Charcoal hemoperfusion in a child with vancomycin overdose and chronic renal failure
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Brief report
Charcoal hemoperfusion in a child with vancomycin overdose and chronic renal failure Valerie M. Panzarino1, Thomas J. Feldstein2, and Clifford E. Kashtan1 1 2
Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, USA Department of Pediatrics, Children's Health Care ± Minneapolis, Minneapolis, Minnesota, USA
Received January 29, 1997; received in revised form and accepted June 27, 1997
Abstract. A 14-month-old girl with chronic renal insufficiency received a massive overdose of vancomycin, resulting in worsened renal failure and ototoxicity. We report the use of combined charcoal hemoperfusion and dialysis to accelerate vancomycin removal in this patient. Key words: Vancomycin ± Overdose ± Charcoal hemoperfusion Introduction Adverse effects of vancomycin include fever, rash, phlebitis, neutropenia, ototoxicity, nephrotoxicity, and the ªred man syndromeº [1, 2]. Nephrotoxicity is uncommon without pre-existing renal disease [3]. Ototoxicity is also uncommon and is usually reversible [4]. Treatment of vancomycin overdose is not necessary in patients with normal renal function because of rapid clearance by the kidneys. Effective treatment of vancomycin by charcoal hemoperfusion has been documented only in an adult patient with end-stage renal disease [5]. We report the present case to document the efficacy of charcoal hemoperfusion in the treatment of a child with chronic renal failure and vancomycin overdose. Case report A 14-month-old, 8-kg female with bilateral renal dysplasia associated with prune-belly syndrome, imperforate anus, and cloacal anomalies was admitted with fever. The baseline serum creatinine level was 3.5 mg/dl and her calculated creatinine clearance was 10 ml/min per 1.73 m2 using the Schwartz formula [6]. Empiric antimicrobial therapy with parenterally administered ceftazidime and vancomycin was initiated. Blood cultures grew Enterobacter cloacea. An error in vancomycin dosing occurred. On the 1st day of hospitalization she received three doses of vancomycin, 6 h apart, totalling 1.5 g (200 mg/kg cumulative dose). The initial serum vancomycin level was 337.6 mg/l, 5 h after the third dose. Over the next 3 days her serum creatinine progressively increased and the Correspondence to: C. E. Kashtan, University of Minnesota Medical School, Department of Pediatrics, Box 491 UMHC, 420 Delaware Street S. E., Minneapolis, MN 55455, USA
vancomycin levels remained markedly elevated. An audiogram showed high-frequency hearing loss. On day 4 she was transferred to the University of Minnesota Variety Club Hospital for Children for charcoal hemoperfusion and hemodialysis.
Methods Access for hemoperfusion consisted of the previously placed 9.6-F (1.6-mm internal diameter) single-lumen Hickman catheter as the aspirating line and a single-lumen temporary dialysis catheter placed in the left femoral vein as the return line. A pediatric charcoal unit was used in series with a Mini-Minor dialysis cartridge, allowing sequential hemoperfusion and dialysis [7]. Because o
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