Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, 3401 Civic Center Blvd, 6th Floor Wood Building, Room 6117, Philadelphia, PA, 19104, USA.
Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
Paediatr Drugs. 2019 Apr;21(2):107-112. doi: 10.1007/s40272-019-00328-8.
Acute kidney injury (AKI) commonly occurs after cardiac arrest. Those subsequently treated with vancomycin are at additional risk for drug-induced kidney injury.
We aimed to determine whether opportunities exist for improved drug monitoring after cardiac arrest.
This was a retrospective cohort study of children aged 30 days-17 years treated after cardiac arrest in an intensive care unit from January 2010 to September 2014 who received vancomycin within 24 h of arrest. Vancomycin dosing and monitoring were compared between those with and without AKI, with AKI defined as pRIFLE (pediatric risk, injury, failure, loss, end-stage renal disease) stage 2-3 AKI at day 5 using Schwartz formula-calculated estimated glomerular filtration rate (eGFR).
Of 43 children, 16 (37%) had AKI at day 5. Age, arrest duration, median time to first vancomycin dose, and the number of doses before and time to first vancomycin concentration measurement were similar between groups. Children with AKI had higher initial vancomycin concentrations than those without AKI (median 16 vs. 7 mg/L; p = 0.003). A concentration was not measured before the second dose in 44% of children with AKI. Initial eGFR predicted day 5 AKI. In children with AKI, the initial eGFR was lower in those with than those without a concentration measurement before the second dose (29 mL/min/1.73 m [interquartile range (IQR) 23-47] vs. 52 [IQR 50-57]; p = 0.03) but well below normal in both.
In children with AKI after cardiac arrest, decreased vancomycin clearance was evident early, and early monitoring was not performed universally in those with low initial eGFR. Earlier vancomycin therapeutic drug monitoring is indicated in this high-risk population.
心脏骤停后常发生急性肾损伤（AKI）。那些随后接受万古霉素治疗的患者有发生药物性肾损伤的额外风险。
我们旨在确定心脏骤停后是否有机会改善药物监测。
这是一项回顾性队列研究，纳入了 2010 年 1 月至 2014 年 9 月期间在重症监护病房接受心脏骤停治疗的年龄在 30 天至 17 岁的儿童患者，他们在心脏骤停后 24 小时内接受了万古霉素治疗。比较了有无 AKI 的患者之间的万古霉素剂量和监测情况，AKI 定义为 Schwartz 公式计算的估算肾小球滤过率（eGFR）的 pRIFLE（儿科风险、损伤、衰竭、损失、终末期肾病）第 2-3 期 AKI 在第 5 天。
43 名儿童中，16 名（37%）在第 5 天发生 AKI。年龄、心脏骤停持续时间、首次万古霉素剂量时间中位数、首次剂量前的剂量数以及首次万古霉素浓度测量时间在两组之间相似。有 AKI 的儿童的初始万古霉素浓度高于无 AKI 的儿童（中位数 16 比 7mg/L；p=0.003）。在 44%的 AKI 儿童中，在第二剂之前没有测量浓度。初始 eGFR 预测第 5 天 AKI。在 AKI 患儿中，初始 eGFR 低于第二剂前未测量浓度的患儿（29mL/min/1.73m[23-47]比 52[50-57]；p=0.03），但在两组中均明显低于正常。
在心脏骤停后发生 AKI 的儿童中，万古霉素清除率明显降低，且 eGFR 较低的患儿普遍未进行早期监测。在这种高危人群中，需要进行更早的万古霉素治疗药物监测。
