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van Saet A, Tibboel D. The influence of cardiopulmonary bypass on pediatric pharmacokinetics. Expert Opin Drug Metab Toxicol 2023; 19:333-344. [PMID: 37334571 DOI: 10.1080/17425255.2023.2227556] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 06/16/2023] [Indexed: 06/20/2023]
Abstract
INTRODUCTION Every year thousands of children undergo surgery for congenital heart disease. Cardiac surgery requires the use of cardiopulmonary bypass, which can have unexpected consequences for pharmacokinetic parameters. AREAS COVERED We describe the pathophysiological properties of cardiopulmonary bypass that may influence pharmacokinetic parameters, with a focus on literature published in the last 10 years. We performed a PubMed database search with the keywords 'Cardiopulmonary bypass' AND 'Pediatric' AND 'Pharmacokinetics'. We searched related articles on PubMed and checked the references of articles for relevant studies. EXPERT OPINION Interest in the influence of cardiopulmonary bypass on pharmacokinetics has increased over the last 10 years, especially due to the use of population pharmacokinetic modeling. Unfortunately, study design usually limits the amount of information that can be obtained with sufficient power and the best way to model cardiopulmonary bypass is yet unknown. More information is needed on the pathophysiology of pediatric heart disease and cardiopulmonary bypass. Once adequately validated, PK models should be integrated in the patient electronic database integrating covariates and biomarkers influencing PK, making it possible to predict real-time drug concentrations and guide further clinical management for the individual patient at the bedside.
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Affiliation(s)
- Annewil van Saet
- Department of Anesthesiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Dick Tibboel
- Department of Intensive Care and Pediatric Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
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2
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Kaplina A, Zaikova E, Ivanov A, Volkova Y, Alkhova T, Nikiforov V, Latypov A, Khavkina M, Fedoseeva T, Pervunina T, Skorobogatova Y, Volkova S, Ulyantsev V, Kalinina O, Sitkin S, Petrova N. Intestinal microbiome changes in an infant with right atrial isomerism and recurrent necrotizing enterocolitis: A case report and review of literature. World J Clin Cases 2022; 10:10583-10599. [PMID: 36312470 PMCID: PMC9602219 DOI: 10.12998/wjcc.v10.i29.10583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/20/2022] [Accepted: 08/17/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) is a multifactorial disease that predominantly affects premature neonates. Intestinal dysbiosis plays a critical role in NEC pathogenesis in premature neonates. The main risk factor for NEC in term infants is mesenteric hypoperfusion associated with ductal-dependent congenital heart disease (CHD) that eventually leads to intestinal ischemia. The incidence of NEC in neonates with critical CHD is 6.8%-13%. However, the role of the intestinal microbiome in NEC pathogenesis in infants with ductal-dependent CHD remains unclear.
CASE SUMMARY A male term neonate with right atrial isomerism underwent modified Blalock-Taussig shunt placement on the 14th day of life and had persistent mesenteric hypoperfusion after surgery. The patient had episodes of NEC stage IIA on the 1st and 28th days after cardiac surgery. Fecal microbial composition was analyzed before and after cardiac surgery by sequencing region V4 of the 16S rRNA gene. Before surgery, species belonging to genera Veillonella and Clostridia and class Gammaproteobacteria were detected, Bifidobacteriaceae showed a low abundance. The first NEC episode was associated with postoperative hemodynamic instability, intestinal ischemia-reperfusion injury during cardiopulmonary bypass, and a high abundance of Clostridium paraputrificum (Clostridium sensu stricto I) (56.1%). Antibacterial therapy after the first NEC episode resulted in increased abundance of Gammaproteobacteria, decreased abundance of Firmicutes, and low alpha diversity. These changes in the microbial composition promoted the growth of Clostridium sensu stricto I (72.0%) before the second NEC episode.
CONCLUSION A high abundance of Clostridium sensu stricto I and mesenteric hypoperfusion may have contributed to NEC in the present case.
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Affiliation(s)
- Aleksandra Kaplina
- Research Laboratory of Physiology and Diseases of Newborns, Almazov National Medical Research Centre, St. Petersburg 197341, Russia
| | - Ekaterina Zaikova
- Research Laboratory of Autoimmune and Autoinflammatory Diseases, Almazov National Medical Research Centre, St. Petersburg 197341, Russia
| | - Artem Ivanov
- International Laboratory of Computer Technologies, ITMO University, St. Petersburg 197101, Russia
| | - Yulia Volkova
- Department of Cardiovascular Surgery for Children, Almazov National Medical Research Centre, St. Petersburg 197341, Russia
| | - Tatiana Alkhova
- Department of Neonatal Physiology with an ICU Ward, Almazov National Medical Research Centre, St. Petersburg 197341, Russia
| | - Vladimir Nikiforov
- Pediatric Cardiac Intensive Care Unit, Almazov National Medical Research Centre, St. Petersburg 197341, Russia
| | - Alexander Latypov
- Department of Cardiovascular Surgery for Children, Almazov National Medical Research Centre, St. Petersburg 197341, Russia
| | - Marina Khavkina
- Neonatal and Preterm Special Care Unit (2nd Stage Care), Almazov National Medical Research Centre, St. Petersburg 197341, Russia
| | - Tatiana Fedoseeva
- Research Laboratory of Physiology and Diseases of Newborns, Almazov National Medical Research Centre, St. Petersburg 197341, Russia
| | - Tatiana Pervunina
- Institute of Perinatology and Pediatrics, Almazov National Medical Research Centre, St. Petersburg 197341, Russia
| | - Yulia Skorobogatova
- Express Laboratory of Perinatal Centre, Almazov National Medical Research Centre, St. Petersburg 197341, Russia
| | - Svetlana Volkova
- Clinical Diagnostic Laboratory, Almazov National Medical Research Centre, St. Petersburg 197341, Russia
| | - Vladimir Ulyantsev
- International Laboratory of Computer Technologies, ITMO University, St. Petersburg 197101, Russia
| | - Olga Kalinina
- Research Laboratory of Autoimmune and Autoinflammatory Diseases, Almazov National Medical Research Centre, St. Petersburg 197341, Russia
| | - Stanislav Sitkin
- Epigenetics and Metagenomics Group, Institute of Perinatology and Pediatrics, Almazov National Medical Research Centre, St. Petersburg 197341, Russia
- Department of Internal Diseases, Gastroenterology and Dietetics, North-Western State Medical University named after I.I. Mechnikov, St. Petersburg 191015, Russia
| | - Natalia Petrova
- Research Laboratory of Physiology and Diseases of Newborns, Almazov National Medical Research Centre, St. Petersburg 197341, Russia
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Pharmacokinetics of Antibiotics in Pediatric Intensive Care: Fostering Variability to Attain Precision Medicine. Antibiotics (Basel) 2021; 10:antibiotics10101182. [PMID: 34680763 PMCID: PMC8532953 DOI: 10.3390/antibiotics10101182] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/22/2021] [Accepted: 09/24/2021] [Indexed: 12/16/2022] Open
Abstract
Children show important developmental and maturational changes, which may contribute greatly to pharmacokinetic (PK) variability observed in pediatric patients. These PK alterations are further enhanced by disease-related, non-maturational factors. Specific to the intensive care setting, such factors include critical illness, inflammatory status, augmented renal clearance (ARC), as well as therapeutic interventions (e.g., extracorporeal organ support systems or whole-body hypothermia [WBH]). This narrative review illustrates the relevance of both maturational and non-maturational changes in absorption, distribution, metabolism, and excretion (ADME) applied to antibiotics. It hereby provides a focused assessment of the available literature on the impact of critical illness—in general, and in specific subpopulations (ARC, extracorporeal organ support systems, WBH)—on PK and potential underexposure in children and neonates. Overall, literature discussing antibiotic PK alterations in pediatric intensive care is scarce. Most studies describe antibiotics commonly monitored in clinical practice such as vancomycin and aminoglycosides. Because of the large PK variability, therapeutic drug monitoring, further extended to other antibiotics, and integration of model-informed precision dosing in clinical practice are suggested to optimise antibiotic dose and exposure in each newborn, infant, or child during intensive care.
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Rimmler C, Lanckohr C, Mittrup M, Welp H, Würthwein G, Horn D, Fobker M, Ellger B, Hempel G. Population pharmacokinetic evaluation of cefuroxime in perioperative antibiotic prophylaxis during and after cardiopulmonary bypass. Br J Clin Pharmacol 2020; 87:1486-1498. [PMID: 32959896 DOI: 10.1111/bcp.14556] [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: 02/11/2020] [Revised: 08/30/2020] [Accepted: 09/09/2020] [Indexed: 11/27/2022] Open
Abstract
AIMS The purpose of this study was to explore pharmacokinetic and pharmacodynamic aspects of a contemporary dosing scheme of cefuroxime as perioperative prophylaxis in cardiac surgery using cardiopulmonary bypass (CPB). METHODS Cefuroxime plasma concentrations were measured in 23 patients. A 1.5-g dose of cefuroxime was administered at start of surgery and CPB, followed by 3 additional doses every 6 hours postoperative. Drug levels were used to build a population pharmacokinetic model. Target attainment for Staphylococcus aureus (2-8 mg/L) and Escherichia coli (8-32 mg/L) were evaluated and dosing strategies for optimization were investigated. RESULTS A dosing scheme of 1.5 g cefuroxime preoperatively with a repetition at start of CPB achieves plasma unbound concentrations of 8 mg/L in almost all patients during surgery. The second administration is critical to provide this level of coverage. Simulations indicate that higher unbound concentrations up to 32 mg/L are reached by a continuous infusion rate of 1 g/h after a bolus of 1 g. In the postoperative phase, most patients do not reach unbound concentrations above 2 mg/L. To improve target attainment up to 8 mg/L, the continuous application of cefuroxime with infusion rates of 0.125-0.25 g/h is simulated and shown to be an alternative to bolus dosing. CONCLUSION Dosing recommendations for cefuroxime as perioperative antibiotic prophylaxis in cardiac surgery are sufficient to reach plasma unbound concentration to cover S. aureus during the operation. Target attainment is not achieved in the postoperative period. Continuous infusion of cefuroxime may optimize target attainment.
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Affiliation(s)
- Christer Rimmler
- Department of Pharmaceutical and Medical Chemistry-Clinical Pharmacy, Muenster, Germany
| | - Christian Lanckohr
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Miriam Mittrup
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Henryk Welp
- Department of Cardiac Surgery, University Hospital Muenster, Muenster, Germany
| | - Gudrun Würthwein
- Department of Pharmaceutical and Medical Chemistry-Clinical Pharmacy, Muenster, Germany
| | - Dagmar Horn
- Department of Pharmacy, University Hospital of Muenster, Muenster, Germany
| | - Manfred Fobker
- Center for Laboratory Medicine, University Hospital Muenster, Muenster, Germany
| | - Björn Ellger
- Department of Anesthesiology, Intensive Care and Pain Medicine, Klinikum Westfalen, Dortmund, Germany
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry-Clinical Pharmacy, Muenster, Germany
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Pharmacokinetic Model for Cefuroxime Dosing during Cardiac Surgery under Cardiopulmonary Bypass. Antimicrob Agents Chemother 2020; 64:AAC.01687-20. [PMID: 33020154 DOI: 10.1128/aac.01687-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 09/24/2020] [Indexed: 12/17/2022] Open
Abstract
Cefuroxime (CXM) is an antibiotic recommended for surgical site infection prevention in cardiac surgery. However, the dosing regimens commonly used do not sustain therapeutic concentrations throughout surgery. The aim of this study was to conduct a population analysis of CXM pharmacokinetics (PK), and to propose an optimized dosing regimen. Adult patients undergoing cardiac surgery under cardiopulmonary bypass (CPB) received a 1,500 mg CXM intravenous bolus followed by a 750 mg bolus at CPB priming, then every 2 h thereafter. Model-based PK simulations were used to develop an optimized dosing regimen and evaluate its efficacy in attaining various concentration thresholds, including those recommended in US and European guidelines. In total, 447 CXM measurements were acquired in 50 patients. A two-compartment model best fit the data, with total body weight and creatinine clearance determining interpatient variability in the central and peripheral volumes of distribution, and in elimination clearance, respectively. Using our optimized dosing regimen, different dosing schemes adapted to body weight and renal function were calculated to attain total concentration thresholds ranging from 12 to 96 mg/liter. Our simulations showed that the dosing regimens recommended in US and European guidelines failed to maintain concentrations above 48 mg/liter. Our individualized dosing strategy was capable of ensuring therapeutic CXM concentrations conforming to each target threshold. Our model yielded an optimized CXM dosing regimen adapted to body weight and renal function, and sustaining therapeutic concentrations consistent with each desired threshold. The optimal target concentration and necessary duration of its maintenance in cardiac surgery still remain unclear.
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Fullerton JN, Della Pasqua O, Likic R. Model antibiotic use to improve outcomes. Br J Clin Pharmacol 2020; 87:738-740. [PMID: 33078437 DOI: 10.1111/bcp.14559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 08/21/2020] [Accepted: 09/11/2020] [Indexed: 11/28/2022] Open
Affiliation(s)
- James N Fullerton
- Centre for Clinical Pharmacology and Therapeutics, University College London, London, UK
| | | | - Robert Likic
- School of Medicine, University of Zagreb, Zagreb, Croatia.,Department of Internal Medicine, Division of Clinical Pharmacology and Therapeutics, University Hospital Centre Zagreb, Zagreb, Croatia
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Gergs U, Becker L, Okoniewski R, Weiss M, Delank KS, Neumann J. Population pharmacokinetics of cefuroxime and uptake into hip and spine bone of patients undergoing orthopaedic surgery. J Pharm Pharmacol 2019; 72:364-370. [PMID: 31858616 DOI: 10.1111/jphp.13214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 11/29/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To reduce the incidence of peri- or postoperative infections in orthopaedic surgery, patients are prophylactically treated with antibiotics. Here, we wanted to know whether effective bone and intervertebral disc concentrations of cefuroxime are reached. METHODS Patients undergoing surgery of hip (N = 40; 62.5% male) or spine (N = 40; 55% male) were pretreated with 1.5 g of the second-generation cephalosporin cefuroxime before surgery. We studied plasma population kinetics and bone and intervertebral disc (C5/6 till L5/S1) concentrations of cefuroxime using high-performance liquid chromatography. KEY FINDINGS The plasma kinetics of cefuroxime in 80 patients was analysed using a population approach. The clearance amounted to 7.86 l/h. The peripheral and central volumes of distribution were estimated as 8.45 and 10.4 l, respectively. The concentrations in hip samples amounted to 9.8 ± 0.6 µg/g in cancellous bone and 8.9 ± 0.8 µg/g in cortical bone. Cefuroxime concentrations in vertebral bone and intervertebral discs were calculated as 9.6 ± 1.3 and 8.9 ± 1.1 µg/g, respectively. CONCLUSION Even if a majority of patients undergoing hip or spine surgery probably achieved adequate concentrations of cefuroxime, not all patients reached bone concentrations of cefuroxime above a recommended breakpoint for susceptible germs at the time of surgery.
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Affiliation(s)
- Ulrich Gergs
- Institute for Pharmacology and Toxicology, Medical Faculty, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Lina Becker
- Department of Orthopedic, Trauma and Reconstructive Surgery, University Hospital of Halle, Halle, Germany
| | - Richard Okoniewski
- Department of Orthopedic, Trauma and Reconstructive Surgery, University Hospital of Halle, Halle, Germany
| | - Michael Weiss
- Institute for Pharmacology and Toxicology, Medical Faculty, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Karl-Stefan Delank
- Department of Orthopedic, Trauma and Reconstructive Surgery, University Hospital of Halle, Halle, Germany
| | - Joachim Neumann
- Institute for Pharmacology and Toxicology, Medical Faculty, Martin Luther University Halle-Wittenberg, Halle, Germany
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Ing RJ, Twite M. The Year in Review: Anesthesia for Congenital Heart Disease 2018. Semin Cardiothorac Vasc Anesth 2019; 23:205-211. [DOI: 10.1177/1089253219845414] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This review article surveys the published literature from January 2018 to March 2019. Three themes were identified and articles were selected based on their originality and interest to anesthesiologists caring for patients with congenital heart disease.
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Affiliation(s)
- Richard J. Ing
- Children’s Hospital Colorado, Anschutz Medical Campus, Aurora, CO, USA
- University of Colorado, Aurora, CO, USA
| | - Mark Twite
- Children’s Hospital Colorado, Anschutz Medical Campus, Aurora, CO, USA
- University of Colorado, Aurora, CO, USA
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Gertler R, Gruber M, Wiesner G, Grassin-Delyle S, Urien S, Tassani-Prell P, Martin K. Pharmacokinetics of cefuroxime in infants and neonates undergoing cardiac surgery. Br J Clin Pharmacol 2018; 84:2020-2028. [PMID: 29761538 DOI: 10.1111/bcp.13632] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 04/22/2018] [Accepted: 04/26/2018] [Indexed: 12/29/2022] Open
Abstract
AIMS Very little data exist regarding the effect of cardiopulmonary bypass (CPB) on cefuroxime (CXM) pharmacokinetics in children less than one year of age. METHODS 50 mg kg-1 CXM i.v. after induction were followed by 75 mg kg-1 into the CPB circuit. In 42 patients undergoing cardiac surgery, 15-20 samples were obtained between 5 and 360 min after the first dose. Total CXM concentrations were measured by high-performance liquid chromatography and a pharmacokinetic/pharmacodynamic (PK/PD) modelling was performed. RESULTS Using a fixed protein binding of 15.6% for CXM, peak plasma concentrations of unbound CXM were 229 ± 52 μg ml-1 after the first bolus and 341 ± 86 μg ml-1 on CPB. Nadir concentrations before CPB were 69 ± 20 μg ml-1 and six hours later decreased to 41 ± 19 μg ml-1 with and 24 ± 14 μg ml-1 without CPB. A two-compartment model was fitted with the main covariates body weight, CPB and postmenstrual age (PMA). PK parameters were as follows: systemic clearance, 5.15 [95% CI 4.5-5.8] l h-1 ; central volume of distribution, 11.25 [9.41-13.09] l; intercompartmental clearance, 18.19 [14.79-21.58] l h-1 ; and peripheral volume, 17.07 [15.7-18.5] L. ƒT > MIC of 32 μg ml-1 for an 8-h time period was between 70 and 100% (2.5-10 kg BW). According to our simulation, 25 mg ml-1 CXM as a primary bolus and into the prime plus a 5 mg kg-1 h-1 infusion maintain CXM concentrations continuously above 32 μg ml-1 . CONCLUSIONS The routine dosing regimen provided was sufficient for prophylaxis, but continuous dosing can provide a higher percentage of ƒT > MIC.
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Affiliation(s)
- Ralph Gertler
- Klinik für Anaesthesie, operative und allgemeine Intensivmedizin, Notfallmedizin, Klinikum Links der Weser, University Medical Center Hamburg-Eppendorf, Bremen, Germany
| | - Michael Gruber
- Department of Anesthesia, University Hospital Regensburg, Germany
| | - Gunther Wiesner
- Institute of Anaesthesiology, German Heart Centre Munich, Technical University Munich, Germany
| | - Stanislas Grassin-Delyle
- Département des Maladies des Voies Respiratoires, Hôpital Foch, Université Versailles Saint Quentin en Yvelines, Université Paris Saclay, F-92150, Suresnes, France.,Plateforme de spectrométrie de masse et INSERM UMR1173, UFR Sciences de la Santé Simone Veil, Université Versailles Saint Quentin en Yvelines, Université Paris Saclay, F-78180, Montigny-le-Bretonneux, France
| | - Saïk Urien
- CIC1419 Inserm Necker-Cochin, URC Paris Descartes Necker Cochin, AP-HP, Paris, France; EAU7323, Université Paris Descartes, Sorbonne Paris Cité, France
| | - Peter Tassani-Prell
- Institute of Anaesthesiology, German Heart Centre Munich, Technical University Munich, Germany
| | - Klaus Martin
- Institute of Anaesthesiology, German Heart Centre Munich, Technical University Munich, Germany
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