After a discussion at work I’ve been looking to current recommendations for proper vancomycin dosing in the ICU and ER.
Drug monitoring should be performed. Through serum concentrations just before the next dose at steady state are recommended. Steady state is achieved normally just before the fourth dose. The minimum through serum concentration should be above 10mg/L to avoid the resistance and at least moderate concentration at the infection theatre. If you have a MRSA with a Minimal Inhibition Concentration (MIC) of 1mg/L or above minimum through concentrations of 15-20mg/L should be targeted. To achieve optimal through concentrations doses of 15-20mg/kg actual body weight (ABW) should be given every 8-12 hours with normal renal function. In case of a MIC of 2 or above conventional dosing regimes fail. If you have a serious ill patient the authors recommend a loading dose of 25-30mg/kg ABW. Vancomycin Induced Nephrotoxicity is defined as two or three increases in serum creatinine concentrations (0,5mg/dL or 50% above baseline) after several days of therapy. Frequent monitoring is not recommended if there is no risk for renal failure. The authors suggest a weekly monitoring for stable patients. Every patient should receive at least one through serum level and repeated as deemed clinically appropriate.
As a part of the poster presentation first details were published.
PRINCIPLE – Predictors of Re-Intubation in Neurological Criticall Ill Planned for Extubation found these predictors and could calculate a significant score to use in daily business. Strengest predictor for itself was tracheal secretion.
Cooling and temperature management are key features of any ICU. NICU tend to cool longer than their counterparts in cardiology1. Also neurologists like their patients awake so that they can perform a neurological examination.
A way to reach that goal is to keep your patient awake in the process of cooling. Kama Guluma2 published in 2006 an article in which he described the feasibility of awake cooling in a small patient collective. He used an endovascular cooling device in 10 ischemic stroke patients. Cooling started as soon as possible. In case of systemic thrombolysis the placement of the femoral iv catheter was performed 30 minutes after completion of the t-PA infusion.
On initiation a meperidine drip was started at 30mg/h. A convective surface warming blanket was applied. 24h of cooling.
Shivering was countered by boluses of merepidine. There was no feeding. There was no significant shivering in the study period.
After all this could be a possible way to cool patients in the near future who received definitive treatment of a large vessel occlusion to prevent cerebral edema and hemorrhagic transformation3.
1. Kollmar R, Schwab S. Hypothermia and Ischemic Stroke. Current treatment options in neurology 2012.
2. Guluma KZ, Hemmen TM, Olsen SE, Rapp KS, Lyden PD. A trial of therapeutic hypothermia via endovascular approach in awake patients with acute ischemic stroke: methodology. Acad Emerg Med 2006;13:820-7.
3. Hong JM, Lee JS, Song HJ, Jeong HS, Choi HA, Lee K. Therapeutic hypothermia after recanalization in patients with acute ischemic stroke. Stroke; a journal of cerebral circulation 2014;45:134-40.