I. Introduction and Goals

Strategic de-escalation of intensive therapies and a seamless transition to enteral medication regimens are crucial for reducing iatrogenic harm and supporting neurological recovery in patients with intracerebral hemorrhage (ICH). Pharmacists play a pivotal role in designing appropriate tapering schedules, guiding intravenous (IV) to enteral conversions, and developing comprehensive discharge protocols to ensure patient safety and continuity of care.

• Emphasis should be placed on facilitating safe transitions through distinct phases of care: acute stabilization, recovery, and maintenance.
• Pharmacist roles encompass protocol development, diligent monitoring for efficacy and adverse effects, patient and staff education, and multidisciplinary coordination to optimize outcomes.

II. Pharmacotherapy De-escalation Protocols

Gradual and systematic adjustment of blood pressure (BP) management and sedation regimens is essential to enable accurate neurologic assessments, prevent rebound physiological events, and facilitate patient recovery.

A. Blood Pressure Weaning

A phased approach to BP targets is recommended, transitioning from aggressive acute control to more conservative subacute and maintenance goals tailored to the individual patient.

• Phased Targets:
  • Acute Phase: Systolic Blood Pressure (SBP) < 140 mmHg
  • Subacute Phase: SBP < 160 mmHg
  • Maintenance Phase: Patient-specific goals, often guided by outpatient management targets.
• Agent Selection & Transition:
  • IV nicardipine (initial infusion 5 mg/h, titrate by 2.5 mg/h every 5–15 minutes, up to 15 mg/h) is a common choice for continuous BP control.
  • IV labetalol boluses (10–20 mg every 10–20 minutes) can be used for rapid, intermittent BP lowering.
  • Oral transition typically involves initiating agents like amlodipine 5–10 mg daily or labetalol 100–200 mg twice daily, with a recommended overlap of at least 12-24 hours with IV therapy.
• Monitoring: SBP and diastolic blood pressure (DBP) should be monitored frequently (e.g., every 15 minutes) during IV titration and tapering. Arterial line monitoring is preferred if available for continuous assessment.
• Pitfalls: Abrupt cessation of IV antihypertensives can lead to rebound hypertension. Comorbidities such as bradycardia or heart failure may influence agent selection and tapering strategies.

B. Sedation Tapering

The goal of sedation tapering is to maintain patient comfort while allowing for regular neurological assessments and minimizing complications associated with prolonged sedation.

• Agent Profiles:
  • Propofol: A rapid-onset, short-acting GABA-A agonist. Typical infusion rates are 5–50 mcg/kg/min. Monitor for hypotension.
  • Dexmedetomidine: An α2-agonist with sedative and analgesic properties, causing minimal respiratory depression. Typical infusion rates are 0.2–1.5 mcg/kg/h.
  • Midazolam: A benzodiazepine GABA-A agonist. Its active metabolites can accumulate, especially in patients with organ dysfunction, prolonging sedation.
• Taper Protocol: A general approach is to reduce the sedative dose by 10–20% every 4–6 hours, targeting a Richmond Agitation-Sedation Scale (RASS) score of –2 (light sedation) to 0 (alert and calm).
• Sedation Interruption: Daily spontaneous awakening trials (“sedation vacations”) should be considered unless contraindicated by elevated intracranial pressure (ICP > 20 mmHg) or other acute instability.
• Monitor for Withdrawal: Signs such as agitation, tachycardia, hypertension, and tremors may indicate withdrawal and necessitate a slower taper or adjunctive therapy.

III. Intravenous to Enteral Medication Conversion

Early and systematic conversion of medications from IV to enteral routes is a key strategy to reduce catheter-related bloodstream infection risks, decrease medication costs, and support patient mobilization and rehabilitation efforts.

A. Assessment of Enteral Access and Function

• Confirm the type of enteral access (e.g., nasogastric (NG), orogastric (OG), percutaneous endoscopic gastrostomy (PEG) tube), verify correct placement (e.g., via imaging or pH testing of aspirate), and ensure tube patency.
• Flush enteral tubes with 15–30 mL of water before and after each medication administration to maintain patency and ensure drug delivery.
• Avoid crushing extended-release (ER) or enteric-coated (EC) tablet formulations. Whenever possible, use liquid formulations, or consult resources for appropriate crushable immediate-release alternatives or sprinkle formulations.

B. Drug-specific Absorption and Formulation Considerations

• Levetiracetam: Exhibits excellent bioavailability (>95%), allowing for a direct 1:1 IV to PO conversion.
• Esomeprazole: An IV dose of 80 mg daily can typically be converted to an enteral suspension of 20 mg twice daily. Pausing enteral feeds around administration times may improve absorption for some proton pump inhibitors.
• Amlodipine: Can be initiated at 5 mg orally once daily, with dose adjustments based on BP response.
• Labetalol: Can typically be switched to 100 mg orally twice daily once the patient is hemodynamically stable on an equivalent IV dose or as BP allows.

C. Monitoring and Dose Adjustment

• For anticonvulsants like levetiracetam, consider obtaining trough serum concentrations 2–3 days after conversion to ensure therapeutic levels.
• Reassess BP, neurologic status, and signs of GI tolerance (e.g., nausea, vomiting, residuals) within 24 hours of converting critical medications.
• Adjust medication doses based on observed efficacy, emergence of side effects, and relevant laboratory results.

IV. Mitigating Post-ICU Syndrome with the ABCDEF Bundle

Systematic application of the ABCDEF bundle (Assess, prevent, and manage pain; Both spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium: assess, prevent, and manage; Early mobility and exercise; Family engagement and empowerment) is a multidisciplinary strategy proven to reduce delirium, ICU-acquired weakness, and long-term cognitive and psychological deficits collectively known as Post-ICU Syndrome (PICS).

A. Risk Stratification

Patients at high risk for PICS include those with:

• Prolonged sedation (e.g., >48 hours)
• Multiple episodes of delirium during their ICU stay
• Development of ICU-acquired weakness

B. ABCDEF Components

C. Pharmacist’s Role

• Optimize analgesic and sedative regimens to minimize pain and agitation while facilitating awakening and reducing delirium risk.
• Collaborate with physical and occupational therapists (PT/OT) to align medication administration (e.g., analgesia) with planned mobilization activities.
• Educate ICU staff and patients’ families on the medication-related aspects of the ABCDEF bundle, including rationale and potential side effects.

V. Medication Reconciliation and Discharge Planning

Meticulous medication reconciliation and comprehensive patient education at discharge are cornerstones of ensuring a safe transition from hospital to home or another care facility, minimizing medication errors and promoting adherence.

A. Comprehensive Medication Reconciliation

• Systematically compare the patient’s pre-admission medication list, current ICU medications, and proposed discharge medications to identify and resolve any discrepancies.
• Screen for potential omissions (e.g., inadvertently discontinued home antihypertensives), duplications of therapy, drug interactions, and inappropriate dosing.
• Assess patient-specific factors that may impact adherence, such as cognitive function, financial barriers to obtaining medications, and the complexity of the prescribed regimen.

B. Discharge Counseling Strategy

• Employ the teach-back method to confirm patient and caregiver understanding of each medication’s indication, dosing schedule, common side effects, and any special administration instructions.
• Provide clear, written medication schedules, preferably in the patient’s primary language, and outline specific monitoring parameters (e.g., when to check BP, signs of worsening to report).
• Emphasize the importance of secondary prevention strategies, including adherence to BP control, dietary modifications, and appropriate physical activity levels.

C. Coordination with Outpatient Providers

• Communicate all medication changes, rationale for changes, and necessary follow-up plans clearly and promptly to the patient’s primary care physician (PCP) and any relevant specialists.
• Arrange for necessary outpatient laboratory checks, such as therapeutic drug monitoring (if applicable), renal function tests, or electrolyte panels.
• Leverage pharmacist-led transitional care services or clinics, where available, to provide additional support and follow-up post-discharge.

VI. Quality Metrics and Follow-up

Tracking key performance indicators and patient outcomes is essential for the continuous improvement of transition of care protocols for ICH patients. This allows for identification of areas for refinement and ensures that interventions are effective.

• Monitor 30-day hospital readmission rates specifically for ICH and all-cause stroke.
• Track the incidence of post-discharge medication errors or discrepancies identified during follow-up.
• Assess patient-reported functional recovery and quality of life at defined intervals (e.g., 3 months and 6 months post-discharge) using validated scales.
• Conduct regular audits of medication reconciliation processes, discharge counseling documentation, and adherence to established transition of care protocols.