Vancomycin - Old drug do we know how to dose in pediatric extracorporeal membrane oxygenation (ECMO)?

Abstract

AIMS & OBJECTIVES: To assess the incidence of vancomycin toxicity in pediatric patients requiring extracorporeal membrane oxygenation (ECMO), in a single centre tertiary pediatric intensive care unit (PICU). METHODS: A retrospective audit from January until December 2017, of patients who received vancomycin whilst on ECMO support. Data collected: patient demographics, renal function, type of ECMO and/or renal replacement therapies, indication for vancomycin, dose, frequency and vancomycin trough levels. Vancomycin toxicity was defined as plasma levels greater than 20 mg/L. Acute kidney injury (AKI) was defined as an increase in serum creatinine by 26 micromol/L and/or urine output less than 0.5 mL/kg/h for 16 hours. RESULTS: Fourteen patients received vancomycin for provisional diagnosis of sepsis, whilst on ECMO. ECMO support consisted of 58% VA ECMO, 28% VV ECMO and 14% combination VA/VV. Hypo-albuminaemia was present in 50% of the patients. Renal support consisted slow continuous ultrafiltration (SCUF, 79%) and hemodialysis (21%). Vancomycin doses ranged from 13 to 21 mg/kg, with number of doses ranging from one to thirty-three. In the first 48 hours of vancomycin therapy, 71% elevated vancomycin trough levels (> 20 mg/L), and 85% had AKI at the commencement of ECMO support. In the patients where more than two doses of vancomycin were administered, eight required a dose reduction and two required a dose increase. CONCLUSIONS: An increase in volume of distribution and altered clearance may account for vancomycin toxicity in pediatric ECMO patients. This audit highlights that vancomycin toxicity is common and pharmacokinetic modelling is required to define dosing of vancomycin for pediatric ECMO patients.L6347728042021-04-21 <br />