In this episode I’ll:
1. Discuss an article about the dose of daptomycin and bacterial clearance.
2. Answer the drug information question “Should lidocaine be added to potassium infusions to reduce pain?”
3. Share a tip for responding to inpatient medical emergencies.
Lead author: Yu-Chung Chuang
Published in Critical Care Medicine June 2018
Background
Vancomycin-resistant enterococcus bacteremia is a serious healthcare-associated infection. Many recent studies have highlighted the need for using higher doses of daptomycin if it is used for VRE bacteremia. And while linezolid is bacteriostatic in vitro, it has an FDA approval for VRE bacteremia. The authors of this study sought to compare the effects of linezolid and two different dose ranges of daptomycin on bacterial clearance in patients with vancomycin-resistant enterococci bloodstream infections.
Methods
The study was a prospective observational study at two university hospitals. Patients with VRE bacteremia were enrolled. Serial blood samples were collected and real-time quantitative PCR testing was used to monitor bacterial load.
Results
108 patients with VRE bactermia were enrolled. Quantitative PCR assays were performed on 465 blood isolates. 63 patients received a conventional dose of daptomycin from 6–9 mg/kg, 15 patients received high-dose daptomycin above 9 mg/kg, and 30 patients were treated with linezolid 600 mg every 12 hr. In each case monotherapy against VRE was used. Survivors had a more rapid early bacterial clearance than nonsurvivors. Multivariable logistic regression showed that a slower early bacterial clearance independently predicted increased mortality with an odds ratio of 3.21, which was statistically significant. The conventional dose of daptomycin was associated with a significantly slower rate of bacterial clearance than both high-dose daptomycin and linezolid.
Conclusion
The authors concluded:
We found that survivors of vancomycin-resistant enterococci bloodstream infection had a significantly more rapid early bacterial clearance by quantitative polymerase chain reaction than nonsurvivors. High-dose daptomycin and linezolid were associated with more rapid bacterial clearance than conventional dose daptomycin. These results support recommendations that conventional dose daptomycin not be used for the treatment of patients with vancomycin-resistant enterococci bloodstream infection.
Discussion
This study highlights the importance of using the correct dose of daptomycin for VRE bacteremia. Other studies that add to the evidence for using high dose daptomycin for VRE have been discussed in episodes 153 and 91. Sometimes, the dose of daptomycin at 10 mg/kg seems excessive for obese patients, and providers are hesitant to use the higher dose. If I can not convince a provider to use high-dose daptomycin for VRE bactermia, then I ask to switch to linezolid instead as this should lead to a better chance of a good outcome for the patient.
Drug information question
Q: Should lidocaine be added to potassium infusions to reduce pain?
A: I don’t think it is worth the risk.
I was surprised to hear that this practice is still considered. There are some small studies from the late 1980’s that examined potassium chloride with and without lidocaine to reduce infusion pain. But there are also case reports of medications errors – some very significant – associated with the practice of adding lidocaine to potassium infusions.
There are many other options for reducing infusion pain with potassium chloride, including diluting the infusion further, slowing the rate, using oral replacement, and using a small bore IV in a large vein. I think the potential risk of adding lidocaine to potassium infusions outweighs the potential benefit, and I personally avoid this practice.
Tip for responding to inpatient medical emergencies
Remember that rapid sequence intubation is not indicated in a “crash airway.” A crash airway scenario is when the patient is unconscious and apneic, or in cardiorespiratory arrest. These patients may be intubated without any premedication. If a patient with a crash airway is not sufficiently relaxed, they may receive a dose of a paralytic without sedation – this is perhaps the only scenario where a paralytic may be considered without the patient being adequately sedated first.
Keep careful track of the time you have given a paralytic for a crash airway – in the event of a return of spontaneous circulation, you will want to check the time against the duration of action of the paralytic to ensure that the patient does not experience an awake-but-paralyzed scenario.
To celebrate 3 years of podcasting at pharmacyjoe.com I am giving away 3 copies of my book, A Pharmacist’s Guide to Inpatient Medical Emergencies and my 6-module Code Blue and Rapid Response Training Program for Hospital Pharmacists.
To enter the giveaway contest go to pharmacyjoe.com/3. The contest ends the evening of Tuesday, July 24 2018.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
Joe, with regards to lido in KCl IVPB, I too avoid this practice, but my rationale is that if it extravasates there can be tissue damage and that could go unnoticed because patient wont feel it, that is strictly based on my own preference. The addition of lido in a prebuilt order set with the lido concentration specified for the most part is not like it was in the 80’s when it wasn’t necessarily added by pharmacy but by the RN at the bedside