ABSTRACT
A 46-year-old morbidly obese man was admitted to the medical intensive care unit with respiratory failure. He required pressure-control ventilation and high levels of sedation with continuous-infusion lorazepam. He developed Stenotrophomonas maltophilia pneumonia; treatment included scheduled intravenous trimethoprim-sulfamethoxazole. Each of these drugs contain several hundred milligrams/milliliter of propylene glycol. On day 17 of his hospital course, 3 days after starting the trimethoprim-sulfamethoxazole, the patient developed acute renal failure consistent with acute tubular necrosis. Propylene glycol toxicity was suspected; therefore, all drugs containing propylene glycol were discontinued, and laboratory data were collected. A marked osmol gap, metabolic acidosis, and renal toxicity were attributed to both continuous and large intermittent doses of intravenous propylene glycol. Particular attention should be paid to the total amount of propylene glycol provided to patients from administered drugs. Patients in the intensive care setting who require high doses of intravenous lorazepam for sedation, as well as antimicrobial therapy with trimethoprim-sulfamethoxazole for treatment of either Stenotrophomonas maltophilia or Pneumocystis carinii pneumonia, may be at increased risk for propylene glycol toxicity and should be monitored closely.
Subject(s)
Acute Kidney Injury/chemically induced , Lorazepam/therapeutic use , Pneumonia, Bacterial/drug therapy , Propylene Glycols/toxicity , Trimethoprim, Sulfamethoxazole Drug Combination/therapeutic use , Acute Kidney Injury/complications , Cross Infection/complications , Cross Infection/drug therapy , Humans , Injections, Intravenous , Lorazepam/administration & dosage , Lorazepam/pharmacokinetics , Male , Middle Aged , Pharmaceutical Solutions/administration & dosage , Pharmaceutical Solutions/toxicity , Pneumocystis carinii , Pneumonia, Bacterial/complications , Propylene Glycols/administration & dosage , Propylene Glycols/blood , Solvents/administration & dosage , Solvents/toxicity , Stenotrophomonas maltophilia , Trimethoprim, Sulfamethoxazole Drug Combination/administration & dosage , Trimethoprim, Sulfamethoxazole Drug Combination/pharmacokineticsABSTRACT
Clinical pharmacy services in the critical care setting have expanded dramatically and include assisting physicians in pharmacotherapy decision making, providing pharmacokinetic consultations, monitoring patients for drug efficacy and safety, providing drug information, and offering medical education to physicians, nurses, and patients. Measurable clinical effects of these services include reduced drug errors and adverse drug events, decreased morbidity and mortality rates, and a positive pharmacoeconomic impact by decreasing overall health care costs.
