Renee Paxton, BCCCP, BCPS, PharmD
Pharmacy Clinical Specialist
Ascension Saint John Hospital
Detroit, MI
Disclosure information not submitted.
Stephanie Edwin, PharmD, BCPS,
Clinical Pharmacy Specialist - Cardiac ICU
Ascension Saint John Hospital
Livonia, MI
Disclosure information not submitted.
Nicole Elkhoury, PharmD
Clinical Pharmacist
Ascension St John, United States
Disclosure information not submitted.
Title: Valproic Acid for Agitation in the Intensive Care Unit
Introduction: Agitation is a frequent occurrence among critically ill patients, often requiring sedation to ensure patient safety. Valproic acid is an emerging treatment for agitation in critically ill patients, as use is not associated with hemodynamic changes or respiratory depression. Given the limited available literature, we conducted a study to describe the potential benefits, safety and utilization patterns of valproic acid for the management of agitation in critically ill patients.
Methods: This was a retrospective, observational study of critically ill adult patients who received valproic acid for refractory agitation in the intensive care unit (ICU) at a Level 1 Trauma Center in Detroit, Michigan. Patients were excluded if they received valproic acid prior to hospitalization or were prescribed valproic acid for an indication other than agitation.
Results: Of 119 charts screened, 47 patients met the study criteria. The majority of patients had a history of substance abuse (85%), with alcohol abuse present in 55.3% of patients. The most common initial valproic acid regimens were 250 mg every 8 hours (n=17) or 12 hours (n=18). Following valproic acid initiation, the median daily midazolam equivalents dose decreased from 21.4 mg/day at initiation to 7 mg/day on Day 7 (p=0.02). Median daily propofol doses significantly decreased from 14 mcg/kg/min at initiation to 3.8 mcg/kg/min on Day 3 (p=0.04). No significant changes in opioid, dexmedetomidine, or quetiapine utilization were observed. The proportion of patients with a RASS score of 0 to -1 increased from 32% to 43% between valproic acid initiation and Day 7. Positive CAM-ICU scores for delirium decreased from 19% at initiation to 11% on Day 7. Of the 33 patients requiring mechanical ventilation at initiation, 78.8% were successfully extubated at Day 7. No major adverse effects were observed during valproic acid therapy.
Conclusion: Valproic acid may be an effective treatment option for persistently agitated critically ill patients. Though encouraging, these results are preliminary and evaluation of valproic acid for agitation is needed in a prospective trial to validate the findings of this study.