Therapeutic drug monitoring in the neurocritical care unit

Abstract

Various antiepileptics, sedative and anesthetic agents are used in the neurocritical care setting and therapeutic drug monitoring (TDM) has been proposed as a means to individualize dosing to ensure efficacy, avoid toxicity, and to account for drug-drug interactions. The purpose of this review is to highlight key articles relating to TDM published in the last 5 years with a focus on drug therapy for seizures, status epilepticus, and traumatic brain injury. Current evidence supports TDM of first-generation antiepileptics, and free-level monitoring for phenytoin and valproic acid is recommended in the neurocritical care population. There are insufficient data to recommend routine TDM of second-generation antiepileptics at this time. In traumatic brain injury, routine TDM of barbiturate infusions appears to be of little value in guiding or evaluating patient response to therapy except to differentiate between drug-induced coma and brain death. Although TDM of sedative agents has been studied, the use of clinical sedation scales is preferred over TDM in evaluating a patient's level of sedation. Therapeutic drug monitoring plays an important role in the care of patients in the neurocritical care setting but is applicable only to a limited number of drugs.