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Nguyen TL, Simon DW, Lai YC. Beyond the brain: General intensive care considerations in pediatric neurocritical care. Semin Pediatr Neurol 2024; 49:101120. [PMID: 38677799 DOI: 10.1016/j.spen.2024.101120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/29/2024] [Accepted: 03/10/2024] [Indexed: 04/29/2024]
Abstract
Managing children with critical neurological conditions requires a comprehensive understanding of several principles of critical care. Providing a holistic approach that addresses not only the acute interactions between the brain and different organ systems, but also critical illness-associated complications and recovery is essential for improving outcomes in these patients. The brain reacts to an insult with autonomic responses designed to optimize cardiac output and perfusion, which can paradoxically be detrimental. Managing neuro-cardiac interactions therefore requires balancing adequate cerebral perfusion and minimizing complications. The need for intubation and airway protection in patients with acute encephalopathy should be individualized following careful risk/benefit deliberations. Ventilatory strategies can have profound impact on cerebral perfusion. Therefore, understanding neuro-pulmonary interactions is vital to optimize ventilation and oxygenation to support a healing brain. Gastrointestinal dysfunction is common and often complicates the care of patients with critical neurological conditions. Kidney function, along with fluid status and electrolyte derangements, should also be carefully managed in the acutely injured brain. While in the pediatric intensive care unit, prevention of critical illness-associated complications such as healthcare-associated infections and deep vein thrombosis is vital in improving outcomes. As the brain emerges from the acute injury, rehabilitation and management of delirium and paroxysmal sympathetic hyperactivity is paramount for optimal recovery. All these considerations provide a foundation for the care of pediatric patients with critical neurological conditions in the intensive care unit.
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Affiliation(s)
- Thao L Nguyen
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, McGovern Medical School, UT Health Houston, Houston, TX
| | - Dennis W Simon
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Yi-Chen Lai
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX.
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Cook AM, Hall K, Kolpek JH, Morbitzer KA, Jordan JD, Rhoney DH. Enhanced renal clearance impacts levetiracetam concentrations in patients with traumatic brain injury with and without augmented renal clearance. BMC Neurol 2024; 24:12. [PMID: 38166710 PMCID: PMC10759330 DOI: 10.1186/s12883-023-03515-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 12/18/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The purpose of this study was to examine the impact of ARC on levetiracetam concentrations during the first week following acute TBI. The hypothesis was levetiracetam concentrations are significantly lower in TBI patients with augmented renal clearance (ARC) compared to those with normal renal clearance. METHODS This is a prospective cohort pharmacokinetic study of adults with moderate to severe TBI treated with levetiracetam during the first week after injury. Serial blood collections were performed daily for analysis of levetiracetam, cystatin C, and 12-hr creatinine clearance (CrCl) determinations. Patients were divided into two cohorts: with (CrCl ≥130 ml/min/1.73 m2) and without ARC. RESULTS Twenty-two patients with moderate to severe TBI were included. The population consisted primarily of young male patients with severe TBI (mean age 40 years old, 68% male, median admission GCS 4). Each received levetiracetam 1000 mg IV every 12 h for the study period. ARC was present in 77.3% of patients, with significantly lower levetiracetam concentrations in ARC patients and below the conservative therapeutic range (< 6mcg/mL) for all study days. In patients without ARC, the serum concentrations were also below the expected range on all but two study days (Days 4 and 5). Four of the 22 (18.2%) patients exhibited seizure activity during the study period (two of these patients exhibited ARC). Cystatin C concentrations were significantly lower in patients with ARC, though the mean for all patients was within the typical normal range. CONCLUSIONS ARC has a high prevalence in patients with moderate to severe TBI. Levetiracetam concentrations after standard dosing were low in all TBI patients, but significantly lower in patients with ARC. This study highlights the need to consider personalized drug dosing in TBI patients irrespective of the presence of ARC. CLINICAL TRIAL REGISTRATION This study was registered at cliicaltrials.gov (NCT02437838) Registered on 08/05/2015, https://clinicaltrials.gov/ct2/show/NCT02437838 .
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Affiliation(s)
- Aaron M Cook
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
- Pharmacy Services UKHealthCare, Lexington, KY, USA
| | - Kaylee Hall
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Jimmi Hatton Kolpek
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Kathryn A Morbitzer
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Campus Box 7574, Chapel Hill, NC, 27599, USA
| | - J Dedrick Jordan
- Departments of Neurology and Neurosurgery, Duke University, Durham, NC, USA
| | - Denise H Rhoney
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Campus Box 7574, Chapel Hill, NC, 27599, USA.
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Monteiro E, Fraga Pereira M, Barroso I, Dias CC, Czosnyka M, Paiva JA, Dias C. Creatinine Clearance in Acute Brain Injury: A Comparison of Methods. Neurocrit Care 2023; 39:514-521. [PMID: 37016059 DOI: 10.1007/s12028-023-01714-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 03/06/2023] [Indexed: 04/06/2023]
Abstract
BACKGROUND Currently, the measurement of glomerular filtration rate is very complex and costly, so its daily evaluation is performed using endogenous markers, of which creatinine is the most frequently used. It allows the estimation of glomerular filtration rate by means of its clearance or by formulas based on its serum and urine concentration. Augmented renal clearance (ARC) is frequent among critically ill patients and is defined as creatinine clearance (CrCl) > 130 ml/min/1.73 m2. The aim of this study was to compare measured CrCl (MCC) and estimated CrCl obtained with the Cockcroft-Gault formula (CG), the Modification of Diet in Renal Disease Study equation (MDRD), and the Chronic Kidney Disease Epidemiology Collaboration formula (CKD-EPI) in patients with severe traumatic brain injury and nontraumatic subarachnoid hemorrhage. The second aim was to assess the incidence of ARC in this population of neurocritical patients. METHODS This was a prospective, observational, single center study from a cohort of 74 patients admitted to the neurocritical intensive care unit due to traumatic brain injury or subarachnoid hemorrhage. Serum creatinine (at 7 a.m.) and a 6-h urine collection were analyzed, and CrCl was measured and estimated by using CG, MDRD, and CKD-EPI. The intraclass correlation coefficient (ICC) was evaluated for each pair, and Bland-Altman plots were used to assess clinical significance. RESULTS Among 74 patients, the median age was 53 (interquartile range [IQR] 36-65), and the median Glasgow Coma Scale score at admission was 6. The median MCC at admission was 176 (IQR 135-214). The medians of CG, MDRD and CKD-EPI were, respectively, 129 ml/min/1.73 m2 (IQR 95-176), 158 (IQR 115-202), and 116 (97-132). An ICC was applied to evaluate the correlation between MCC and estimated methods and showed a weak correlation between MCC and estimated CrCl obtained with the three different methods. The strongest ICC statistical correlation was found between MCC and MDRD, and the weakest correlation was found between MCC and CKD-EPI. Bland-Altman plots showed that differences between each pair were not clinically acceptable. ARC was present in 78% of measurements, using MCC. A weak correlation was observed between MCC and calculated CrCl. CG, MDRD, and CKD-EPI overestimated MCC when MCC ≤ 130 ml/min/1.73 m2 and underestimated it when MCC > 130 ml/min/1.73 m2. CONCLUSIONS In this population, there was a weak statistical correlation between measured and estimated methods. In patients with ARC, formulas underestimated MCC. MCC should probably be the preferred methodology for renal function assessment in the clinical setting to better adjust drug dosage and guarantee drug effectiveness.
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Affiliation(s)
- Elisabete Monteiro
- Department of Intensive Care Medicine, Centro Hospitalar e Universitário São João, Porto, Portugal.
- Faculdade de Medicina, Universidade do Porto, Porto, Portugal.
| | | | - Isaac Barroso
- Department of Clinical Pathology, Centro Hospitalar e Universitário São João, Porto, Portugal
- EPIUnit - Institute of Public Health, University of Porto, Porto, Portugal
- Laboratory for Integrative, Translational Research in Population Health, Porto, Portugal
| | - Cláudia Camila Dias
- Knowledge Management Unit and Department of Community Medicine, Information and Health Decision Sciences, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- Centre for Health Technology and Services Research, Porto, Portugal
- RISE, Health Research Network, Porto, Portugal
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - José Artur Paiva
- Department of Intensive Care Medicine, Centro Hospitalar e Universitário São João, Porto, Portugal
- Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Celeste Dias
- Department of Intensive Care Medicine, Centro Hospitalar e Universitário São João, Porto, Portugal
- Faculdade de Medicina, Universidade do Porto, Porto, Portugal
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Monteiro E, Dias CC, Czosnyka M, Paiva JA, Dias C. Measured Creatinine Clearance: Still a Good Surrogate of Glomerular Filtration Rate in Neurocritically Ill Patients! Neurocrit Care 2023; 39:545-546. [PMID: 37634179 DOI: 10.1007/s12028-023-01805-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 08/29/2023]
Affiliation(s)
- Elisabete Monteiro
- Department of Intensive Care Medicine, Centro Hospitalar e Universitário São João, Porto, Portugal.
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal.
| | - Cláudia Camila Dias
- Knowledge Management Unit and Department of Community Medicine, Information and Health Decision Sciences, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- Centre for Health Technology and Services Research, Porto, Portugal
- RISE Health Research Network: From the Lab to the Community, Porto, Portugal
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - José Artur Paiva
- Department of Intensive Care Medicine, Centro Hospitalar e Universitário São João, Porto, Portugal
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Celeste Dias
- Department of Intensive Care Medicine, Centro Hospitalar e Universitário São João, Porto, Portugal
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
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John G, Heffner E, Carter T, Beckham R, Smith N. Augmented Renal Clearance in Patients with Acute Ischemic Stroke: A Prospective Observational Study. Neurocrit Care 2023; 38:35-40. [PMID: 35918629 PMCID: PMC9345739 DOI: 10.1007/s12028-022-01569-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 06/27/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Augmented renal clearance (ARC) is a phenomenon that has been demonstrated in many subsets of critically ill patients and is characterized by a creatinine clearance (CrCl) > 130 mL/min. Prior research has examined ARC prevalence in the presence of sepsis, traumatic brain injury, subarachnoid hemorrhage, and intracranial hemorrhage. However, to our knowledge, no studies have examined whether this phenomenon occurs in patients suffering from an acute ischemic stroke (AIS). The objective of this study was to evaluate whether patients experiencing an AIS exhibit ARC, identify potential contributing factors, and examine the precision of current renal clearance estimation methods in patients with AIS experiencing ARC. METHODS This was a single-center prospective observational study conducted in adult patients admitted to a neurocritical intensive care unit (ICU) at a community hospital. Once consent was gained, patients with an admitting diagnosis of an AIS underwent a 24-h urine collection to assess measured CrCl. The primary end point assessed for ARC, defined as a measured CrCl > 130 mL/min. The secondary end point evaluated length of stay in the neurocritical ICU. RESULTS Twenty-eight patients met enrollment criteria, and data was analyzed for 20 patients. ARC was present in 35% of enrolled patients. Mathematical estimations of renal function were inadequate in detecting ARC manifestation. Patients experiencing ARC were associated with nonsignificantly shorter ICU length of stay. CONCLUSIONS ARC appears to manifest in patients with AIS inconsistently. Patients experiencing ARC were associated with nonsignificantly shorter ICU length of stay.
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Affiliation(s)
- Grace John
- CHRISTUS Mother Frances Hospital - Tyler, 800 E. Dawson St., Tyler, TX, 75701, USA.
| | - Erika Heffner
- grid.417305.4CHRISTUS Mother Frances Hospital - Tyler, 800 E. Dawson St., Tyler, TX 75701 USA
| | - Tracy Carter
- grid.417305.4CHRISTUS Mother Frances Hospital - Tyler, 800 E. Dawson St., Tyler, TX 75701 USA
| | - Regan Beckham
- grid.267327.50000 0001 0626 4654Department of Mathematics, The University of Texas at Tyler, Tyler, TX USA
| | - Nathan Smith
- grid.267327.50000 0001 0626 4654Department of Mathematics, The University of Texas at Tyler, Tyler, TX USA
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Meropenem Population Pharmacokinetics and Simulations in Plasma, Cerebrospinal Fluid, and Brain Tissue. Antimicrob Agents Chemother 2022; 66:e0043822. [PMID: 35862739 PMCID: PMC9380529 DOI: 10.1128/aac.00438-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Meropenem is a broad spectrum carbapenem used for the treatment of cerebral infections. There is a need for data describing meropenem pharmacokinetics (PK) in the brain tissue to optimize therapy in these infections. Here, we present a meropenem PK model in the central nervous system and simulate dosing regimens. This was a population PK analysis of a previously published prospective study of patients admitted to the neurointesive care unit between 2016 and 2019 who received 2 g of meropenem intravenously every 8 h. Meropenem concentration was determined in blood, cerebrospinal fluid (CSF), and brain microdialysate. Meropenem was described by a six-compartment model: two compartments in the blood, two in the CSF, and two in the brain tissue. Creatinine clearance and brain glucose were included as covariates. The median elimination rate constant was 1.26 h-1, the central plasma volume was 5.38 L, and the transfer rate constants from the blood to the CSF and from the blood to the brain were 0.001 h-1 and 0.02 h-1, respectively. In the first 24 h, meropenem 2 g, administered every 8 h via intermittent and extended infusions achieved good target attainment in the CSF and brain, but continuous infusion (CI) was better at steady-state. Administering a 3 g loading dose (LD) followed by 8 g CI was beneficial for early target attainment. In conclusion, a meropenem PK model was developed using blood, CSF, and brain microdialysate samples. An 8 g CI may be needed for good target attainment in the CSF and brain. Giving a LD prior to the CI improved the probability of early target attainment.
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Campassi ML, Repetto FG, Banegas Litardo DM, Castor R, Gómez G, Tiseyra B, Flores L, Ramirez I, Maspoli D, Báez J, Boroni I, Bertola R, Estenssoro E, Dubin A. Incidence and determinats of augmented renal clearance in traumatic brain injury: A prospective observational study. J Crit Care 2022; 70:154065. [DOI: 10.1016/j.jcrc.2022.154065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 11/29/2022]
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Bing E, Archambault K, Sananikone A, Nguyen KD, Fang YT, Jabamikos C, Gras C, Marsot A, Duceppe MA, Perreault MM. Risk factors associated with augmented renal clearance in a mixed intensive care unit population: a retrospective study. Int J Clin Pharm 2022; 44:1277-1286. [PMID: 35834093 DOI: 10.1007/s11096-022-01458-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 06/28/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Augmented renal clearance is increasingly recognized in critically ill patients. This condition may lead to suboptimal dosing of renally excreted medications. AIM Our primary objective was to identify demographic and clinical factors associated with augmented renal clearance in a mixed critically ill population. METHOD This retrospective single center observational cohort study evaluated patients admitted in a mixed adult intensive care unit for augmented renal clearance, defined as a creatinine clearance of ≥ 130 ml/min/1.73m2, through weekly 24-h urine collection. Variables associated with augmented renal clearance were identified using univariate analysis, then served as covariates in a backward stepwise logistic regression. Goodness-of-fit of the model was assessed and receiver operating characteristic curve was generated. RESULTS Augmented renal clearance was observed in 25.3% of the study cohort (n = 324). Age below 50 years (adjusted odds ratio 7.32; 95% CI 4.03-13.29, p < 0.001), lower serum creatinine at intensive care admission (adjusted odds ratio 0.97; 95% CI 0.96-0.99, p < 0.001) and trauma admission (adjusted odds ratio 2.26; 95% CI 1.12-4.54, p = 0.022) were identified as independent risk factors. Our model showed acceptable discrimination in predicting augmented renal clearance (Area under receiver operating characteristic curve (0.810; 95% CI 0.756-0.864, p < 0.001)). CONCLUSION We identified age below 50 years, lower serum creatinine upon intensive care admission and trauma as independent risk factors for augmented renal clearance, consistent with the literature suggesting that patients with low serum creatinine upon admission could have a higher risk of developing augmented renal clearance.
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Affiliation(s)
- Emily Bing
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Kym Archambault
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Alice Sananikone
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Kim-Dan Nguyen
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Yi Tong Fang
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Caren Jabamikos
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Cécile Gras
- Département de Pharmacie, Centre Hospitalier de Montpellier, 91 av. du Doyen Giraud, 34295, Montpellier cedex 5, France
| | - Amélie Marsot
- Faculté de Pharmacie de L'Université de Montréal, Pavillon Jean-Coutu 2940, Chemin de Polytechnique, Montreal, QC, H3T 1J4, Canada
| | - Marc-Alexandre Duceppe
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
| | - Marc M Perreault
- Faculté de Pharmacie de L'Université de Montréal, Pavillon Jean-Coutu 2940, Chemin de Polytechnique, Montreal, QC, H3T 1J4, Canada. .,Department of Pharmacy, McGill University Health Center, Montreal General Hospital, 1650 Cedar Ave, Montreal, QC, H3G 1A4, Canada.
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Jabamikos C, Fang YT, Nguyen KD, Sananikone A, Archambault K, Bing E, Chagnon M, Husainalamoodi O, Marsot A, Duceppe MA, Perreault MM. Validation of the Augmented Renal Clearance in Trauma Intensive Care scoring system for augmented renal clearance prediction in a trauma subgroup of a mixed ICU population. J Clin Pharm Ther 2022; 47:1517-1524. [PMID: 35633117 DOI: 10.1111/jcpt.13695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 04/24/2022] [Accepted: 05/04/2022] [Indexed: 01/25/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Augmented renal clearance is prevalent in trauma patients and leads to subtherapeutic levels of renally eliminated medications with potentially unfavourable clinical outcomes. The Augmented Renal Clearance of Trauma in Intensive Care (ARCTIC) score has been developed to predict augmented renal clearance in critically ill trauma patients. Our primary objective was to validate this score among the trauma subgroup of a mixed intensive care patient cohort. METHODS This single-centre, retrospective, observational cohort study assessed augmented renal clearance using a timed 24-h urine collection performed weekly. ARC was defined as a measured creatinine clearance of ≥130 ml/min/1.73 m2 . ARCTIC score performance was evaluated through a receiver operator characteristic curves and analysis of sensitivities and specificities for the trauma subgroup, the medical/surgical subgroup and the pooled cohort. RESULTS AND DISCUSSION Augmented renal clearance was observed in 33.9% (n = 58) of trauma patients (n = 171) and 15.7% (n = 24) of medical/surgical patients (n = 153). Examination of different cutoffs for the ARCTIC score in our trauma population confirmed that the optimal cutoff score was ≥6. Comparison between ROC curves for ARCTIC score and for regression model based upon our data in trauma patients indicated validation of the score in this subgroup. Comparison of sensitivities and specificities for ARCTIC score between trauma (93.1% and 41.6%, respectively) and medical/surgical subjects (87.5% and 49.6%, respectively) showed no clinical nor statistical difference, suggesting validation for the medical/surgical subgroup as well. WHAT IS NEW AND CONCLUSION In our mixed ICU population, the ARCTIC score was validated in the trauma subgroup. We also found that the score performed well in the medical/surgical population. Future studies should assess the performance of the ARCTIC score prospectively.
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Affiliation(s)
- Caren Jabamikos
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Yi Tong Fang
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Kim-Dan Nguyen
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Alice Sananikone
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Kym Archambault
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Emily Bing
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Miguel Chagnon
- Department of Mathematics and Statistics, University of Montreal, Montreal, Quebec, Canada
| | - Omar Husainalamoodi
- Department of Critical Care, McGill University Health Center, Montreal General Hospital, Montreal, Quebec, Canada
| | - Amélie Marsot
- Faculté de pharmacie de l'Université de Montréal, Montreal, Quebec, Canada
| | - Marc-Alexandre Duceppe
- Department of Pharmacy, McGill University Health Center, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Marc M Perreault
- Faculté de pharmacie de l'Université de Montréal, Montreal, Quebec, Canada.,Department of Pharmacy, McGill University Health Center, Montreal General Hospital, Montreal, Quebec, Canada
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Bilbao-Meseguer I, Barrasa H, Rodríguez-Gascón A, Asín-Prieto E, Maynar J, Sánchez-Izquierdo JÁ, Solinís MÁ, Isla A. Optimization of levetiracetam dosing regimen in critically ill patients with augmented renal clearance: a Monte Carlo simulation study. J Intensive Care 2022; 10:21. [PMID: 35449037 PMCID: PMC9022299 DOI: 10.1186/s40560-022-00611-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 04/05/2022] [Indexed: 11/28/2022] Open
Abstract
Background Levetiracetam pharmacokinetics is extensively altered in critically ill patients with augmented renal clearance (ARC). Consequently, the dosage regimens commonly used in clinical practice may not be sufficient to achieve target plasma concentrations. The aim of this study is to propose alternative dosage regimens able to achieve target concentrations in this population. Furthermore, the feasibility of the proposed dosing regimens will be discussed from a clinical point of view. Methods Different dosage regimens for levetiracetam were evaluated in critically ill patients with ARC. Monte Carlo simulations were conducted with extended or continuous infusions and/or high drug doses using a previously developed population pharmacokinetic model. To assess the clinical feasibility of the proposed dosages, we carried out a literature search to evaluate the information on toxicity and efficacy of continuous administration or high doses, as well as the post-dilution stability of levetiracetam. Results According to the simulations, target concentrations in patients with CrCl of 160 or 200 mL/min can be achieved with the 3000 mg daily dose by prolonging the infusion time of levetiracetam. For patients with CrCl of 240 mL/min, it would be necessary to administer doses higher than the maximum recommended. Available evidence suggests that levetiracetam administration in continuous infusion or at higher doses than those approved seems to be safe. It would be desirable to re-examinate the current recommendations about drug stability and to achieve a consensus in this issue. Conclusions Conventional dosage regimens of levetiracetam (500–1500 mg twice daily in a short infusion) do not allow obtaining drug plasma concentrations among the defined target in critically ill patients with ARC. Therefore, new dosing guidelines with specific recommendations for patients in this subpopulation are needed. This study proposes new dosages for levetiracetam, including extended (4 or 6 h) infusions, continuous infusions or the administration of doses higher than the recommended in the summary of product characteristics (> 3000 mg). These new dosage recommendations take into account biopharmaceutical and pharmacokinetic aspects and meet feasibility criteria, which allow them to be transferred to the clinical environment with safety and efficacy. Nevertheless, further clinical studies are needed to confirm these results.
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Affiliation(s)
- Idoia Bilbao-Meseguer
- Pharmacokinetic, Nanotechnology and Gene Therapy Group (PharmaNanoGene), Faculty of Pharmacy, Centro de Investigación Lascaray Ikergunea, University of the Basque Country UPV/EHU, Paseo de la Universidad 7, 01006, Vitoria-Gasteiz, Spain.,Department of Pharmacy, Cruces University Hospital, Plaza de Cruces 12, Barakaldo, 48903, Bizkaia, Spain
| | - Helena Barrasa
- Bioaraba, Intensive Care Unit, Vitoria-Gasteiz, Spain.,Osakidetza Basque Health Service, Araba University Hospital, Intensive Care Unit, c/ Olaguibel no. 29, Vitoria-Gasteiz, Spain
| | - Alicia Rodríguez-Gascón
- Pharmacokinetic, Nanotechnology and Gene Therapy Group (PharmaNanoGene), Faculty of Pharmacy, Centro de Investigación Lascaray Ikergunea, University of the Basque Country UPV/EHU, Paseo de la Universidad 7, 01006, Vitoria-Gasteiz, Spain.,Bioaraba, Microbiology, Infectious Disease, Antimicrobial Agents, and Gene Therapy, Vitoria-Gasteiz, Spain
| | - Eduardo Asín-Prieto
- Inserm U1070: Pharmacologie des anti-infectieux, Pôle Biologie Santé-Bâtiment B36, Université de Poitiers, 1 rue Georges Bonnet, 86022, Poitiers, France.,PharmaMar, Avda. De los Reyes, 1, Pol. Ind. La Mina-Norte, Colmenar Viejo, 28770, Madrid, Spain
| | - Javier Maynar
- Bioaraba, Intensive Care Unit, Vitoria-Gasteiz, Spain.,Osakidetza Basque Health Service, Araba University Hospital, Intensive Care Unit, c/ Olaguibel no. 29, Vitoria-Gasteiz, Spain
| | | | - María Ángeles Solinís
- Pharmacokinetic, Nanotechnology and Gene Therapy Group (PharmaNanoGene), Faculty of Pharmacy, Centro de Investigación Lascaray Ikergunea, University of the Basque Country UPV/EHU, Paseo de la Universidad 7, 01006, Vitoria-Gasteiz, Spain. .,Bioaraba, Microbiology, Infectious Disease, Antimicrobial Agents, and Gene Therapy, Vitoria-Gasteiz, Spain.
| | - Arantxazu Isla
- Pharmacokinetic, Nanotechnology and Gene Therapy Group (PharmaNanoGene), Faculty of Pharmacy, Centro de Investigación Lascaray Ikergunea, University of the Basque Country UPV/EHU, Paseo de la Universidad 7, 01006, Vitoria-Gasteiz, Spain. .,Bioaraba, Microbiology, Infectious Disease, Antimicrobial Agents, and Gene Therapy, Vitoria-Gasteiz, Spain.
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Xiao Q, Zhang H, Wu X, Qu J, Qin L, Wang C. Augmented Renal Clearance in Severe Infections-An Important Consideration in Vancomycin Dosing: A Narrative Review. Front Pharmacol 2022; 13:835557. [PMID: 35387348 PMCID: PMC8979486 DOI: 10.3389/fphar.2022.835557] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/25/2022] [Indexed: 12/15/2022] Open
Abstract
Vancomycin is a hydrophilic antibiotic widely used in severe infections, including bacteremia and central nervous system (CNS) infections caused by Gram-positive bacteria such as methicillin-resistant Staphylococcus aureus (MRSA), coagulase-negative staphylococci and enterococci. Appropriate antimicrobial dosage regimens can help achieve the target exposure and improve clinical outcomes. However, vancomycin exposure in serum and cerebrospinal fluid (CSF) is challenging to predict due to rapidly changing pathophysiological processes and patient-specific factors. Vancomycin concentrations may be decreased for peripheral infections due to augmented renal clearance (ARC) and increased distribution caused by systemic inflammatory response syndrome (SIRS), increased capillary permeability, and aggressive fluid resuscitation. Additionally, few studies on vancomycin’s pharmacokinetics (PK) in CSF for CNS infections. The relationship between exposure and clinical response is unclear, challenging for adequate antimicrobial therapy. Accurate prediction of vancomycin pharmacokinetics/pharmacodynamics (PK/PD) in patients with high interindividual variation is critical to increase the likelihood of achieving therapeutic targets. In this review, we describe the interaction between ARC and vancomycin PK/PD, patient-specific factors that influence the achievement of target exposure, and recent advances in optimizing vancomycin dosing schedules for severe infective patients with ARC.
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Affiliation(s)
- Qile Xiao
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, China
| | - Hainan Zhang
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, China
| | - Xiaomei Wu
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, China
| | - Jian Qu
- Department of Pharmacy, Second Xiangya Hospital, Central South University, Changsha, China
| | - Lixia Qin
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, China
| | - Chunyu Wang
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, China
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12
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Prevalence and Risk Factors of Augmented Renal Clearance: A Systematic Review and Meta-Analysis. Pharmaceutics 2022; 14:pharmaceutics14020445. [PMID: 35214177 PMCID: PMC8878755 DOI: 10.3390/pharmaceutics14020445] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/14/2022] [Accepted: 02/15/2022] [Indexed: 02/04/2023] Open
Abstract
Kidney function assessment in the critically ill overlooks the possibility for hyperfunctioning kidneys, known as augmented renal clearance (ARC), which could contribute to therapeutic failures in the intensive care unit (ICU). The aim of this research is to conduct a systematic review and meta-analysis of prevalence and risk factors of ARC in the critically ill. MEDLINE, Embase, Cochrane Library, CINAHL, Scopus, ProQuest Dissertations and Theses Global databases were searched on 27 October 2020. We included studies conducted in critically ill adults who reported the prevalence and/or risk factors of ARC. We evaluated study quality using the Joanna Briggs Institute appraisal tool. Case reports, reviews, editorials and commentaries were excluded. We generated a random-effects meta-analytic model using the inverse variance method and visualized the pooled estimates using forest plots. Seventy studies were included. The pooled prevalence (95% CI) was 39% (34.9–43.3). Prevalence for neuro, trauma, mixed and sepsis ICUs were 74 (55–87), 58 (48–67), 36 (31–41) and 33 (21–48), respectively. Age, male sex and trauma were associated with ARC with pooled OR (95% CI) of 0.95 (0.93–0.96), 2.36 (1.28–4.36), 2.60 (1.21–5.58), respectively. Limitations included variations in ARC definition, inclusion and exclusion criteria and studies design. In conclusion, ARC is prevalent in critically ill patients, especially those in the neurocritical care and trauma ICU population. Young age, male sex and trauma are risk factors for ARC in those with apparently normal renal function. Further research on optimal dosing of drugs in the setting of ARC is warranted. (Prospero registration: CRD42021246417).
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13
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Esteve-Pitarch E, Gumucio-Sanguino VD, Cobo-Sacristán S, Shaw E, Maisterra-Santos K, Sabater-Riera J, Pérez-Fernandez XL, Rigo-Bonnin R, Tubau-Quintano F, Carratalà J, Colom-Codina H, Padullés-Zamora A. Continuous Infusion of Piperacillin/Tazobactam and Meropenem in ICU Patients Without Renal Dysfunction: Are Patients at Risk of Underexposure? Eur J Drug Metab Pharmacokinet 2021; 46:527-538. [PMID: 34131869 DOI: 10.1007/s13318-021-00694-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Morbidity and mortality from serious infections are common in intensive care units (ICUs). The appropriateness of the antibiotic treatment is essential to combat sepsis. We aimed to evaluate pharmacokinetic/pharmacodynamic target attainment of meropenem and piperacillin/tazobactam administered at standard total daily dose as continuous infusion in critically ill patients without renal dysfunction and to identify risk factors of non-pharmacokinetic/pharmacodynamic target attainment. RESULTS We included 118 patients (149 concentrations), 47% had microorganism isolation. Minimum inhibitory concentration (MIC) [median (interquartile range, IQR) values in isolated pathogens were: meropenem: 0.05 (0.02-0.12) mg/l; piperacillin: 3 (1-4) mg/l]. Pharmacokinetic/pharmacodynamic target attainments (100%fCss≥1xMIC, 100%fCss≥4xMIC and 100%fCss ≥ 8xMIC, respectively) were: 100%, 96.15%, 96.15% (meropenem) and 95.56%, 91.11%, 62.22% (piperacillin) for actual MIC; 98.11%, 71.70%, 47.17% (meropenem, MIC 2 mg/l), 95.83%, 44.79%, 6.25% (piperacillin, MIC 8 mg/l), 83.33%, 6.25%, 1.04% (piperacillin, MIC 16 mg/l) for EUCAST breakpoint of Enterobacteriaceae spp. and Pseudomonas spp. Multivariable linear analysis identified creatinine clearance (CrCL) as a predictive factor of free antibiotic concentrations (fCss) of both therapies (meropenem [β = - 0.01 (95% CI - 0.02 to - 0.0; p = 0.043)] and piperacillin [β = - 0.01 (95% CI - 0.02 to 0.01, p < 0.001)]). Neurocritical status was associated with lower piperacillin fCss [β = - 0.36 (95% CI - 0.61 to - 0.11; p = 0.005)]. CONCLUSION Standard total daily dose of meropenem allowed achieving pharmacokinetic/pharmacodynamic target attainments in ICU patients without renal dysfunction. Higher doses of piperacillin/tazobactam would be needed to cover microorganisms with MIC > 8 mg/l. CrCL was the most powerful factor predictive of fCss in both therapies.
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Affiliation(s)
- Erika Esteve-Pitarch
- Department of Pharmacy, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain.,Farmacoteràpia, Farmacogenètica i Tecnologia Farmacèutica, Institut d'Investigació Biomèdica de Bellvitge, IDIBELL, Hospitalet de Llobregat, Barcelona, Spain
| | - Víctor Daniel Gumucio-Sanguino
- Department of Intensive Care Medicine, Hospital Universitari de Bellvitge-IDIBELL, Hospitalet de Llobregat, Barcelona, Spain
| | - Sara Cobo-Sacristán
- Farmacoteràpia, Farmacogenètica i Tecnologia Farmacèutica, Institut d'Investigació Biomèdica de Bellvitge, IDIBELL, Hospitalet de Llobregat, Barcelona, Spain.,Department of Pharmacy, Hospital Universitari de Bellvitge-IDIBELL, Hospitalet de Llobregat, C/Feixa Llarga s/n., 08907, Barcelona, Spain
| | - Evelyn Shaw
- Department of Infectious Diseases, Hospital Universitari de Bellvitge. Hospitalet de Llobregat, Barcelona, Spain.,Epidemiologia de les infeccions bacterianes, Patologia Infecciosa i Transplantament, Institut d'Investigació Biomèdica de Bellvitge, IDIBELL, Hospitalet de Llobregat, Barcelona, Spain.,Spanish Network for Research in Infectious Diseases, Instituto de Salud Carlos III, Madrid, Spain
| | - Kristel Maisterra-Santos
- Department of Intensive Care Medicine, Hospital Universitari de Bellvitge-IDIBELL, Hospitalet de Llobregat, Barcelona, Spain
| | - Joan Sabater-Riera
- Department of Intensive Care Medicine, Hospital Universitari de Bellvitge-IDIBELL, Hospitalet de Llobregat, Barcelona, Spain
| | - Xosé L Pérez-Fernandez
- Department of Intensive Care Medicine, Hospital Universitari de Bellvitge-IDIBELL, Hospitalet de Llobregat, Barcelona, Spain
| | - Raül Rigo-Bonnin
- Department of Clinical Laboratory, Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Spain
| | - Fe Tubau-Quintano
- Department of Microbiology, Hospital Universitari de Bellvitge-IDIBELL, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain.,Department of Microbiology, CIBERES-Instituto de Salud Carlos III, Madrid, Spain
| | - Jordi Carratalà
- Department of Infectious Diseases, Hospital Universitari de Bellvitge. Hospitalet de Llobregat, Barcelona, Spain.,Infeccions respiratòries i en l'hoste immunocompromès, Institut d'Investigació Biomèdica de Bellvitge, IDIBELL, Hospitalet de Llobregat, Barcelona, Spain
| | - Helena Colom-Codina
- Farmacoteràpia, Farmacogenètica i Tecnologia Farmacèutica, Institut d'Investigació Biomèdica de Bellvitge, IDIBELL, Hospitalet de Llobregat, Barcelona, Spain.,Pharmacy and Pharmaceutical Technology and Physical Chemistry Department, Faculty of Barcelona, University of Barcelona, Barcelona, Spain
| | - Ariadna Padullés-Zamora
- Farmacoteràpia, Farmacogenètica i Tecnologia Farmacèutica, Institut d'Investigació Biomèdica de Bellvitge, IDIBELL, Hospitalet de Llobregat, Barcelona, Spain. .,Department of Pharmacy, Hospital Universitari de Bellvitge-IDIBELL, Hospitalet de Llobregat, C/Feixa Llarga s/n., 08907, Barcelona, Spain.
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14
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Wells MA, Morbitzer K, Rhoney DH. Evaluation of the Accuracy of Standard Renal Function Equations in Critically Ill Patients with Subarachnoid Hemorrhage. Neurocrit Care 2021; 32:828-835. [PMID: 31591691 DOI: 10.1007/s12028-019-00854-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Obtaining an accurate estimation of renal function is germane to optimizing care in critically ill patients. However, there is no consensus on the most accurate renal function assessment to utilize in this patient population, particularly in aneurysmal subarachnoid hemorrhage (aSAH) patients. Thus, the objective of this observational study was to determine the comparability of renal function equations to body surface area (BSA)-adjusted 8-h creatinine clearance (CrCl) in aSAH patients. METHODS A PubMed search investigated the applicability of various renal function equations in critically ill patient populations. A subset of these equations was compared to BSA-adjusted 8-h CrCl from a previous study with aSAH patients with no evidence of renal dysfunction (admission serum creatinine < 1.5 mg/dL) and no history of chronic kidney disease. Area-under-the-curve (AUC) calculations were completed using serial laboratory measurements to validate preliminary findings. RESULTS A total of 14 renal function equations were identified with seven carried forward for further analysis based upon a priori criteria. Seven equations were excluded for various reasons, including lack of available clinical data, redundancy with other equations, and dissimilar patient populations to this study. When directly compared to the BSA-adjusted 8-h CrCl, only the Cockcroft-Gault and BSA-adjusted Cockcroft-Gault equations were not statistically significantly different (P = 0.0886 and P = 0.4805, respectively); all other equations were statistically significantly different (P < 0.0001). Additionally, only 52% and 44% of patients had average values within 20% of the BSA-adjusted 8-h CrCl using the Cockcroft-Gault and BSA-adjusted Cockcroft-Gault equations, respectively. Finally, the AUC calculations corroborated the preliminary findings with similar results in statistical testing for the Cockcroft-Gault and BSA-adjusted Cockcroft-Gault (P = 0.6300 and P = 0.1513, respectively). CONCLUSIONS The Cockcroft-Gault equation may be the best renal function equation to assess in critically ill patients diagnosed with aSAH. However, accuracy and consistency in assessing renal function when compared to the BSA-adjusted 8-h CrCl were lacking. Thus, this study suggests the BSA-adjusted 8-h CrCl may be the most appropriate assessment of renal function in patients with aSAH.
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Affiliation(s)
- Michael A Wells
- Division of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences, Boston, MA, USA
| | - Kathryn Morbitzer
- Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy, 115E Beard Hall, Campus, Box 7574, Chapel Hill, NC, 27599-7574, USA
| | - Denise H Rhoney
- Division of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy, 115E Beard Hall, Campus, Box 7574, Chapel Hill, NC, 27599-7574, USA.
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15
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Ong CLJ, Goh PSJ, Teo MM, Lim TP, Goh KKK, Ang XY, Lim LJK, Jamaludin NHB, Ang BT, Kwa LHA. Pharmacokinetics of levetiracetam in neurosurgical ICU patients. J Crit Care 2021; 64:255-261. [PMID: 34051579 DOI: 10.1016/j.jcrc.2021.04.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 04/15/2021] [Accepted: 04/15/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND/OBJECTIVES The pharmacokinetics (PK) of drugs is dramatically altered in critical illness. Augmented renal clearance (ARC), a phenomenon characterized by creatinine clearance (CrCl) greater than 130 ml/min/1.73m2, is commonly described in critically ill patients. Levetiracetam, an antiepileptic drug commonly prescribed for seizure prophylaxis in the neurosurgical ICU, undergoes predominant elimination via the kidneys. Hence, we hypothesize that current dosing practice of intravenous (IV) levetiracetam 500 mg twice daily is inadequate for critically ill patients due to enhanced drug elimination. The objectives of our study were to describe the population PK of levetiractam using a nonparametric approach to design an optimal dosing regimen for critically ill neurosurgical patients. METHODS This was a prospective, observational, population PK study. Serial blood samples were obtained from neurosurgical ICU patients who received at least one dose of IV levetiracetam. We used uHPLC to analyze these samples and Pmetrics™ software to perform PK analysis. RESULTS Twenty subjects were included, with a median age of 54 years and CrCl of 104 ml/min. A two-compartmental model with linear elimination adequately described the profile of levetiracetam. Mean clearance (CL) was 3.55 L/h and volume of distribution (V) was 18.8 L. No covariates were included in the final model. Monte Carlo simulations showed a low probability of target attainment (PTA, trough at steady state of ≥6 mg/L) with a standard dose of 500 mg twice daily. A dose of at least 1000 mg twice daily was required to achieve 80% PTA. Two subjects, both with subtherapeutic trough levels, developed early onset seizures. CONCLUSION Our study examined the population PK of levetiracetam in a critically ill neurosurgical population. We found that this population displayed higher clearance and required higher doses to achieve target levels.
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Affiliation(s)
| | - Pheck Suan June Goh
- Department of Anaesthesiology, Singapore General Hospital, Singapore, Singapore
| | - Miqi Mavis Teo
- Department of Anaesthesiology, Singapore General Hospital, Singapore, Singapore
| | - Tze Peng Lim
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore
| | | | - Xiu Yun Ang
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore
| | | | | | - Beng Ti Ang
- Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research (A*STAR), Singapore, Singapore; Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore, Singapore; Department of Physiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Lay Hoon Andrea Kwa
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore; Emerging Infectious Diseases, Duke-NUS Medical School, Singapore, Singapore; Singhealth Duke-NUS Medicine Academic Clinical Programme, Singapore, Singapore
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16
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Tomasa-Irriguible TM, Sabater-Riera J, Pérez-Carrasco M, Ortiz-Ballujera P, Díaz-Buendía Y, Navas-Pérez A, Betbesé-Roig A, Rodríguez-López M, Ibarz-Vilamayor M, Olmo-Isasmendi A, Oliva-Zelaya I, Rovira-Anglès C, Cano-Hernández S, Vendrell-Torra E, Catalan-Ibars RM, Miralbés-Torner M, González de Molina J, Xirgu-Cortacans J, Marcos-Neira P. Augmented renal clearance. An unnoticed relevant event. Sci Prog 2021; 104:368504211018580. [PMID: 34078190 PMCID: PMC10359677 DOI: 10.1177/00368504211018580] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Augmented renal clearance (ARC) is a phenomenon that can lead to a therapeutic failure of those drugs of renal clearance. The purpose of the study was to ascertain the prevalence of ARC in the critically ill patient, to study the glomerular filtration rate (GFR) throughout the follow-up and analyze the concordance between the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) estimation formula and measured GFR. Observational, prospective, multicenter study. ARC was defined as a creatinine clearance greater than 130 ml/min/1.73 m2. Eighteen hospitals were recruited. GFR measurements carried out twice weekly during a 2-month follow-up period. A total of 561 patients were included. ARC was found to have a non-negligible prevalence of 30%. More even, up to 10.7% already had ARC at intensive care unit (ICU) admission. No specific pattern of GFR was found during the follow-up. Patients in the ARC group were younger 56.5 (53.5-58.5) versus 66 (63.5-68.5) years than in the non-ARC group, p < 0.001. ICU mortality was lower in the ARC group, 6.9% versus 14.5%, p = 0.003. There was no concordance between the estimation of GFR by the CKD-EPI formula and GFR calculated from the 4-h urine. ARC is found in up to 30% of ICU patients, so renal removal drugs could be under dosed by up to 30%. And ARC is already detected on admission in 10%. It is a dynamic phenomenon without an established pattern that usually occurs in younger patients that can last for several weeks. And the CKD-EPI formula does not work to estimate the real creatinine clearance of these patients.
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Affiliation(s)
| | | | | | | | | | - Ana Navas-Pérez
- Intensive Care Department, Corporació Sanitària Parc Taulí, Sabadell, Spain
| | | | | | | | - Aitor Olmo-Isasmendi
- Intensive Care Department, General de Catalunya Hospital, Sant Cugat del Vallès, Spain
| | | | | | - Silvia Cano-Hernández
- Intensive Care Department, Fundació Althaia Xarxa Assistencial Universitària, Manresa, Spain
| | | | | | | | | | | | - Pilar Marcos-Neira
- Intensive Care Department, Germans Trias i Pujol Hospital, Barcelona, Spain
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17
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Jalusic KO, Hempel G, Arnemann PH, Spiekermann C, Kampmeier TG, Ertmer C, Gastine S, Hessler M. Population pharmacokinetics of vancomycin in patients with external ventricular drain-associated ventriculitis. Br J Clin Pharmacol 2020; 87:2502-2510. [PMID: 33202067 DOI: 10.1111/bcp.14657] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/27/2020] [Accepted: 11/05/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND To determine the distribution of vancomycin into the cerebrospinal fluid (CSF) in patients with external ventricular drain (EVD)-associated ventriculitis, the pharmacokinetics of vancomycin were evaluated and covariate relationships explored. METHODS For the population pharmacokinetic model patients were recruited in a neurocritical care unit at the University Hospital of Muenster in the period between January 2014 and June 2015. All patients had a clinical evidence of EVD-associated ventriculitis. Population pharmacokinetic analysis of vancomycin was performed using NONMEM. RESULTS A total of 184 blood and 133 CSF samples were collected from 29 patients. The final population pharmacokinetic model is a three-compartment model with linear elimination. Creatinine clearance (ClCr ) and CSF-lactate were detected as significant covariates, showing that the total vancomycin plasma clearance (Cl) depends on ClCr and furthermore the clearance (Cldif ) between the central and CSF compartment correlates with CSF lactate concentration. Based on the final model, the following values were estimated by NONMEM: Cl = 5.15 L/h, Q (intercompartmental clearance) = 3.31 L/h, Cldif = 0.0031 L/h, Vcentral = 42.1 L, VCSF = 0.32 L and the value of Vperipheral was fixed to 86.2 L. With the developed pharmacokinetic model, area under the curve (AUC) values as well as CSF trough levels were simulated. CONCLUSION Based on our analysis, the dosing of vancomycin should be referred to the degree of inflammation (derived from the CSF lactate concentration) and renal function (derived from ClCr ).
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Affiliation(s)
- Kris Oliver Jalusic
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Muenster, Muenster, Germany.,Institute of Epidemiology and Social Medicine, Faculty of Medicine, University of Muenster, Muenster, Germany
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Muenster, Muenster, Germany
| | - Philip-Helge Arnemann
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
| | - Christina Spiekermann
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
| | - Tim-Gerald Kampmeier
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
| | - Christian Ertmer
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
| | - Silke Gastine
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Muenster, Muenster, Germany.,Infection, Immunity & Inflammation Research & Teaching Department, GOS Institute of Child Health, University College London, London, UK
| | - Michael Hessler
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
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18
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Der-Nigoghossian C, Tesoro EP, Strein M, Brophy GM. Principles of Pharmacotherapy of Seizures and Status Epilepticus. Semin Neurol 2020; 40:681-695. [PMID: 33176370 DOI: 10.1055/s-0040-1718721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Status epilepticus is a neurological emergency with an outcome that is highly associated with the initial pharmacotherapy management that must be administered in a timely fashion. Beyond first-line therapy of status epilepticus, treatment is not guided by robust evidence. Optimal pharmacotherapy selection for individual patients is essential in the management of seizures and status epilepticus with careful evaluation of pharmacokinetic and pharmacodynamic factors. With the addition of newer antiseizure agents to the market, understanding their role in the management of status epilepticus is critical. Etiology-guided therapy should be considered in certain patients with drug-induced seizures, alcohol withdrawal, or autoimmune encephalitis. Some patient populations warrant special consideration, such as pediatric, pregnant, elderly, and the critically ill. Seizure prophylaxis is indicated in select patients with acute neurological injury and should be limited to the acute postinjury period.
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Affiliation(s)
- Caroline Der-Nigoghossian
- Department of Pharmacy, Neurosciences Intensive Care Unit, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Eljim P Tesoro
- Department of Pharmacy Practice (MC 886), College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Micheal Strein
- Pharmacotherapy and Outcomes Science and Neurosurgery, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, Virginia
| | - Gretchen M Brophy
- Pharmacotherapy and Outcomes Science and Neurosurgery, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, Virginia
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19
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Smetana KS, Hannawi Y, May CC. Indirect Calorimetry Measurements Compared With Guideline Weight-Based Energy Calculations in Critically Ill Stroke Patients. JPEN J Parenter Enteral Nutr 2020; 45:1484-1490. [PMID: 33085101 DOI: 10.1002/jpen.2035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 10/14/2020] [Accepted: 10/14/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Perturbations in resting energy expenditure (REE) among critically ill stroke patients are ill defined, and guidelines recommend weight-based dosing when indirect calorimetry (IC) is not feasible to estimate daily energy requirements. We aimed to determine whether guideline-recommended weight-based dosing provides adequate energy requirements compared with guidelines recommended IC target. METHODS IC data was collected on stroke patients admitted to a neurocritical care unit. We compared low-weight-based dosing (25 kcal/kg) and high (30 kcal/kg) with the IC REE target. Subsequently, we analyzed the effect of stroke subtype on the differences among these measurements. RESULTS Seventy-two metabolic studies were performed (45.1% intracerebral hemorrhage [ICH], 18.3% aneurysmal subarachnoid hemorrhage [aSAH], and 36.6% acute ischemic stroke [AIS]). Energy needs, estimated using low-weight-based group, were significantly lower than IC REE target (1496 kcal/day [IQR, 1224-1850] vs 1770 kcal/day [IQR, 1400-2150]; P = .003). High weight-based group energy measurements were similar to IC REE target (1806 kcal/day [IQR, 1530-2236] vs 1770 kcal/day; P = .343). Subgroup analysis showed that low-weight-based calculations were significantly lower than those of IC in ICH and aSAH, but they were similar in AIS (P ≤ .001, .016, and .078, respectively). Linear regression analysis showed that weight, height, and hemorrhagic stroke subtype were associated with IC (P ≤ .001, .024, and .051, respectively). CONCLUSION Important differences between weight-based estimation of energy needs and guideline-recommended IC estimation exist for critically ill stroke patients. Low-weight-based calculations of REE underestimate energy needs in ICH and aSAH patients.
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Affiliation(s)
- Keaton S Smetana
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Yousef Hannawi
- Division of Cerebrovascular Diseases and Neurocritical Care, Department of Neurology, The Ohio State University, Columbus, Ohio, USA
| | - Casey C May
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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20
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Abstract
OBJECTIVES To evaluate enhanced renal clearance over time in patients with aneurysmal subarachnoid hemorrhage or intracerebral hemorrhage via measured creatinine clearance and to compare measured creatinine clearance to creatinine clearance calculated by the Cockcroft-Gault equation and estimated glomerular filtration rate calculated by the Modification of Diet in Renal Diseases equation. DESIGN Prospective, observational study. SETTING Neurosciences ICU in a tertiary care academic medical center. PATIENTS Study participants had an admission diagnosis of aneurysmal subarachnoid hemorrhage or intracerebral hemorrhage, an expected neurosciences ICU length of stay greater than 48 hours, no evidence of renal dysfunction (admission serum creatinine < 1.5 mg/dL), and no history of chronic kidney disease. INTERVENTIONS Eight-hour urine collections to measure creatinine clearance were collected daily as the primary method of measuring renal function. Creatinine clearance was also calculated using the Cockcroft-Gault equation and estimated glomerular filtration rate was calculated using the Modification of Diet in Renal Disease equation. Enhanced renal clearance was defined as a measured creatinine clearance greater than the calculated creatinine clearance via Cockcroft-Gault and estimated glomerular filtration rate via Modification of Diet in Renal Disease. Augmented renal clearance was defined by a measured creatinine clearance greater than or equal to 130 mL/min/1.73 m. Relevant demographic, clinical, and outcome data were recorded. MEASUREMENTS AND MAIN RESULTS Fifty aneurysmal subarachnoid hemorrhage patients and 30 intracerebral hemorrhage patients were enrolled, contributing 590 individual measurements. Patients with aneurysmal subarachnoid hemorrhage had a higher mean measured creatinine clearance compared with the mean calculated creatinine clearance based on the Cockcroft-Gault equation (147.9 ± 50.2 vs 109.1 ± 32.7 mL/min/1.73 m; p < 0.0001) and higher mean measured creatinine clearance compared with the mean calculated estimated glomerular filtration rate based on the Modification of Diet in Renal Disease equation (147.9 ± 50.2 vs 126.0 ± 41.9 mL/min/1.73 m; p = 0.04). Ninety-four percent of participants with aneurysmal subarachnoid hemorrhage experienced augmented renal clearance on at least 1 day. In patients with intracerebral hemorrhage, there was a higher mean measured creatinine clearance over the study period compared with the mean calculated creatinine clearance (119.5 ± 57.2 vs 77.8 ± 27.6 mL/min/1.73 m; p < 0.0001) and higher mean measured creatinine clearance compared with the mean calculated estimated glomerular filtration rate based on the Modification of Diet in Renal Disease equation (119.5 ± 57.2 vs 93.0.0 ± 32.8 mL/min/1.73 m; p = 0.02). Fifty percent of participants with intracerebral hemorrhage experienced augmented renal clearance on at least 1 day. CONCLUSIONS A substantial group of patients with aneurysmal subarachnoid hemorrhage or intracerebral hemorrhage experienced enhanced renal clearance, which may be otherwise unknown to clinicians. Enhanced renal clearance may lead to increased renal solute elimination over what is expected, resulting in subtherapeutic renally eliminated drug concentrations. This may result in underexposure to critical medications, leading to treatment failure and other medical complications.
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Dhont E, Van Der Heggen T, De Jaeger A, Vande Walle J, De Paepe P, De Cock PA. Augmented renal clearance in pediatric intensive care: are we undertreating our sickest patients? Pediatr Nephrol 2020; 35:25-39. [PMID: 30374606 DOI: 10.1007/s00467-018-4120-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 10/04/2018] [Accepted: 10/16/2018] [Indexed: 10/28/2022]
Abstract
Many critically ill patients display a supraphysiological renal function with enhanced renal perfusion and glomerular hyperfiltration. This phenomenon described as augmented renal clearance (ARC) may result in enhanced drug elimination through renal excretion mechanisms. Augmented renal clearance seems to be triggered by systemic inflammation and therapeutic interventions in intensive care. There is growing evidence that ARC is not restricted to the adult intensive care population, but is also prevalent in critically ill children. Augmented renal clearance is often overlooked due to the lack of reliable methods to assess renal function in critically ill children. Standard equations to calculate glomerular filtration rate (GFR) are developed for patients who have a steady-state creatinine production and a stable renal function. Those formulas are not reliable in critically ill patients with acutely changing GFR and tend to underestimate true GFR in patients with ARC. Tools for real-time, continuous, and non-invasive measurement of fluctuating GFR are most needed to identify changes in kidney function during critical illness and therapeutic interventions. Such devices are currently being validated and hold a strong potential to become the standard of practice. In the meantime, urinary creatinine clearance is considered the most reliable method to detect ARC in critically ill patients. Augmented renal clearance is clearly associated with subtherapeutic antimicrobial concentrations and subsequent therapeutic failure. This warrants the need for adjusted dosing regimens to optimize pharmacokinetic and pharmacodynamic target attainment. This review aims to summarize current knowledge on ARC in critically ill children, to give insight into its possible pathophysiological mechanism, to evaluate screening methods for ARC in the pediatric intensive care population, and to illustrate the effect of ARC on drug exposure, therapeutic efficacy, and clinical outcome.
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Affiliation(s)
- Evelyn Dhont
- Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium. .,Pediatric Intensive Care 1K12D, Ghent University Hospital, Heymanslaan 10, 9000, Ghent, Belgium.
| | | | - Annick De Jaeger
- Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium
| | - Johan Vande Walle
- Department of Pediatrics, Ghent University Hospital, Ghent, Belgium.,Department of Pediatric Nephrology, Ghent University Hospital, Ghent, Belgium
| | - Peter De Paepe
- Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
| | - Pieter A De Cock
- Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium.,Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium.,Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
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22
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Morbitzer KA, Rhoney DH, Dehne KA, Jordan JD. Enhanced renal clearance and impact on vancomycin pharmacokinetic parameters in patients with hemorrhagic stroke. J Intensive Care 2019; 7:51. [PMID: 31832200 PMCID: PMC6868795 DOI: 10.1186/s40560-019-0408-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/15/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The majority of patients with hemorrhagic stroke experience enhanced renal clearance or augmented renal clearance (ARC). The purpose of this study was to determine the impact of enhanced renal clearance or ARC on vancomycin pharmacokinetic (PK) parameters. METHODS This was a post hoc analysis of a prospective study of adult patients with aneurysmal subarachnoid hemorrhage (aSAH) or intracerebral hemorrhage (ICH) admitted to the neurosciences intensive care unit who received vancomycin. Creatinine clearance (CrCl) was measured and also estimated using the Cockcroft-Gault equation. Predicted PK parameters were compared with calculated PK parameters using serum peak and trough concentrations. RESULTS Seventeen hemorrhagic stroke patients met inclusion criteria. All patients experienced enhanced renal clearance on the day that the vancomycin concentrations were obtained, and 12 patients (71%) experienced ARC. The mean calculated elimination rate constant was significantly higher than the predicted value (0.141 ± 0.02 vs. 0.087 ± 0.01 h-1; p = 0.004) and the mean calculated half-life was significantly lower than the predicted half-life (6.5 ± 0.9 vs. 8.7 ± 0.6 h; p = 0.03). CONCLUSIONS Patients with hemorrhagic stroke and enhanced renal clearance displayed PK alterations favoring an increased elimination of vancomycin than expected. This may result in underexposure to vancomycin, leading to treatment failure.
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Affiliation(s)
- Kathryn A. Morbitzer
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Denise H. Rhoney
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Kelly A. Dehne
- Department of Pharmacy, UNC Health Care, Chapel Hill, NC USA
| | - J. Dedrick Jordan
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, University of North Carolina School of Medicine, 170 Manning Drive, Physician Office Building 2118, Chapel Hill, NC 27599 USA
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23
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Damen C, Dhaese S, Verstraete AG, Stove V, De Waele JJ. Subtherapeutic piperacillin concentrations in neurocritical patients. J Crit Care 2019; 54:48-51. [PMID: 31349159 DOI: 10.1016/j.jcrc.2019.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 06/25/2019] [Accepted: 07/09/2019] [Indexed: 11/17/2022]
Abstract
PURPOSE Increased renal elimination is the leading cause for subtherapeutic concentrations of renally cleared antibiotics and it has been hypothesized that brain damaged patients in the intensive care unit (ICU) are particularly at risk. The objective of this study is to determine the prevalence of subtherapeutic piperacillin concentrations in neurocritical patients and to investigate if having a neurocritical diagnosis is a risk factor for this. MATERIALS AND METHODS Single center retrospective analysis of a prospective cohort study of adult ICU patients receiving continuous infusion piperacillin/tazobactam. Patients were categorized as either having a neurocritical diagnosis or not. An unbound piperacillin concentration > 4× the epidemiologic cut-off value (ECOFF) of Pseudomonas aeruginosa was selected as the PKPD target of choice. Multivariable logistic regression was performed to identify risk factors for subtherapeutic piperacillin concentrations. RESULTS 356 patients had a measured creatinine clearance (mCrCl) and matched piperacillin concentration, 52 of which had a neurocritical diagnosis. Subtherapeutic piperacillin concentrations were reported significantly more frequent in neurocritical patients. In multivariate analysis, the only risk factor identified for subtherapeutic piperacillin concentration was an increasing mCrCl. CONCLUSION Subtherapeutic piperacillin concentrations are common in neurocritical patients yet having a neurocritical admission diagnosis was not identified as an independent risk factor.
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Affiliation(s)
- Caroline Damen
- Department of Critical Care Medicine, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Gent, Belgium; Department of Internal Medicine, Elisabeth Tweesteden Hospital, Doctor Deelenlaan 5, 5042 AD Tilburg, the Netherlands.
| | - Sofie Dhaese
- Department of Critical Care Medicine, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Gent, Belgium
| | - Alain G Verstraete
- Department of Laboratory Medicine, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Gent, Belgium; Department of Diagnostic Sciences, Ghent University, Corneel Heymanslaan 10, 9000 Gent, Belgium
| | - Veronique Stove
- Department of Laboratory Medicine, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Gent, Belgium; Department of Diagnostic Sciences, Ghent University, Corneel Heymanslaan 10, 9000 Gent, Belgium
| | - Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Gent, Belgium
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25
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Abstract
Augmented renal clearance (ARC) is a phenomenon in critically ill patients characterized by increased creatinine clearance and elimination of renally eliminated medications. Patients with severe neurologic injury, sepsis, trauma, and burns have been consistently identified as at risk of ARC, with mean creatinine clearances ranging from 170 ml/minute to more than 300 ml/minute. Several potential mechanisms may contribute to the occurrence of ARC including endogenous responses to increased metabolism and solute production, alterations in neurohormonal balance, and therapeutic maneuvers such as fluid resuscitation. Augmented renal clearance is associated with suboptimal exposure to critical medications, including β-lactams and vancomycin, increasing the risk of treatment failure. Although definitive screening tools are not yet known, critical care pharmacists must be vigilant in recognizing when ARC may be a contributing factor affecting expected treatment outcomes in individual patients. Optimizing dosing strategies in critically ill patients with ARC remains a goal of continued research. The current review discusses the clinical characteristics and methods of identifying patients at risk of ARC, potential mechanisms for ARC, and describes pharmacotherapy dosing considerations in patients with ARC.
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Affiliation(s)
- Aaron M Cook
- UKHealthcare, Pharmacy Services, University of Kentucky, Lexington, Kentucky.,University of Kentucky College of Pharmacy, Pharmacy Practice and Science, Lexington, Kentucky
| | - Jimmi Hatton-Kolpek
- University of Kentucky College of Pharmacy, Pharmacy Practice and Science, Lexington, Kentucky
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Abstract
Adding to the complexity of caring for critically ill patients is the fact that many of them have a creatinine clearance that exceeds 130 mL/min/1.73 m2. This phenomenon, termed augmented renal clearance (ARC), has only recently been widely recognized and its pathogenesis remains incompletely understood. However, ARC has been shown to result in increased dose requirements for drugs that are primarily eliminated by renal excretion, including many antimicrobial agents and enoxaparin. Recognition of ARC is hampered by the fact that the standard creatinine-based equations used to estimate renal function are not accurate in this clinical setting and the diagnosis is best established using both serum and urine creatinine measurements to calculate clearance. So a high index of clinical suspicion and awareness is usually required before this step is taken to confirm the diagnosis of ARC.
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Affiliation(s)
- Arthur J Atkinson
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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27
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β-Lactam Dosage Regimens in Septic Patients with Augmented Renal Clearance. Antimicrob Agents Chemother 2018; 62:AAC.02534-17. [PMID: 29987138 PMCID: PMC6125556 DOI: 10.1128/aac.02534-17] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 06/20/2018] [Indexed: 12/14/2022] Open
Abstract
Augmented renal clearance is commonly observed in septic patients and may result in insufficient β-lactam serum concentrations. The aims of this study were to evaluate potential correlations between drug concentrations or total body clearance of β-lactam antibiotics and measured creatinine clearance and to quantify the need for drug dosage adjustments in septic patients with different levels of augmented renal clearance. Augmented renal clearance is commonly observed in septic patients and may result in insufficient β-lactam serum concentrations. The aims of this study were to evaluate potential correlations between drug concentrations or total body clearance of β-lactam antibiotics and measured creatinine clearance and to quantify the need for drug dosage adjustments in septic patients with different levels of augmented renal clearance. We reviewed 256 antibiotic measurements (512 drug concentrations) from a cohort of 215 critically ill patients who had a measured creatinine clearance of ≥120 ml/min and who received therapeutic drug monitoring of meropenem, cefepime, ceftazidime, or piperacillin from October 2009 until December 2014 at Erasme Hospital. Population pharmacokinetic (PK) analysis of the data was performed using the Pmetrics software package for R. Fifty-five percent of drug concentrations showed insufficient β-lactam serum concentrations to treat infections due to Pseudomonas aeruginosa. There were significant, yet weak, correlations between measured creatinine clearance and trough concentrations of meropenem (r = −0.21, P = 0.01), trough concentrations of piperacillin (r = −0.28, P = 0.0071), concentrations at 50% of the dosage interval (r = −0.41, P < 0.0001), and total body clearance of piperacillin (r = 0.39, P = 0.0002). Measured creatinine clearance adequately explained changes in drug concentrations in population pharmacokinetic models for cefepime, ceftazidime, and meropenem but not for piperacillin. Therefore, specific PK modeling can predict certain β-lactam concentrations based on renal function but not on absolute values of measured creatinine clearance, easily available for clinicians. Currently, routine therapeutic drug monitoring is required to adjust daily regimens in critically ill patients receiving standard dosing regimens.
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Kassel LE, Van Matre ET, Foster CJ, Fish DN, Mueller SW, Sherman DS, Wempe MF, MacLaren R, Neumann RT, Kiser TH. A Randomized Pharmacokinetic and Pharmacodynamic Evaluation of Every 8-Hour and 12-Hour Dosing Strategies of Vancomycin and Cefepime in Neurocritically ill Patients. Pharmacotherapy 2018; 38:921-934. [PMID: 29906310 DOI: 10.1002/phar.2156] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
PURPOSE Neurocritically ill patients have clinically significant alterations in pharmacokinetic parameters of renally eliminated medications that may result in subtherapeutic plasma and cerebrospinal fluid antibiotic concentrations. METHODS We conducted a prospective randomized open-label study of adult neurocritically ill patients treated with vancomycin and cefepime. Vancomycin 15 mg/kg and cefepime 2 g were dosed at every-8- or 12-hour intervals. The primary outcomes were the achievement of pharmacodynamic (PD) targets related to time of unbound drug above minimum inhibitory concentrations (MIC) for 60% or more of the dosing interval (fT > MIC ≥ 60%) for β-lactams and ratio of 24-hour area under the curve (AUC):MIC of 400 or greater for vancomycin. RESULTS Twenty patients were included in the study. They were divided equally between the every-12-hour and every-8-hour dosing groups. Patients (mean age 51.8 ± 11 yrs) were primarily male (60%) and white (95%), and most had an admission diagnosis of intracranial hemorrhage (80%). Compared with the every-12-hour group, the every-8-hour vancomycin group achieved target trough concentrations (higher than 15 μg/ml) significantly more frequently at initial measurement (0% vs 80%, p<0.01) and at 7-10 days (0% vs 90%, p=0.045) and achieved PD targets more frequently at increasing MICs. Similarly, compared with every-12-hour dosing, the every-8-hour cefepime dosing strategy significantly increased PD target attainment (fT > MIC ≥ 60%) at an MIC of 8 μg/ml (20% vs 70%, p=0.02). CONCLUSIONS This study demonstrated that more frequent dosing of vancomycin and cefepime is required to achieve optimal PD targets in adult neurocritically ill patients. The need for increased total daily doses is potentially secondary to the development of augmented renal clearance.
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Affiliation(s)
- Lynn E Kassel
- Drake University College of Pharmacy and Health Sciences, Des Moines, Iowa
| | - Edward T Van Matre
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | | | - Douglas N Fish
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Scott W Mueller
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | | | - Michael F Wempe
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado.,Medicinal Chemistry Core Facility, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Robert MacLaren
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Robert T Neumann
- Department of Neurosurgery, School of Medicine, University of Colorado, Aurora, Colorado
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
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Cojutti PG, Barbarino C, De Monte A, Hope W, Pea F. Higher than standard meropenem and linezolid dosages needed for appropriate treatment of an intracerebral hemorrhage patient with augmented renal clearance. Eur J Clin Pharmacol 2018; 74:1091-1092. [DOI: 10.1007/s00228-018-2465-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 04/22/2018] [Indexed: 11/28/2022]
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Augmented Renal Clearance in Critically Ill Patients: A Systematic Review. Clin Pharmacokinet 2018; 57:1107-1121. [DOI: 10.1007/s40262-018-0636-7] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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May CC, Erwin BL, Childress M, Cortopassi J, Curtis G, Kilpatrick T, Taylor J, Vance B, Wylie D. Assessment of acute kidney injury in neurologically and traumatically injured intensive care patients receiving large vancomycin doses. Int J Crit Illn Inj Sci 2018; 8:194-200. [PMID: 30662865 PMCID: PMC6311967 DOI: 10.4103/ijciis.ijciis_39_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background: Previous reports note that in a mixed patient population, vancomycin doses >4 g/day are associated with increased rates of acute kidney injury (AKI). Objective: The objective of the study is to determine if vancomycin regimens >4 g/day are associated with a higher incidence of AKI in neurocritical care unit (NCCU) and trauma/burn Intensive Care Unit (TBICU) patients. Materials and Methods: This single-centered, retrospective study enrolled adult patients initiated on vancomycin in the NCCU and TBICU at an academic medical center during 2016. Based on maximum steady-state dose exposure, patients were separated into two groups: ≤4 g/day and >4 g/day. The primary outcome of incidence of AKI was defined by the AKI Network criteria. Results: A total of 284 patients were screened for eligibility; 165 patients met inclusion criteria, 98 patients received ≤4 g/day and 67 patients received >4 g/day. The >4 g/day group had a lower mean age (32.6±11.1 vs. 47.8±16.2, P < 0.001), included more male patients (81% vs. 60%, P = 0.008), were more often treated for a central nervous system infection (31% vs. 11%, P = 0.001), had, on average, more concomitant use of nephrotoxic drugs (2.2±1.2 vs. 1.8±0.9, P = 0.02) and had a higher exposure to contrast (94% vs. 79%, P < 0.001). The primary outcome of AKI occurred in 14 patients receiving ≤4 g/day and five patients receiving >4 g/day which was not statistically significant (14% vs. 7%, P = 0.22). Conclusions: Our results indicate that administering >4 g/day of vancomycin to achieve therapeutic vancomycin troughs does not appear to lead to an increased incidence of AKI in a mixed NCCU and TBICU population.
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Affiliation(s)
- Casey C May
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Beth L Erwin
- Department of Pharmacy, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Margaret Childress
- Department of Pharmacy, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Josh Cortopassi
- Department of Pharmacy, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Garrett Curtis
- Department of Pharmacy, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Tyson Kilpatrick
- Department of Pharmacy, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Jennifer Taylor
- Department of Pharmacy, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Bonnie Vance
- Department of Pharmacy, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Doug Wylie
- Department of Pharmacy, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
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Augmented Renal Clearance in Patients With Febrile Neutropenia is Associated With Increased Risk for Subtherapeutic Concentrations of Vancomycin. Ther Drug Monit 2017; 38:706-710. [PMID: 27681114 DOI: 10.1097/ftd.0000000000000346] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Augmented renal clearance (ARC) has frequently been observed in critically ill patients. The risk factors for ARC in patients, including those in the general ward, and their influences on vancomycin (VCM) treatment remain unclear. The aims of this study were to investigate the risk factors for ARC and to evaluate the influence of ARC on the pharmacokinetic parameters of VCM. METHODS This study included a total of 292 patients with VCM treatment who had normal serum creatinine concentrations. ARC was defined by an estimated creatinine clearance ≥130 mL·min·1.73 m. The risk factors for ARC were determined with stepwise logistic regression analysis. The pharmacokinetic parameters of VCM were estimated through the Bayesian method using a 2-compartment model. RESULTS ARC was observed in 48 patients (16.4%). Age ≤65 years [odds ratio (OR): 5.77; 95% CI: 2.89-11.97; P < 0.0001], brain injury (OR: 5.11; 95% CI: 1.49-17.57; P = 0.0086), febrile neutropenia (OR: 2.76; 95% CI: 1.11-6.67; P = 0.0254), and a mean volume of infusion fluid ≥1500 mL/d (OR: 2.53; 95% CI: 1.27-5.16; P = 0.0091) were independent risk factors for the occurrence of ARC. The patients with ARC exhibited higher VCM clearance values than the non-ARC patients. The median trough serum concentrations of VCM were 7.4 (interquartile range: 5.2-11.6) mcg/mL in the ARC patients and 12.2 (8.9-16.3) mcg/mL in the non-ARC patients (P < 0.0001). Subtherapeutic trough concentrations of VCM (<10.0 mcg/mL) were found in 68.8% of the ARC patients and in 32.8% of the non-ARC patients (P < 0.0001). CONCLUSIONS This observational study investigated the influence of febrile neutropenia on the emergency of ARC for the first time. ARC was strongly associated with VCM pharmacokinetics, and two-thirds of the ARC patients had subtherapeutic VCM concentrations. In patients with ARC, individualized dosing regimens are required to achieve the target trough concentration.
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Seizures and Choice of Antiepileptic Drugs Following Subarachnoid Hemorrhage: A Review. Can J Neurol Sci 2017; 44:643-653. [DOI: 10.1017/cjn.2017.206] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractSeizures are important complications following a subarachnoid hemorrhage (SAH). The evidence for the use of antiepileptic drugs (AEDs) in treatment and prevention of those seizures is conflicting. The purpose of this review is to provide an up-to-date evidence summary of the incidence and outcomes of seizures following an SAH as well as the use of different AEDs post-SAH in order to evaluate the need for seizure prophylaxis, the choice of AEDs, and their dosing considerations in SAH patients. A literature search of PubMed, Medline, Embase, and the Cochrane Library was performed. A total of 37 studies were reviewed, mostly observational. Definitions of seizures in temporal relation to initial hemorrhage were variable. Similarly, the rates of seizures varied in the literature, ranging from 0 to 31%. Given the reported adverse outcomes associated with AED usage, seizure prophylaxis is not warranted. Levetiracetam appears to be better tolerated than phenytoin in SAH patients, though further research is needed. Higher initial dosing of levetiracetam might be required due to its enhanced clearance in SAH patients. In conclusion, there is a lack of quality evidence to definitively recommend the use of one AED over another. Further prospective research comparing the use of different AEDs in patients with an SAH is needed.
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Association between augmented renal clearance and clinical failure of antibiotic treatment in brain-injured patients with ventilator-acquired pneumonia: A preliminary study. Anaesth Crit Care Pain Med 2017; 37:35-41. [PMID: 28756331 DOI: 10.1016/j.accpm.2017.06.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 06/20/2017] [Accepted: 06/20/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVES This preliminary study aimed to determine whether augmented renal clearance (ARC) impacts negatively on the clinical outcome in traumatic brain-injured patients (TBI) treated for a first episode of ventilator-acquired pneumonia (VAP). METHODS During a 5-year period, all TBI patients who had developed VAP were retrospectively reviewed to assess variables associated with clinical failure in multivariate analysis. Clinical failure was defined as an impaired clinical response with a need for escalating antibiotics during treatment and/or within 15 days after the end-of-treatment. Recurrence was considered if at least one of the initial causative bacterial strains was growing at a significant concentration from a second sample. Augmented renal clearance (ARC) was defined by an enhanced creatinine clearance exceeding 130mL/min/1.73m2 calculated from a urinary sample during the first three days of antimicrobial therapy. MAIN RESULTS During the study period, 223 TBI patients with VAP were included and 59 (26%) presented a clinical failure. Factors statistically associated with clinical failure were GSC≤7 (OR=2.2 [1.1-4.4], P=0.03), early VAP (OR=3.9 [1.9-7.8], P=0.0001), bacteraemia (OR=11 [2.2-54], P=0.003) and antimicrobial therapy≤7 days (OR=3.7 [1.8-7.4], P=0.0003). ARC was statistically associated with recurrent infections with an OR of 4.4 [1.2-16], P=0.03. CONCLUSION ARC was associated with recurrent infection after a first episode of VAP in TBI patients. The optimal administration and dosing of the antimicrobial agents in this context remain to be determined.
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Burnham JP, Micek ST, Kollef MH. Augmented renal clearance is not a risk factor for mortality in Enterobacteriaceae bloodstream infections treated with appropriate empiric antimicrobials. PLoS One 2017; 12:e0180247. [PMID: 28678812 PMCID: PMC5497982 DOI: 10.1371/journal.pone.0180247] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 05/10/2017] [Indexed: 11/19/2022] Open
Abstract
The main objective of the study was to assess whether augmented renal clearance was a risk factor for mortality in a cohort of patients with Enterobacteriaceae sepsis, severe sepsis, or septic shock that all received appropriate antimicrobial therapy within 12 hours. Using a retrospective cohort from Barnes-Jewish Hospital, a 1,250-bed teaching hospital, we collected data on individuals with Enterobacteriaceae sepsis, severe sepsis, and septic shock who received appropriate initial antimicrobial therapy between June 2009 and December 2013. Clinical outcomes were compared according to renal clearance, as assessed by Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formulas, sepsis classification, demographics, severity of illness, and comorbidities. We identified 510 patients with Enterobacteriaceae bacteremia and sepsis, severe sepsis, or septic shock. Sixty-seven patients (13.1%) were nonsurvivors. Augmented renal clearance was uncommon (5.1% of patients by MDRD and 3.0% by CKD-EPI) and was not associated with increased mortality. Our results are limited by the absence of prospective determination of augmented renal clearance. However, in this small cohort, augmented renal clearance as assessed by MDRD and CKD-EPI does not seem to be a risk factor for mortality in patients with Enterobacteriaceae sepsis. Future studies should assess this finding prospectively.
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Affiliation(s)
- Jason P. Burnham
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, United States of America
- * E-mail:
| | - Scott T. Micek
- St. Louis College of Pharmacy, St. Louis, Missouri, United States of America
| | - Marin H. Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri, United States of America
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Identifying augmented renal clearance in trauma patients: Validation of the Augmented Renal Clearance in Trauma Intensive Care scoring system. J Trauma Acute Care Surg 2017; 82:665-671. [PMID: 28129261 DOI: 10.1097/ta.0000000000001387] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Augmented renal clearance (ARC) is common in trauma patients and associated with subtherapeutic antimicrobial concentrations. This study reported the incidence of ARC, identified ARC risk factors, and described a model to predict ARC (i.e., ARCTIC) that is specific to trauma patients. METHODS Consecutive trauma patients who were admitted to the intensive care unit between March 2015 and January 2016 and had a measured creatinine clearance (CrCl) were considered for inclusion. Patients were excluded if their serum creatinine (SCr) was greater than 1.3 mg/dL. ARC was defined as a measured CrCl of 130 mL/min or greater. Demographic and trauma-specific variables were then compared, and multivariate analysis was performed. Using these results, a weighted scoring system was constructed and evaluated using receiver operating characteristic curve analysis. ARCTIC score cutoffs were chosen based on sensitivity, specificity, positive predictive value, and negative predictive value. The derived scoring system was then compared to a previously published scoring system for accuracy. RESULTS There were 133 patients with a mean age of 48 ± 19 years and SCr of 0.8 ± 0.2 mg/dL. The mean measured CrCl was 168 ± 65 mL/min, and the incidence of ARC was 67%. Multivariate analysis revealed the following risk factors for ARC (age, <56: odds ratios [OR], 58.3; 95% confidence interval [CI], 5.2-658.9; age, 56 to 75: OR, 13.5; 95% CI, 1.2-151.7), SCr less than 0.7 mg/dL (OR, 12.5; 95% CI, 3-52.6), and male sex (OR, 6.9; 95% CI, 1.9-24.9). Using these results, the ARCTIC scoring system was: 4 points if younger than 56 years, 3 points if aged 56 years to 75 years, 3 points if SCr less than 0.7 mg/dL, and 2 points if male sex. Receiver operating characteristic curve analysis revealed an area (95% CI) of 0.813 (0.735-0.892) (p < 0.001). An ARCTIC score of 6 or higher had a sensitivity, specificity, positive predictive value, and negative predictive value of 0.843, 0.682, 0.843, and 0.682, respectively. CONCLUSION The incidence of ARC in trauma patients is high. The ARCTIC score represents a practical, pragmatic system that can be easily applied at the bedside. An ARCTIC score of 6 or higher represents an appropriate cutoff to screen for ARC where antimicrobial adjustments should be considered. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.
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Zhang SQ, Peng B, Stary CM, Jian ZH, Xiong XX, Chen QX. Serum prealbumin as an effective prognostic indicator for determining clinical status and prognosis in patients with hemorrhagic stroke. Neural Regen Res 2017; 12:1097-1102. [PMID: 28852391 PMCID: PMC5558488 DOI: 10.4103/1673-5374.211188] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Serum prealbumin is a recognized marker of malnutrition, but its prognostic role in patients with hemorrhagic stroke remains unclear. In this study, we retrospectively reviewed the records of 105 patients with hemorrhagic stroke admitted to Renmin Hospital of Wuhan University, China, from January to December 2015. We collected demographic and radiological data, and recorded serum prealbumin levels at admission and on days 1, 3, 6, 9, and 14–21. The existence of infections and gastrointestinal hemorrhage, and clinical condition at discharge were also recorded. Serum prealbumin levels during hospitalization were significantly lower in patients with infections compared with those without infections, and also significantly lower in patients with gastrointestinal hemorrhage compared with those without. Serum prealbumin levels at discharge were significantly higher in patients with good recovery than in those with poor recovery. We conclude that regular serum prealbumin measurements in patients with hemorrhagic stroke may be a useful indicator for determining clinical status and prognosis, which may therefore help to guide clinical decision-making.
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Affiliation(s)
- Shen-Qi Zhang
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Bin Peng
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Creed M Stary
- Department of Anesthesiology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Zhi-Hong Jian
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Xiao-Xing Xiong
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Qian-Xue Chen
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
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Kim AJ, Lee JY, Choi SA, Shin WG. Comparison of the pharmacokinetics of vancomycin in neurosurgical and non-neurosurgical patients. Int J Antimicrob Agents 2016; 48:381-7. [PMID: 27546217 DOI: 10.1016/j.ijantimicag.2016.06.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 05/28/2016] [Accepted: 06/10/2016] [Indexed: 11/29/2022]
Abstract
Although vancomycin concentrations in neurosurgical patients tend to be lower following standard dosing compared with other patient populations, factors influencing vancomycin pharmacokinetics in neurosurgical patients are poorly understood. In this study, pharmacokinetic (PK) parameters in neurosurgical and non-neurosurgical patients were compared. Furthermore, factors influencing vancomycin PK alterations, including those known to augment renal clearance, were determined. Routine therapeutic drug monitoring data from neurosurgical and non-neurosurgical patients were retrospectively collected. Vancomycin PK parameters were estimated using non-linear mixed-effects modelling (NONMEM v.7.2.0); analyses were performed for the entire population and for neurosurgical patients only. Furthermore, the final models performed a bootstrap, visual predictive check and external validation. A total of 359 serum vancomycin concentration data variables from 132 patients were used to execute the PK modelling. Neurosurgical patient factor, the early phase of treatment, underlying liver cirrhosis, co-administration of a nephrotoxic drug and estimated creatinine clearance influenced vancomycin clearance (CL). However, other factors known to augment renal clearance did not affect vancomycin pharmacokinetics. Vancomycin CL was significantly higher in neurosurgical patients than in controls (0.104 ± 0.036 L/h/kg vs. 0.073 ± 0.042 L/h/kg; P <0.01). Augmented vancomycin CL should be considered when determining vancomycin dosages in neurosurgical patients.
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Affiliation(s)
- A Jeong Kim
- Department of Pharmacy, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea; College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, 103 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - Ju-Yeun Lee
- College of Pharmacy, Institute of Pharmaceutical Science and Technology, Hanyang University, 55 Hanyangdaehak-ro, Sangnok-gu, Ansan, Gyeonggi-do 15588, Republic of Korea
| | - Soo An Choi
- College of Pharmacy, Korea University, 2511 Sejong-ro, Sejong-si 30019, Republic of Korea
| | - Wan Gyoon Shin
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, 103 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea.
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Hobbs ALV, Shea KM, Roberts KM, Daley MJ. Implications of Augmented Renal Clearance on Drug Dosing in Critically Ill Patients: A Focus on Antibiotics. Pharmacotherapy 2015; 35:1063-75. [DOI: 10.1002/phar.1653] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Athena L. V. Hobbs
- Department of Pharmacy; Baptist Memorial Hospital - Memphis; Memphis Tennessee
| | | | - Kirsten M. Roberts
- Department of Pharmacy; Northwestern Memorial Hospital; Chicago Illinois
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Sime FB, Udy AA, Roberts JA. Augmented renal clearance in critically ill patients: etiology, definition and implications for beta-lactam dose optimization. Curr Opin Pharmacol 2015; 24:1-6. [DOI: 10.1016/j.coph.2015.06.002] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 06/10/2015] [Indexed: 02/08/2023]
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