北京大学学报(医学版) ›› 2018, Vol. 50 ›› Issue (5): 915-920. doi: 10.19723/j.issn.1671-167X.2018.05.026

• 病例报告 • 上一篇    下一篇

持续静脉血液滤过联合体外膜肺氧合治疗1例急性重症胰腺炎的万古霉素个体化治疗方案报道

何娜1,2,闫盈盈1,应颖秋1,伊敏3,么改琦3,葛庆岗3△,翟所迪1△   

  1. (1. 北京大学第三医院药剂科,北京100191;2. 北京大学药学院药事管理与临床药学系,北京100191; 3. 北京大学第三医院重症医学科,北京100191)
  • 出版日期:2018-10-18 发布日期:2018-10-18
  • 通讯作者: 葛庆岗,翟所迪 E-mail:qingganggelin@126.com, zhaisuodi@163.com

Individualized vancomycin dosing for a patient diagnosed as severe acute pancreatitis with concurrent extracorporeal membrane oxygenation and continuous veno-venous hemofiltration therapy: a case report

HE Na1,2, YAN Ying-ying1, YING Ying-qiu1, YI Min3, YAO Gai-qi3, GE Qing-gang3△, ZHAI Suo-di1△   

  1. (1. Department of Pharmacy, Peking University Third Hospital, Beijing 100191, China; 2. Department of Pharmaceutical Administration and Clinical Pharmacy, Peking University School of Pharmaceutical Sciences, Beijing 100191, China; 3. Intensive Care Unit, Peking University Third Hospital, Beijing 100191, China)
  • Online:2018-10-18 Published:2018-10-18
  • Contact: GE Qing-gang, ZHAI Suo-di E-mail:qingganggelin@126.com, zhaisuodi@163.com

摘要: 万古霉素是临床常用的糖肽类抗菌药物,用于革兰阳性球菌感染,特别是耐甲氧西林金黄色葡萄球菌(methicillin-resistant Staphylococcus aureus, MRSA)感染的一线治疗,具有治疗窗窄、肾毒性的特点[1]。2016年《中国万古霉素治疗药物监测指南》[2]推荐对重症患者进行万古霉素治疗药物监测,对于重症成人患者推荐10~20 mg/L为目标谷浓度,并基于药代动力学原理和方法进行个体化给药。

关键词: 万古霉素, 体外膜肺氧合, 持续血液滤过, 药物监测

Abstract: Pharmacokinetic parameters can be significantly altered for acute kidney injury (AKI), extracorporeal membrane oxygenation (ECMO) and continuous venovenous hemofiltration therapy (CVVH). Here we reported a case of individualized vancomycin dosing for a patient diagnosed as severe acute pancreatitis treated with concurrent ECMO and CVVH. A 65 kg 32-year-old woman was admitted to hospital presented with severe acute pancreatitis (SAP), respiratory failure, metabotropic acidosis and hyperkalemia. She was admitted to intensive care unit (ICU) on hospital day 1 and was initiated on CVVH. She progressed to multiple organ dysfunction syndrome (MODS) and acute respiratory distress syndrome (ARDS) on ICU day 2, and veno-venous ECMO was instituted. Several catheters were inserted into the body to support ECMO, CVVH and pulse indicator continuous cardiac output (PiCCO), so vancomycin was prescribed empirically on ICU day 3 for prevention of catheter-related infection. Given the residual renal function and continuous hemofiltration intensity on day 3, vancomycin bolus of 1 000 mg was prescribed, followed by a maintenance dose of 500 mg every 8 hours. On ICU day 4, a vancomycin trough serum concentration of 14.1 mg/L was obtained before the fourth dose, which was within the target range of 10-20 mg/L. By ICU day 7, vancomycin dosage was elevated to 1.0 g every 12 hours because of aggravated infection and improved kidney function. On ICU day 14, a vancomycin trough serum concentration of 17 mcg/mL was obtained. Her white blood cell (WBC) and neutrophil percentage (Neut%) dropped to the normal level by ICU day 19. This vancomycin regimen was successful in providing a target attainment of trough serum concentration ranging from 10-20 mcg/mL quickly and in controlling infection-related symptoms and signs properly. With the help of this case report we want to call attention to the clinically significant alteration in vancomycin pharmacokinetics among critically ill patients. Individualized vancomycin dosing regimens and therapeutic drug monitoring are necessary for critically ill patients receiving CVVH and ECMO to ensure that the target serum vancomycin levels are reached to adequately treat the infection and avoid nephrotoxicity.

Key words: Vancomycin, Extracorporeal membrane oxygenation, Continuous veno-venous hemofiltration, Drug monitoring

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