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Nashua Pain Management Corporation. All rights reserved.
The material herein reflects the extensive research and experience of the author. Any medication discussed herein must be prescribed and consumed in accord with the prescribing information released from the manufacturer and/or attending physician.
Treating the Comatose, Vegetative, and
Aaron S. Geller, M.D., Medical Director and President
Suboptimal arousal, attention, and initiation profoundly impair quality of life and predispose to conditions which endanger duration of life. The earliest step in the management of suboptimal cognition is confirmation that no dangerous medical condition is ongoing. Confirmation that mood depression, locked in states, schizophrenic catatonia, or other conditions are not mimicking primary disorders of arousal, attention, or initiation must be performed. Offensive environmental and pharmaceutical agents must be addressed prior to trials with agents which may enhance cognition. A host of drug options exist which may dramatically ameliorate disorders of arousal, attention, and initiation and be utilized in coma awakening and reversal of the vegetative state. Severely neurologically traumatized patients may benefit more from psychostimulants to facilitate coma ascension whereas individuals with attention and initiation disorders may require medications to enhance subcomponents of these systems.
New medications which positively modulate neurotransmitters related to AAI are constantly in development. If the magic cure does not currently exist, then it may in the future. Though coma awakening and reversal of the vegetative state require perseverance and patience in terms of psychostimulant trials, successful responses are extremely common, enormously satisfying to the clinician, and invaluable to the family.
It is the pinnacle of arrogance to suggest that MRI and CT scan can be utilized to state that a patient will not respond to psychostimulants. Only clinical trials with monitored dose escalation can result in such a conclusion for that patient at a specific stage of recovery. The benefits of coma awakening and reversal of the vegetative state to the patient, patient's family, and society cannot be overly stressed.
Patients with loved ones in coma or the vegetative state must understand that all medications utilized to reverse the state are utilized in an off-label manner. The pharmaceutical manufacturing companies have not found it cost effect to petition the FDA for official approval for psychostimulants to be used for the indication of coma awakening or reversal of the vegetative state.
As such, many clinicians are not trained in this off-label use of these medications. Given this fact, the epidemic of frivolous litigation, and the rare but valid potential dangers accompanying use of any medication including psychostimulants, many clinicians will refuse to participate in coma awakening or vegetative state reversal unless patient’s family members sign detailed and all inclusive informed consent.
Patients families must document that they understand the risks for everything from the spectrum of retroperitoneal fibrosis, pleural fibrosis/thickening, pulmonary infiltrates, pericardial effusion, myocardial infarction, cardiac arrhythmia, hepatorenal failure, status epilepticus with further brain damage, pulmonary hypertension, valvular heart, and death. These outcomes are extremely rare, but comprehensive informed consent may reassure clinicians to provide care without concern for litigation despite the most admirable of intentions.
Informed consent must extend to encompass the institution, as the “deeper pockets” may be enticing for easy money. Informed consent must include trials with supra-maximal dosing which may be required to effect coma awakening and reversal of the vegetative state.