CRRT中の薬物投与 - jikeimasuika.jp

1 crrt crrt crrt crrt crrt Iwagami M et al,Nephrol Dial Transplant. crrt crrt INTENSIVIST 2010,2,2 :329-345 crrt (continuous replacement therapy) hemodialysis(HD) CHD,CVVHD hemofiltration(HF) + continuous(C)=CHF,CVVH hemodiafiltration(HDF) CHDF,CVVHD (C)HF (C)HD A B INTENSIVIST 2010,2,2.

2 287-296 Federico P et al,Clinical Pharmacokinetics; 2007; 46, 12 CL=(QE CE-QD CO)/CB CL=QB (CB-CB0)/CB Qoutflow=QD+QF INTENSIVIST 2010,2,2 :241-255 crrt dose 23 ( ~ )L/hr 80 35mL/kg/hr 1825(1200~2400)ml/hr CVVH:32(29~36)mL/kg/hr CVVHDF:44(29~57)mL/kg/hr ( ) 62 2L/hr 8 27(22~34)mL/kg/hr 12mL/kg/hr(720mL/hr) crrt 10mg/L 15 20mg/L 10 15mg/L MRSA MRSA VCM MIC 15 20mg/L Sakoulas G Gold HS Cohen RA et al Effects of prolonged vancomycin administration on methicillin-resistant Staphylococcus aureus MRSA in a patient with recurrent bacteraemia J Antimicrob Chemother 2006 Apr 57 4 699-704 Hidayat LK Hsu DI Quist R et al High-dose vancomycin therapy for methicillin-resistant Staphylococcus

3 Aureus infections efficacy and toxicity Arch Intern Med 2006 Oct 23 166 19 2138-44 PK/PD AUC/MIC or Cmax/MIC Time above MIC AUC/MIC PK Gordon C et al,Crit Care Med 2009,37, 7 CHD 500mg 24st 250mg 500mg 24st 20 TDM c. CHDF 1) 15-20 mg/kg 1 C1-III 2) 1 mg/kg 24 TDM C1-III 3) TDM C1-III crrt CAVH/CVVH: 24~48 500mg VCM CAVH/CVVH CHF crrt Antibiotic Dosing in Critically Ill Adult Patients Receiving Continuous Renal Replacement Therapy CLINICAL PRACTICE CID 2005.

4 41 (15 October) 15~20mg/kg CVVH 500mg q24h~1500mg q48h CVVHD,CVVHDF 1~ q24h crrt crrt The Impact of Variation in Renal Replacement Therapy Settings on Piperacillin, Meropenem,and Vancomycin Drug Clearance in the Critically Ill: An Analysis of Published Literature and Dosing Regimens* Crit Care Med. 2014 Jul;42(7):1640-50. RRT MEPM PIPC VCM MEPM PIPC VCM MEPM 89% PIPC 83% VCM 60% MEPM PIPC VCM MEPM rs= , p= PIPC rs= ,p= VCM rs= , p= (ml/min) (ml/min) RRT RRT Vancomycin pharmacokinetics in critically ill patients receiving continuous venovenous haemodiafiltration Br J Clin Pharmacol.

5 2004 Sep;58(3):259-68. ICU 750mg q12st CVVHDF 10 crrt /hr CVVHDF L/hr 30 /min) crrt L/hr /min CVVHDF 76 CVVHDF 12 413 mg crrt VCM 750mg 12st 15 450mg 12st CHDF 15mg/kg 24 3~4 TDM 1g/24 or 12 3~4 TDM crrt crrt 12st crrt crrt

6 crrt crrt crrt crrt PK/PD crrt CLcrrt), CLtot ke PK Gordon C et al,Crit Care Med 2009,37, 7 Clearance CL CL CL [L/h] Q [L/h] crrt CLr=Curine Rurine/Cp,in,r (L/hr) =Coutflow (Qd+Qf) =Coutflow Qoutflow Coutflow/Cp,in,r=Sd(Sc) CLcrrt=Sd Qoutflow fu Qoutflow fu Qoutflow (Qb) crrt (CLcrrt) (CLtot) CLtot=fu Qoutflow+fu CLcr fu Vd (ke) Ke=CLtot/Vd Vd.

7 (L/kg) Ex) 24 AUC0-24hr,vcm/MICvcm 400 AUC0-24hr,vcm MIC AUC0-24hr,vcm (D) CLtot AUC0-24hr=D(mg/24hr)/CLtot D(mg/24hr) Ctrough=(Dvcm/Vd) (exp(-ke 24)/((1-exp(-ke 24)) D(mg) Ctrough 50 60kg crrt Qb,in=80mL/min Qoutflow= VCM:MIC=1 VCM AUC0-24hr/MIC=400hr Ctrough=10~20mg/L crrt (CLcrrt,vcm) (CLtot,vcm) CLcrrt,vcm=fu Qoutflow VCM fu L/mL)= (L/hr) CLcrrt,vcm fu CLcr 0 VCM Vd(Vd,vcm) (ke,vcm) Ke,vcm=CLtot/Vdvcm Vd= Vd= (L/kg) 60(kg)=42(L) Ke,vcm=CLtot/Vdvcm= (L/hr)/42(L) = (hr-1) PK/PD AUC0-24hr,vcm/MICvcm 400 AUC0-24,vcm(mg/hr/L)/1(mg/L)=400(hr) AUC0-24,vcm=400(mg/hr/L) AUC0-24hr=D(mg/24hr)/CLtot,vcm(L/hr) Dvcm(mg/24hr) Dvcm(mg/24hr)

8 (L/hr) =400(mg/hr/L/24hr) Dvcm(mg/24hr)=400 =336(mg/24hr) Ctrough=(Dvcm/Vd) (exp(-ke 24)/((1-exp(-ke 24)) Ctrough= (mg/L) crrt crrt crrt ))