行体外膜肺氧合支持伴肾功能亢进患者应用万古霉素的剂量调整策略

Dose adjustment strategy of vancomycin in one patient with augmented renal clearance taking extracorporeal membrane pulmonary oxygenation support

1例暴发性心肌炎患者行体外膜肺氧合(ECMO)治疗且伴随肾功能亢进(ARC)状态,医生应用万古霉素(1000 mg q12h)预防导管相关性血流感染,临床药师测得万古霉素初始谷浓度为5.99μg·ml^(-1),且血药浓度-时间曲线下面积(AUC)和细菌最低抑菌浓度(MIC)的比值为312,提示低于杀菌浓度。经文献研究,ECMO机器构造原理及ARC病理生理状态均改变抗菌药物的药代动力学,进而影响血药浓度。临床药师运用斯坦福万古霉素计算器模拟出达稳态时的药代动力学参数,并推测合适的剂量方案为1000 mg q8h。调整后复测谷浓度升高至18.39μg·ml^(-1),AUC/MIC升高至498,万古霉素血药浓度达标,患者感染指标显著下降。

One patient with fulminant myocarditis was treated with extracorporeal membrane pulmonary oxygenation(ECMO)and was complicated with augmented renal clearance(ARC);the physician applied vancomycin(1000 mg q12h)to prevent catheter-associated bloodstream infection;the clinical pharmacist measured the initial vancomycin concentration of 5.99μg·ml^(-1) and the ratio of the area under the serum drug concentration-time curve(AUC)to the minimum bacterial inhibitory concentration(MIC)312,suggesting that it was lower than the bactericidal concentration.The literatures show that the principle of ECMO machine construction and the pathophysiological state of ARC both alter the pharmacokinetics of antimicrobial drugs,which in turn affects the blood concentration.The clinical pharmacist used the Stanford Vancomycin Calculator to simulate the pharmacokinetic parameters at steady state and speculated that the appropriate dosing regimen would be 1000 mg q8h.After adjustment,the retest concentration increased to 18.39μg·ml^(-1),the AUC/MIC increased to 498,the vancomycin blood concentration reached the standard,and the patient's infection index decreased significantly.