Surgery Section, Hamad General Hospital, Doha, Qatar
| | - Talat Chughtai
- Department of Surgery, Trauma Surgery Section, Hamad General Hospital, Doha, Qatar
| | - Ayman El-Menyar
- Department of Surgery, Clinical Research, Trauma and Vascular Surgery, Hamad General Hospital, Doha, Qatar
- Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| | - Vishwajit Verma
- Department of Surgery, Trauma Surgery Section, Hamad General Hospital, Doha, Qatar
| | - Gustav Strandvik
- Department of Surgery, Trauma Surgery Section, Hamad General Hospital, Doha, Qatar
| | - Mohammad Asim
- Department of Surgery, Clinical Research, Trauma and Vascular Surgery, Hamad General Hospital, Doha, Qatar
| | - Rafael Consunji
- Department of Surgery, Injury Prevention, Trauma Surgery Section, Hamad General Hospital, Doha, Qatar
| | - Basil Younis
- Department of Surgery, Trauma Surgery Section, Hamad General Hospital, Doha, Qatar
| | - Ashok Parchani
- Department of Surgery, Trauma Surgery Section, Hamad General Hospital, Doha, Qatar
| | - Sandro Rizoli
- Department of Surgery, Trauma Surgery Section, Hamad General Hospital, Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Trauma Surgery Section, Hamad General Hospital, Doha, Qatar
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Kiang TKL, Ensom MHH. A Comprehensive Review on the Predictive Performance of the Sheiner-Tozer and Derivative Equations for the Correction of Phenytoin Concentrations. Ann Pharmacother 2016; 50:311-25. [PMID: 26825643 DOI: 10.1177/1060028016628166] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE In settings where free phenytoin concentrations are not available, the Sheiner-Tozer equation-Corrected total phenytoin concentration = Observed total phenytoin concentration/[(0.2 × Albumin) + 0.1]; phenytoin in µg/mL, albumin in g/dL-and its derivative equations are commonly used to correct for altered phenytoin binding to albumin. The objective of this article was to provide a comprehensive and updated review on the predictive performance of these equations in various patient populations. DATA SOURCES A literature search of PubMed, EMBASE, and Google Scholar was conducted using combinations of the following terms: Sheiner-Tozer, Winter-Tozer, phenytoin, predictive equation, precision, bias, free fraction. STUDY SELECTION AND DATA EXTRACTION All English-language articles up to November 2015 (excluding abstracts) were evaluated. DATA SYNTHESIS This review shows the Sheiner-Tozer equation to be biased and imprecise in various critical care, head trauma, and general neurology patient populations. Factors contributing to bias and imprecision include the following: albumin concentration, free phenytoin assay temperature, experimental conditions (eg, timing of concentration sampling, steady-state dosing conditions), renal function, age, concomitant medications, and patient type. Although derivative equations using varying albumin coefficients have improved accuracy (without much improvement in precision) in intensive care and elderly patients, these equations still require further validation. CONCLUSIONS Further experiments are also needed to yield derivative equations with good predictive performance in all populations as well as to validate the equations' impact on actual patient efficacy and toxicity outcomes. More complex, multivariate predictive equations may be required to capture all variables that can potentially affect phenytoin pharmacokinetics and clinical therapeutic outcomes.
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Affiliation(s)
- Tony K L Kiang
- The University of British Columbia, Vancouver, BC, Canada Vancouver General Hospital, Vancouver, BC, Canada
| | - Mary H H Ensom
- The University of British Columbia, Vancouver, BC, Canada Children's and Women's Health Centre of British Columbia, Vancouver, BC, Canada
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Abstract
Measurement of drug concentrations in biological samples is of utmost importance in many research areas. The information about the amount of drug in a biological sample can be given as either total concentration, which ignores the interaction of the drug with the sample matrix, or as free concentration, which shows the portion of molecules able to diffuse through membranes and exert biological activity. Although the historical trend has been towards determining total concentrations, measurement of free concentrations is becoming more important since it correlates better with pharmacological and toxicological effects. This review will discuss the most popular experimental approaches for monitoring free drug concentrations, based on the type of sample to be investigated and the kind of information to be collected. It is shown that the current challenges in measuring free concentrations are: convenience, accuracy, precision, wide applicability, availability of accurate and precise reference methods, ruggedness, and standardized sample conditions.
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