Is There a Need for Early Seizure Prophylaxis After Traumatic Brain Injury?

Abstract

You are the consulting physiatrist of a busy surgical intensive care unit (ICU) at a large, urban academic medical center. You are part of a Pharmacy and Therapeutics Ad Hoc Subcommittee charged with exploring all “routineeper protocol” use of medications in the ICU. Your charge is to critically assess these types of medications from the perspective of both safety and expense. One of the categories the Subcommittee is charged with reviewing is the routine use of seizure prophylaxis in the first week after traumatic brain injury (TBI). Data provided by the finance department have indicated that there has been a steady trend during the past 3 years to use levetiracetam rather than phenytoin as the prophylactic agent of choice in the first days to weeks after TBI. The financial ramification of this trend has been significant, to the magnitude of $100,000 annually. The chief of trauma surgery and chair of neurosurgery are completely comfortable in designating the less expensive phenytoin as the prophylactic drug of choice in the ICU, citing little evidence base for the use of levetiracetam as a prophylactic agent in persons with TBI. You voice your opposition to the return to phenytoin based on reasonable animal and clinical evidence of a detrimental impact on neurologic recovery. The pharmacist-in-chief for the hospital reminds you that this year’s budget is extremely tight and the potential cost saving of designating phenytoin as the drug of choice is quite significant. Consequently, it will take a great deal of convincing for the chief medical officer to support anything other than a whole-scale return to the use of phenytoin. Much to the surprise of the entire group, the chief of the epilepsy service suggests that the hospital use neither agent and abandon entirely the policy of routine early seizure prophylaxis after TBI. Although the group is surprised by this suggestion, they agree to consider it and table a vote until the next meeting in a week. You spend some time exploring your position on this suggestion. After your research, what position do you take regarding a new hospital policy stating that seizure prophylaxis is not required in the first week after a TBI? Dr Monica Verduzco-Gutierrez will argue that early seizure prophylaxis should be administered after a TBI. Dr Cara Camiolo Reddy will take the position that the use of antiepileptic agents for prevention of early seizures after TBI is not warranted.