Safe Administration of Vancomycin

My team of pharmacists and I are always on the lookout for ways to enhance medication safety in your ASC. Sometimes I notice a routine part of our everyday patient care that can be enhanced. In this case, administration of vancomycin. I suggest you discuss vancomycin administration with your staff, along with potential complications and treatments. Vancomycin needs special consideration for safe administration in the ASC since this drug has potential for adverse events. Below is an excerpt from LexiComp: Infusion Reactions: Rapid IV administration (eg, over <60 minutes) may result in hypotension, flushing, erythmia, urticaria, pruritus, and rarely, cardiac arrest. Reactions usually cease promptly after infusion is stopped. Frequency of infusion reactions may increase with concomitant administration of anesthetics. If used in conjunction with anesthesia, complete the vancomycin infusion prior to anesthesia inducted. As you can see, vancomycin should be infused over no less than 60 minutes using a pump.

Over the years, surgical facilities have reported all types of vancomycin adverse events to me. Adverse reactions to vancomycin range from mild skin rashes to cardiac arrest. Because reactions are unpredictable, it's always best to be prepared. Much like having methylene blue available in the event of benzocaine toxicity, you can be prepared for a potential vancomycin reactions, too. Hyaluronidase is the treatment for extravasation caused by vancomycin. Although reports of extravasation are rare, it's always best to be prepared! Another reaction associated with vancomycin administration is "Red Man Syndrome", which is a skin irritation associated with vancomycin being infused too rapidly. This can be treated with antihistamines and steriods and the irritation will dissipate.

VANCOMYCIN ADMINISTRATION

  • Administer vancomycin with a final concentration not to exceed 5mg/mL by IV intermittent infusion over at least 60 minutes (recommended infusion period of at least more than 30 minutes for every 500mg administered {ASHP/IDSA/SIDP (Rybak 2009)); in adult patients in need of fluid restriction, a concentration up to 10mg/mL may be used but risk of infusion-related reactions is increased. Not for IM administration.

  • If a maculopapular rash appears on the face, neck, trunk, and/ or upper extremeties (red man syndrome), slow the infusion rate to over 11/2 to 2 hours and increase the dilution volume (Healy 1990; Rybak 1986; Szymusiak-Mutnick 1996). Hypotension, shock, and cardiac arrest (rare) have also been reported with too rapid of infusion. Administration of antihistamines prior to infusion may prevent or minimize this reaction (Rybak 1986; Wilhem 1999).

EXTRAVASATION MANAGEMENT

  • If extravasation occurs, stop infusion immediately and disconnect (leave cannula/ needle in place; gently aspirate extracasated solution (do NOT flush the line); remove needle/ cannula; elevate extremity. Information conflicts regarding the use of dry cold or dry warm compresses (Hurst 2004; Reynolds 2014); However, dry warm compresses may be of benefit in increasing local blood flow to enhance drug removal from the extravasation site. Intradermal hyaluronidase may be considered for refractory cases (Reynolds 2014).

  • Hyaluronidase: Intradermal: inject a total of 1mL (15 units/ mL) as 5 separate 0.2,L injections (using a tuberculin syringe) along injection site and edematous area (Reynolds 2014)

ADVERSE EVENTS RELATED TO VANCOMYCIN

  • Extravasation and thrmbophlebitis: IV vancomycin is an irritant; ensure proper needle or catheter placement prior to and during infusion; avoid extravasation. Pain, tenderness, and necrosis may occur with extravasation. If thrombophlebitis occurs, slow infusion rates, dilute solution (eg, 2.5 to 5g/L) and rotate infusion sites.

  • Nephrotoxicity: May cause nephrotoxicity although limited data suggest direct causal relationship; usual risk factors include preexisting renal impairment, concomitant nephrotoxic medications, advanced age, and dehydration. If multiple sequential (greater than 2) serum creatinine concentrations demonstrate an increase of 0.5 mg/dL or more than 50% increase from baseline (whichever is greater) in the absence of an alternative explanation, the patient should be identified as having vancomycin induced nephrotoxicity (ASHP/IDSA/SIDP [Rybak 2009]). Discontinue treatment if signs of nephrotoxocity occur; renal damage is usually reversible. Nephrotoxicity has been reported following treatment with oral vancomycin (typically in patients >65).

  • Neutropenia: Prolonged therapy and use of concomitant drugs that cause neutropenia may increase the risk; monitor leukocyte counts periodically in these patients. Prompt reversal of neutropenia is expected after discontinuation of therapy.

  • Ototoxicity: Ototoxicity is rarely associated with monotherapy. It has been most frequently reported in patients receiving excessive doses, those who have underlying hearing loss, or those receiving concomitant ototoxic drugs (eg, aminoglycosides). Serial auditory function testing may be helpful to minimize risk. Tototoxicity may be transient or permanent; discontinue treatment if sighs of ototoxicity occur.

  • Superinfection: prolonged use may result in fungal or bacterial superinfection including C. difficile infection (CDI); CDI has been observed >2 months postantibiotic treatment.

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