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Kim M, Mahmood M, Estes LL, Wilson JW, Martin NJ, Marcus JE, Mittal A, O'Connell CR, Shah A. A narrative review on antimicrobial dosing in adult critically ill patients on extracorporeal membrane oxygenation. Crit Care 2024; 28:326. [PMID: 39367501 DOI: 10.1186/s13054-024-05101-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2024] [Accepted: 09/14/2024] [Indexed: 10/06/2024] Open
Abstract
The optimal dosing strategy of antimicrobial agents in critically ill patients receiving extracorporeal membrane oxygenation (ECMO) is unknown. We conducted comprehensive review of existing literature on effect of ECMO on pharmacokinetics and pharmacodynamics of antimicrobials, including antibacterials, antifungals, and antivirals that are commonly used in critically ill patients. We aim to provide practical guidance to clinicians on empiric dosing strategy for these patients. Finally, we discuss importance of therapeutic drug monitoring, limitations of current literature, and future research directions.
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Affiliation(s)
- Myeongji Kim
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Maryam Mahmood
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lynn L Estes
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - John W Wilson
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Joseph E Marcus
- Department of Medicine, Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, Fort Sam Houston, TX, USA
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Ankit Mittal
- Department of Infectious Diseases, AIG Hospitals, Hyderabad, India
| | | | - Aditya Shah
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, MN, USA
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Dhanani JA, Shekar K, Parmar D, Lipman J, Bristow D, Wallis SC, Won H, Sumi CD, Abdul-Aziz MH, Roberts JA. COVID-19 Drug Treatments Are Prone to Sequestration in Extracorporeal Membrane Oxygenation Circuits: An Ex Vivo Extracorporeal Membrane Oxygenation Study. ASAIO J 2024; 70:546-552. [PMID: 38829573 DOI: 10.1097/mat.0000000000002120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024] Open
Abstract
Drug treatments for coronavirus disease 2019 (COVID-19) dramatically improve patient outcomes, and although extracorporeal membrane oxygenation (ECMO) has significant use in these patients, it is unknown whether ECMO affects drug dosing. We used an ex vivo adult ECMO model to measure ECMO circuit effects on concentrations of specific COVID-19 drug treatments. Three identical ECMO circuits used in adult patients were set up. Circuits were primed with fresh human blood (temperature and pH maintained within normal limits). Three polystyrene jars with 75 ml fresh human blood were used as controls. Remdesivir, GS-441524, nafamostat, and tocilizumab were injected in the circuit and control jars at therapeutic concentrations. Samples were taken from circuit and control jars at predefined time points over 6 h and drug concentrations were measured using validated assays. Relative to baseline, mean (± standard deviation [SD]) study drug recoveries in both controls and circuits at 6 h were significantly lower for remdesivir (32.2% [±2.7] and 12.4% [±2.1], p < 0.001), nafamostat (21.4% [±5.0] and 0.0% [±0.0], p = 0.018). Reduced concentrations of COVID-19 drug treatments in ECMO circuits is a clinical concern. Remdesivir and nafamostat may need dose adjustments. Clinical pharmacokinetic studies are suggested to guide optimized COVID-19 drug treatment dosing during ECMO.
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Affiliation(s)
- Jayesh A Dhanani
- From the University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Chermside, Queensland, Australia
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Dinesh Parmar
- Adult Intensive Care Services, The Prince Charles Hospital, Chermside, Queensland, Australia
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Jeffrey Lipman
- From the University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- Jamieson Trauma Institute, Royal Brisbane and Womens Hospital
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
| | - Debra Bristow
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Steven C Wallis
- From the University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Australia
| | - Hayoung Won
- From the University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Australia
| | - Chandra D Sumi
- From the University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Australia
| | - Mohd H Abdul-Aziz
- From the University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Australia
| | - Jason A Roberts
- From the University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- Jamieson Trauma Institute, Royal Brisbane and Womens Hospital
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
- Department of Pharmacy, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
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Cies JJ, Moore WS, Deacon J, Enache A, Chopra A. Impact of Extracorporeal Membrane Oxygenation Circuitry on Remdesivir. J Pediatr Pharmacol Ther 2024; 29:248-254. [PMID: 38863849 PMCID: PMC11163913 DOI: 10.5863/1551-6776-29.3.248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/01/2023] [Indexed: 06/13/2024]
Abstract
OBJECTIVES This study aimed to determine the oxygenator impact on alterations of remdesivir (RDV) in a contemporary neonatal/pediatric (1/4-inch) and adolescent/adult (3/8-inch) extracorporeal membrane -oxygenation (ECMO) circuit including the Quadrox-i oxygenator. METHODS One-quarter-inch and a 3/8-inch, simulated closed-loop ECMO circuits were prepared with a Quadrox-i pediatric and Quadrox-i adult oxygenator and blood primed. Additionally, 1/4-inch and 3/8-inch circuits were also prepared without an oxygenator in series. A 1-time dose of RDV was administered into the circuits and serial preoxygenator and postoxygenator concentrations were obtained at 0 to 5 minutes, and 1-, 2-, 3-, 4-, 5-, 6-, 8-, 12-, and 24-hour time points. The RDV was also maintained in a glass vial and samples were taken from the vial at the same time periods for control purposes to assess for spontaneous drug degradation. RESULTS For the 1/4-inch circuits with an oxygenator, there was a 35% to 60% RDV loss during the study period. For the 1/4-inch circuits without an oxygenator, there was a 5% to 20% RDV loss during the study period. For the 3/8-inch circuit with and without an oxygenator, there was a 60% to 70% RDV loss during the study period. CONCLUSIONS There was RDV loss within the circuit during the study period and the RDV loss was more pronounced with the larger 3/8-inch circuit when compared with the 1/4-inch circuit. The impact of the -oxygenator on RDV loss appears to be variable and possibly dependent on the size of the circuit and -oxygenator. These preliminary data suggest RDV dosing may need to be adjusted for concern of drug loss via the ECMO circuit. Additional single- and multiple-dose studies are needed to validate these findings.
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Affiliation(s)
- Jeffrey J. Cies
- The Center for Pediatric Pharmacotherapy LLC (JJC, WSM, AC), Pottstown, PA
- St. Christopher’s Hospital for Children (JJC, JD), Philadelphia, PA
- Drexel University College of Medicine (JJC), Philadelphia, PA
| | - Wayne S. Moore
- The Center for Pediatric Pharmacotherapy LLC (JJC, WSM, AC), Pottstown, PA
| | - Jillian Deacon
- St. Christopher’s Hospital for Children (JJC, JD), Philadelphia, PA
| | - Adela Enache
- Atlantic Diagnostic Laboratories (AE), Bensalem, PA
| | - Arun Chopra
- The Center for Pediatric Pharmacotherapy LLC (JJC, WSM, AC), Pottstown, PA
- NYU Langone Medical Center (AC), New York, NY
- NYU School of Medicine (AC), New York, NY
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Nishikawa A, Ito I, Yonezawa A, Itohara K, Matsubara T, Sato Y, Matsumura K, Hamada S, Tanabe N, Kai S, Imoto E, Yoshikawa K, Ohtsuru S, Yanagita M, Hirai T, Terada T. Pharmacokinetics of GS-441524, the active metabolite of remdesivir, in patients receiving continuous renal replacement therapy: A case series. J Infect Chemother 2024; 30:348-351. [PMID: 37866621 DOI: 10.1016/j.jiac.2023.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 09/22/2023] [Accepted: 10/19/2023] [Indexed: 10/24/2023]
Abstract
Remdesivir plays a key role in the treatment of coronavirus disease in 2019 (COVID-19). Haemodialysis is sometimes required for hospitalised patients with COVID-19, and patients undergoing haemodialysis are at an increased risk of severe COVID-19. In the present study, we report the serum concentrations of GS-441524, the active metabolite of remdesivir, in four patients undergoing continuous renal replacement therapy (CRRT). Patient 1, a male aged 70s, received a loading dose of 200 mg remdesivir on day 1, followed by 100 mg remdesivir from day 2, according to the package insert as in non-haemodialysis patients. The mean trough serum concentration of GS-441524 was 783.5 ng/mL, which was approximately 7-fold higher than the mean for patients with an estimated glomerular filtration rate (eGFR) ≥ 60 mL/min. Patients 2-4 received a loading dose of 200 mg remdesivir on day 1, followed by 100 mg once every 2 days from day 2. The mean trough serum concentrations of GS-441524 were 302.2 ng/mL, 585.8 ng/mL and 677.3 ng/mL, respectively. These were 3 to 6-fold higher than the mean for patients with eGFR ≥60 mL/min. The target doses for patients 1, 2, 3, and 4 receiving CRRT were 13.6 mL/kg/h, 6.0-12.5 mL/kg/h, 20.1 mL/kg/h, and 15.1 mL/kg/h, respectively, using a polysulphone membrane. The package insert dose of remdesivir is an overdose for CRRT patients with a target dose of 10-20 mL/kg/h. In low-intensity CRRT, as in Japan, it may be necessary to extend the interval between the doses of remdesivir.
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Affiliation(s)
- Asami Nishikawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Isao Ito
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Atsushi Yonezawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan; Division of Integrative Clinical Pharmacology, Faculty of Pharmacy, Keio University, Tokyo, Japan.
| | - Kotaro Itohara
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Takeshi Matsubara
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yuki Sato
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Katsuyuki Matsumura
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
| | - Satoshi Hamada
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Naoya Tanabe
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinichi Kai
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
| | | | | | - Shigeru Ohtsuru
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Motoko Yanagita
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Institute for the Advanced Study of Human Biology (WPI-ASHBi), Kyoto University, Kyoto, Japan
| | - Toyohiro Hirai
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tomohiro Terada
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, Kyoto, Japan
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Honeycutt CC, McDaniel CG, McKnite A, Hunt JP, Whelan A, Green DJ, Watt KM. Meropenem extraction by ex vivo extracorporeal life support circuits. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2023; 55:159-166. [PMID: 38099629 PMCID: PMC10723574 DOI: 10.1051/ject/2023035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/28/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Meropenem is a broad-spectrum carbapenem-type antibiotic commonly used to treat critically ill patients infected with extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae. As many of these patients require extracorporeal membrane oxygenation (ECMO) and/or continuous renal replacement therapy (CRRT), it is important to understand how these extracorporeal life support circuits impact meropenem pharmacokinetics. Based on the physicochemical properties of meropenem, it is expected that ECMO circuits will minimally extract meropenem, while CRRT circuits will rapidly clear meropenem. The present study seeks to determine the extraction of meropenem from ex vivo ECMO and CRRT circuits and elucidate the contribution of different ECMO circuit components to extraction. METHODS Standard doses of meropenem were administered to three different configurations (n = 3 per configuration) of blood-primed ex vivo ECMO circuits and serial sampling was conducted over 24 h. Similarly, standard doses of meropenem were administered to CRRT circuits (n = 4) and serial sampling was conducted over 4 h. Meropenem was administered to separate tubes primed with circuit blood to serve as controls to account for drug degradation. Meropenem concentrations were quantified, and percent recovery was calculated for each sample. RESULTS Meropenem was cleared at a similar rate in ECMO circuits of different configurations (n = 3) and controls (n = 6), with mean (standard deviation) recovery at 24 h of 15.6% (12.9) in Complete circuits, 37.9% (8.3) in Oxygenator circuits, 47.1% (8.2) in Pump circuits, and 20.6% (20.6) in controls. In CRRT circuits (n = 4) meropenem was cleared rapidly compared with controls (n = 6) with a mean recovery at 2 h of 2.36% (1.44) in circuits and 93.0% (7.1) in controls. CONCLUSION Meropenem is rapidly cleared by hemodiafiltration during CRRT. There is minimal adsorption of meropenem to ECMO circuit components; however, meropenem undergoes significant degradation and/or plasma metabolism at physiological conditions. These ex vivo findings will advise pharmacists and physicians on the appropriate dosing of meropenem.
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Affiliation(s)
| | | | - Autumn McKnite
- Department of Pharmacology and Toxicology, University of Utah College of Pharmacy Salt Lake City Utah USA
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah Medical Center Salt Lake City Utah USA
| | - J. Porter Hunt
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah Medical Center Salt Lake City Utah USA
| | - Aviva Whelan
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah Medical Center Salt Lake City Utah USA
- Division of Critical Care, Department of Pediatrics, University of Utah Medical Center Salt Lake City Utah USA
| | - Danielle J. Green
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah Medical Center Salt Lake City Utah USA
- Division of Critical Care, Department of Pediatrics, University of Utah Medical Center Salt Lake City Utah USA
| | - Kevin M. Watt
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah Medical Center Salt Lake City Utah USA
- Division of Critical Care, Department of Pediatrics, University of Utah Medical Center Salt Lake City Utah USA
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Khurana N, Sünner T, Hubbard O, Imburgia C, Stoddard GJ, Yellepeddi V, Ghandehari H, Watt KM. Micellar Encapsulation of Propofol Reduces its Adsorption on Extracorporeal Membrane Oxygenator (ECMO) Circuit. AAPS J 2023; 25:52. [PMID: 37225960 DOI: 10.1208/s12248-023-00817-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 04/30/2023] [Indexed: 05/26/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life-saving cardiopulmonary bypass device used on critically ill patients with refractory heart and lung failure. Patients supported with ECMO receive numerous drugs to treat critical illnesses and the underlying diseases. Unfortunately, most drugs prescribed to patients on ECMO lack accurate dosing information. Dosing can be variable in this patient population because the ECMO circuit components can adsorb drugs and affect drug exposure substantially. Propofol is a widely used anesthetic in ECMO patients and is known to have high adsorption rates in ECMO circuits due to its high hydrophobicity. In an attempt to reduce adsorption, we encapsulated propofol with Poloxamer 407 (Polyethylene-Polypropylene Glycol). Size and polydispersity index (PDI) were characterized using dynamic light scattering. Encapsulation efficiency was analyzed using High performance liquid chromatography. Cytocompatibility of micelles was analyzed against human macrophages and the formulation was finally injected in an ex-vivo ECMO circuit to determine the adsorption of propofol. Size and PDI of micellar propofol were 25.5 ± 0.8 nm and 0.08 ± 0.01, respectively. Encapsulation efficiency of the drug was 96.1 ± 1.3%. Micellar propofol demonstrated colloidal stability at physiological temperature for a period of 7 days, and was cytocompatible with human macrophages. Micellar propofol demonstrated a significant reduction in adsorption of propofol in the ECMO circuit at earlier time points compared to free propofol (Diprivan®). We observed 97 ± 2% recovery of the propofol from the micellar formulation after an infusion. These results demonstrate the potential of micellar propofol to reduce drug adsorption to ECMO circuit.
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Affiliation(s)
- Nitish Khurana
- Utah Center for Nanomedicine, Department of Molecular Pharmaceutics, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
| | - Till Sünner
- Philipps Universität Marburg, Institut für Pharmazeutische Technologie und Biopharmazie, Marburg, Germany
| | - Oliver Hubbard
- Department of Biomedical Engineering, College of Engineering, University of Utah, Salt Lake City, UT, USA
| | - Carina Imburgia
- Division of Clinical Pharmacology, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Gregory J Stoddard
- Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Venkata Yellepeddi
- Utah Center for Nanomedicine, Department of Molecular Pharmaceutics, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
- Division of Clinical Pharmacology, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Hamidreza Ghandehari
- Utah Center for Nanomedicine, Department of Molecular Pharmaceutics, College of Pharmacy, University of Utah, Salt Lake City, UT, USA.
- Department of Biomedical Engineering, College of Engineering, University of Utah, Salt Lake City, UT, USA.
| | - Kevin M Watt
- Division of Clinical Pharmacology, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, UT, USA
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Cefepime Extraction by Extracorporeal Life Support Circuits. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2022; 54:212-222. [PMID: 36742220 PMCID: PMC9891479 DOI: 10.1182/ject-212-222] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 06/23/2022] [Indexed: 02/07/2023]
Abstract
Extracorporeal life support (ECLS) devices are lifesaving for critically ill patients with multi-organ dysfunction. Despite this, patients supported with ECLS are at high risk for ECLS-related complications, including nosocomial infections, and mortality rates are high in this patient population. The high mortality rates are suspected to be, in part, a result of significantly altered drug disposition by the ECLS circuit, resulting in suboptimal antimicrobial dosing. Cefepime is commonly used in critically ill patients with serious infections. Cefepime dosing is not routinely guided by therapeutic drug monitoring and treatment success is dependent upon the percentage of time of the dosing interval that the drug concentration remains above the minimum inhibitory concentration of the organism. This ex vivo study measured the extraction of cefepime by continuous renal replacement therapy (CRRT) and extracorporeal membrane oxygenation (ECMO) circuits. Cefepime was studied in four closed-loop CRRT circuit configurations and a single closed-loop ECMO circuit configuration. Circuits were primed with a physiologic human blood-plasma mixture and the drug was dosed to achieve therapeutic concentrations. Serial blood samples were collected over time and concentrations were quantified using validated assays. In ex vivo CRRT experiments, cefepime was rapidly cleared by dialysis, hemofiltration, and hemodiafiltration, with greater than 96% cefepime eliminated from the circuit by 2 hours. In the ECMO circuits, the mean recovery of cefepime was similar in both circuit and standard control. Mean (standard deviation) recovery of cefepime in the ECMO circuits (n = 6) was 39.2% (8.0) at 24 hours. Mean recovery in the standard control (n = 3) at 24 hours was 52.2% (1.5). Cefepime is rapidly cleared by dialysis, hemofiltration, and hemodiafiltration in the CRRT circuit but minimally adsorbed by either the CRRT or ECMO circuits. Dosing adjustments are needed for patients supported with CRRT.
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