Department of Pharmacy, Mayo Clinic, Rochester, Minnesota.
Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota.
Pharmacotherapy. 2020 Jan;40(1):89-95. doi: 10.1002/phar.2348. Epub 2019 Dec 13.
Drug pharmacokinetics may be significantly altered in patients receiving extracorporeal membrane oxygenation (ECMO). Ensuring the optimized effective dosing of antimicrobials on ECMO remains a challenge. To date, limited data are available regarding the optimal use of amphotericin and triazoles during ECMO. We report a case of altered pharmacokinetics, insufficient liposomal amphotericin B and isavuconazole levels, and the need for escalated doses during ECMO in a patient with severe acute respiratory distress syndrome secondary to pulmonary blastomycosis. A 2-fold increase in the standard total daily dose of both drugs was necessary to overcome low serum concentrations thought to be secondary to drug loss from ECMO circuit sequestration. These findings have important implications for optimizing antimicrobial therapy in patients receiving ECMO to maximize therapeutic efficacy. The use of therapeutic drug monitoring for patients receiving antimicrobial therapy with concurrent ECMO may facilitate appropriate drug dosing to achieve adequate serum concentrations and optimize favorable patient outcomes. Further studies exploring antimicrobial pharmacokinetics during ECMO are needed to inform dosing recommendations in critically ill patients.
接受体外膜肺氧合（ECMO）治疗的患者，其药物药代动力学可能会发生显著改变。确保 ECMO 治疗时优化抗菌药物的有效给药剂量仍然是一个挑战。迄今为止，关于 ECMO 期间两性霉素和三唑类药物的最佳使用，相关数据有限。我们报告了一例因肺球孢子菌病导致严重急性呼吸窘迫综合征而接受 ECMO 治疗的患者，其出现了药物代谢动力学改变、脂质体两性霉素 B 和伊曲康唑水平不足，以及需要在 ECMO 期间增加剂量的情况。为了克服由于 ECMO 回路隔离而导致药物丢失，认为药物浓度低的问题，这两种药物的标准日总剂量需要增加 2 倍，以达到足够的血清浓度，从而提高治疗效果。这些发现对于优化接受 ECMO 治疗的患者的抗菌治疗方案具有重要意义，可最大限度地提高治疗效果。对于同时接受 ECMO 治疗的接受抗菌治疗的患者，使用治疗药物监测可能有助于进行适当的药物剂量调整，以达到足够的血清浓度，并优化有利的患者预后。需要进一步研究 ECMO 期间的抗菌药物药代动力学，以为危重症患者的剂量推荐提供信息。
