今日药学

2018, v.28(11) 767-770+778

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重症患者万古霉素谷浓度监测回顾性研究
Retrospective Analysis of Vancomycin Trough Concentrations in Critical ill Patients

彭怀东;冯霞;王若伦;
PENG Huaidong;FENG Xia;WANG Ruolun;Department of Pharmacy,The Second Affiliated Hospital of Guangzhou Medical University;

摘要(Abstract):

目的通过分析重症患者万古霉素谷浓度的监测情况,为临床合理使用万古霉素提供参考。方法采用回顾性分析研究,选择2015年1月~2016年12月入住广州医科大学附属第二医院重症医学科使用万古霉素并监测谷浓度的患者,根据谷浓度监测时机分为首次监测组和总纳入组,首次监测组又分为监测时机规范组(取血时间为第4或第5剂给药前30 min内)和监测时机非规范组(取血时间为第N剂给药前30 min内,N>5),比较组间谷浓度分布的差异以及是否给予负荷剂量对首次监测组理想谷浓度(15~20μg·mL~(-1))达标率的影响。对患者的性别、年龄、APACHEⅡ评分、总胆红素、血清白蛋白、肌酐、单位体重日剂量、是否给予负荷剂量、是否合并使用利尿剂(包括甘露醇)、是否CRRT等对万古霉素谷浓度(10~20μg·mL~(-1))达标率的影响以及谷浓度是否达标对患者28 d死亡率的影响等进行统计分析。结果共纳入145例患者313例次万古霉素谷浓度监测数据,理想谷浓度(15~20μg·mL~(-1))达标率为21.72%(68/313)。145例首次监测数据中监测时机规范组纳入76例,监测时机规范组理想谷浓度达标率仅为13.16%(10/76)。监测时机规范组万古霉素理想谷浓度达标率明显低于监测时机非规范组(P=0.004)。亚组分析显示,是否给予负荷剂量对首次监测组万古霉素理想谷浓度达标率差异有统计学意义(P=0.029)。高龄、APACHEⅡ评分高、血清白蛋白水平低、肌酐升高、合并使用利尿剂(包括甘露醇)对谷浓度(10~20μg·mL~(-1))达标率差异有统计学意义(P<0.05),性别、单位体重日剂量、总胆红素、是否给予负荷剂量、是否CRRT等对谷浓度(10~20μg·mL~(-1))达标率的影响差异无统计学意义(P>0.05)。万古霉素谷浓度达标者与未达标者28 d生存率比较差异无统计学意义(χ~2=0. 805,P=0.369)。结论对重症患者经验性使用万古霉素第4或第5剂给药前理想谷浓度达标率低,对重症患者有必要给予负荷剂量,用药早期规范监测谷浓度,特别是高龄、APACHEⅡ评分高、血清白蛋白水平低、肌酐升高和合并使用利尿剂的患者。
OBJECTIVE This paper aims to provide a reference for the rational use of vancomycin by investigating the prevalence of serum vancomycin trough concentration in critically ill patients. METHODS A retrospective study was conducted on patients who used vancomycin and monitored trough concentration during Jan 2015 to Dec 2016 in intensive care unit( ICU) of the second affiliated hospital of Guangzhou Medical University.According to the timing of trough concentration monitoring,the data were divided into the first monitoring group and the total inclusion group. The first monitoring group was divided into monitoring time conventional group( trough concentration should be obtained within 30 min before the 4 th or 5 th dose) and monitoring time non-canonical group( trough concentration obtained within 30 min before the Nth dose,N> 5). The differences in the distribution of trough concentrations between groups and the effect of loading dose on the compliance rate of the ideal trough concentration( 15-20 μg·mL~(-1)) in the first monitoring group were compared. Gender,age,APACHE Ⅱ score,total bilirubin,serum albumin,creatinine,daily dose per unit mass,whether to give loading dose,whether to use diuretics( including mannitol),whether to CRRT,etc were performed the influence on the compliance rate of vancomycin trough concentration( 10-20 μg·mL~(-1)).The effect of trough concentration on the 28-day mortality rate was also investigated. RESULTS A total of 313 cases of vancomycin trough concentration data were collected in 145 patients,the compliance rate of ideal trough concentration( 15-20 μg·mL~(-1)) was 21.72%( 68/313). 76 patients were included in monitoring time conventional group,while only 13.16%( 10/76) achieved 15-20 μg·mL~(-1). Subgroup analysis showed that whether the loading dose was given to the first monitoring group had a significant difference( P = 0.029) in the vancomycin ideal trough concentration compliance rate. Advanced age,high APACHE Ⅱ score,low serum albumin level,elevated creatinine,and whether to use diuretics( including mannitol) had significant differences in compliance rate of trough concentration 10-20 μg·mL~(-1)( P<0.05). The effects of gender,daily dose per unit mass,total bilirubin,whether to give loading dose,whether to CRRT had no statistical significance on gained concentration 10-20 μg·mL~(-1)( P>0.05). There was no significant difference in the 28 d survival rate between vancomycin trough concentration reached 10-20μg·mL~(-1) or not( χ~2= 0.805,P = 0.369). CONCLUSION The ideal trough concentration compliance rate before 4 or 5 th dosage is low in empirical use of vancomycin in critically ill patients. It is necessary to provide a loading dose for critically ill patients,and to monitor the trough concentration in an early and standardized manner,particularly patients with advanced age,high APACHE Ⅱ scores,low serum albumin,elevated creatinine and combined use of diuretics.

关键词(KeyWords): 重症患者;万古霉素;血药谷浓度
critically ill patients;Vancomycin;trough concentration

Abstract:

Keywords:

基金项目(Foundation): 广东省医院药学研究基金(2016A30)

作者(Author): 彭怀东;冯霞;王若伦;
PENG Huaidong;FENG Xia;WANG Ruolun;Department of Pharmacy,The Second Affiliated Hospital of Guangzhou Medical University;

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