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Reducing Vancomycin Dosage in Children on ECMO with Renal Impairment
Alexej Bobrowski1, René Höhn1, Rouven Kubicki1
1Department of Congenital Heart Defects and Pediatric Cardiology, University Heart Center Freiburg - Bad Krozingen, Medical Center - University of Freiburg, Freiburg, Baden-Württemberg, Germany.
Insights
Lower vancomycin doses are needed for children on extracorporeal membrane oxygenation (ECMO) with impaired renal function. Early therapeutic drug monitoring is recommended for optimizing vancomycin treatment in these pediatric patients.
Area of Science:
- Pediatric Critical Care Medicine
- Pharmacokinetics and Pharmacodynamics
- Infectious Disease Management
Background:
- Extracorporeal membrane oxygenation (ECMO) significantly alters drug pharmacokinetics.
- Vancomycin dosing requires careful consideration in pediatric patients undergoing ECMO.
- Limited data exists on specific vancomycin dosage adjustments for children on ECMO.
Purpose of the Study:
- To compare vancomycin pharmacokinetics in pediatric patients on ECMO versus critically ill non-ECMO patients.
- To determine appropriate vancomycin dosage adjustments for children receiving ECMO.
- To evaluate the impact of renal function on vancomycin dosing in ECMO patients.
Main Methods:
- Retrospective cohort study of pediatric patients in a cardiac intensive care unit.
- Comparison between ECMO support group and a non-ECMO control group (delayed sternal closure).
- Analysis of vancomycin trough levels and daily dosage relative to body weight (mg/kg/d).
Main Results:
- ECMO patients received significantly lower daily vancomycin doses (33.3 mg/kg/d) compared to non-ECMO patients (38.5 mg/kg/d).
- Vancomycin serum trough levels were similar and within the target range (10-20 μg/ml) for both groups.
- Lower vancomycin doses were necessary in ECMO patients with impaired renal function at treatment initiation (22.5 mg/kg/d vs. 42.1 mg/kg/d).
Conclusions:
- Pediatric patients on ECMO with initial renal impairment require lower vancomycin doses.
- Therapeutic drug monitoring of vancomycin should be initiated early in ECMO patients, even before achieving a steady state.
- Vancomycin dosing protocols may need adjustment for pediatric ECMO patients, particularly those with renal dysfunction.
Background:
Extracorporeal membrane oxygenation (ECMO) can influence pharmacokinetics. We investigated the vancomycin dosage in children on ECMO compared to critically ill children to determine the necessary dosage adjustment on ECMO.
Methods:
Eight-year, single-center, retrospective cohort study at a tertiary heart center's pediatric cardiac intensive care unit (ICU) of children undergoing ECMO support. Our control group (non-ECMO) was critically ill children with delayed sternal closure after cardiac surgery. We included consecutively all children undergoing vancomycin administration. The starting dose was 10 to 15 mg/kg BW per dose, every 8 to 12 hours depending on age. The vancomycin trough level was maintained in the 10 to 20 μg/ml range.
Results:
85 total courses on ECMO and 99 non-ECMO courses were included. The ECMO group's daily vancomycin dose was significantly lower than non-ECMO's at a median of 33.3 and 38.5 mg/kg/d, respectively (p < 0.001). Vancomycin serum trough levels were similar between groups and within the target range. The ECMO group's daily vancomycin dose dropped faster over time, with a dose on day 3 of 28.7 and 33.7 mg/kg/d, respectively. The impact of renal function on vancomycin dosing was more apparent in the ECMO group. If the renal function was reduced at the start of treatment, the vancomycin dose was lower in the ECMO group compared to the non-ECMO group with renal impairment (22.5 vs. 42.1 mg/kg/d; p < 0.001). When renal function was normal, the doses were similar between groups.
Conclusion:
In children on ECMO with impaired renal function at treatment initiation, lower vancomycin doses were necessary. Early therapeutic drug monitoring, even before reaching a steady state, should be considered.
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