Hypotension vancomycin

The rate of infusion is checked every 15 minutes and adjusted as needed. This is especially important when administering vancomycin because rapid infusion of the drug can result in severe hypotension and shock. The nurse inspects the vein used for the IV infusion every 4 to 8 hours for signs of tenderness, pain, and redness (which may indicate phlebitis or thrombophlebitis). If these symptoms are apparent, the nurse restarts the IV in another vein and bring the problem to the attention of the primary health care provider. 

Severe disease is defined as the presence of complications of colitis, such as sepsis, volume depletion, electrolyte imbalance, hypotension, paralytic ileus, and toxic megacolon. Patients with signs of severe disease should receive oral vancomycin as initial therapy. Surgical intervention may be indicated and lifesaving, particularly in cases complicated by toxic megacolon or colonic perforation. 

Erythema multiforme Stevens-Johnson syndrome sulphonamides Red-man syndrome (vasodilatation-hypotension due to histamine release) characteristic of rapid administration of vancomycin... 

In a retrospective cost analysis, the records of 527 patients with acute leukemia were studied (11). They had been treated in a multicenter, randomized trial for febrile neutropenia with ceftazidime and amikacin plus either teicoplanin (6 mg/kg in a single dose n — 275) or vancomycin (30 mg/kg/day in 2 doses n — 252). Qinical responses were equivalent. Again the higher acquisition costs for teicoplanin were counterbalanced by the lower incidence of adverse events and easier administration, resulting in overall similar costs for both regimens. A total of 8% of patients treated with vancomycin reported adverse events compared with 3.2% of patients treated with teicoplanin. Rashes occurred in 6.0 versus 1.4% respectively. Nephrotoxicity, ototoxicity, fever, and hypotension occurred in very few patients. 

The most common adverse events associated with teicoplanin are hypersensitivity, fever, rash, diarrhea, nephrotoxicity, and thrombocytopenia (12,13). Local reactions at the injection site include pain, redness, or discomfort after intramuscular injection, or phlebitis after intravenous injection. Erythroderma has occurred during infusion of teicoplanin with fever and hypotension. Allergic reactions have been reported with teicoplanin, with cross-reactivity between teicoplanin and vancomycin documented by in vitro studies showing IgE release by basophils in response to stimulation by both vancomycin and teicoplanin. However, known hypersensitivity to vancomycin is not a contraindication to teicoplanin. Tumor-inducing effects have not been reported. 

A unique and peculiar adverse reaction related to the rapid infusion of large doses is the so-caUed red neck or red man sjmdrome. It is the most common adverse reaction to vancomycin, characterized by fever, chills, paresthesia, and eiythema at the base of the neck and the upper back, and can be followed by a hypotensive episode (12). It is not a true allergic reaction. It seems to be due to vancomycin-induced release of histamine and possibly other vasoactive substances without the involvement of preformed antibodies (13,14). In rat peritoneal mast cells vancomycin provoked histamine release dose-dependently fosfomycin inhibited this effect (15). 

A 45-year-old man developed hypotension, bradycardia, a change in consciousness, and an erythematous macular rash 10 minutes after the slow infusion of 0.1% vancomycin (20). After appropriate management, he recovered well and was discharged on the following day. 

In 50 patients, in whom vancomycin 15 mg/kg was continuously infused at a constant rate over 30 minutes, the occurrence of pruritus suggested that systemic vascular resistance was falling, exposing the patient to a risk of hypotension (21). Therapy with a beta-blocker appeared to confer protection against this hemodynamic effect. 

Pretreatment with Hi and H2 receptor antagonists (diphenhydramine 1 mg/kg and cimetidine 4 mg/kg) intravenously serially over 3 minutes starting 10 minutes before the infusion of vancomycin permitted rapid vancomycin administration (1 g over 10 minutes) in 17 of 19 patients compared with eight of 19 patients treated with placebo in a prospective, randomized, double-blind, placebo-controUed study of patients undergoing elective arthroplasty (22). Hypotension occurred in 2 versus 12 of the patients, and 12 versus 19 of the patients had a rash. Serum histamine concentrations were raised after vancomycin administration in both groups. 

The early formulations of vancomycin, termed "Mississippi mud" because of its brownish color, were replete with impurities. Fever, hypotension and severe dose-limiting phlebitis were frequently seen in the patients first treated with vancomycin and were attributed to these impurities and pyrogens in these early preparations of vancomycin. In addition, the nephrotoxicity and ototoxicity first seen with vancomycin was also attributed to these impure formulations. Since its introduction, however, preparations of vancomycin have consistently improved achieving 92 to 95% purity since 1980 and the incidence of nephrotoxicity and ototoxicity has attenuated [172,174]. The incidence of nephrotoxicity associated with vancomycin is wide ranging with reports ranging from 0 to 44% in several prospective studies [174-178]. However, obtaining an accurate estimate of the incidence of nephrotoxicity from these studies is hindered by the variable purity of the vancomycin preparations administered, the different endpoints used to define nephrotoxicity, the presence of severe comorbid disease and the concomitant use of nephrotoxic medications in many of the study patients [174]. More recent reviews of the more contemporary vancomycin formulations place the overall incidence of nephrotoxicity of from 0 to 5% [183, 184]. 

Note The vancomycin-induced red man syndrome is characterized by pruritus, erythema and, in severe cases, angioedema, hypotension, and cardiovascular collapse... 

Vancomycin may be considered for prophylactic therapy in surgical procedures involving implantation of a prosthetic device in which the rate of MRSA is high. If the risk of MRSA is low and a /3-lactam hypersensitivity exists, clindamycin can be used for many procedures instead of cefazolin in order to limit vancomycin use. Infusion-related side effects, such as thrombophlebitis and hypotension, particularly with vancomycin, usually can be controlled by adequate dilution and slower administration rates. "... 

Vancomycin has caused reversible neutropenia, nephrotoxicity, hypotension (rapid bolus injection), and pseudomembranous colitis (rare). The concomitant use of vancomycin with aminoglycosides increases the risk of... 

Many compounds, including a large number of therapeutic agents, stimulate the release of histamine from mast cells directly and without prior sensitization. Responses of this sort are most likely to occur following intravenous injections of certain substances. Tubocurarine, succinyl-choline, morphine, some antibiotics, radiocontrast media, and certain carbohydrate plasma expanders may elicit the response. The phenomenon may account for unexpected anaphylactoid reactions. Vancomycin-induced red-man syndrome involving upper body and facial flushing and hypotension may be mediated through histamine release. 

UNTOWARD EFFECTS Among the hypersensitivity reactions produced by vancomycin are rashes and anaphylaxis. Chills and fever may occur. Rapid intravenous infusion may cause erythematous or urticarial reactions, flushing, tachycardia, and hypotension. The extreme flushing that can occur is called red-neck or red-man syndrome. This results from a direct toxic effect of vancomycin on mast cells to induce histamine release. 

Vancomycin (Vancocin) Prevents transfer of cell wall precurser from plasma membrane to cell wall. DOC Antibiotic associated colitis (C. d/ff/c//e). Staph and Strep infections which are resistant to penicillin or methacillin. Thrombophlebitis, ototoxicity, nephrotoxicity. When administered by rapid IV tachycardia, flushing, paresthesias, hypotension, severe nephrotoxicity... 

Vancomycin is highly associated with adverse infusion-related events. These are especially prevalent with higher doses and a rapid infusion rate. A rapid infusion rate has been shown to cause anaphylactoid reactions, including hypotension, wheezing, dyspnea, urticaria, and pruritus. A significant drug rash (the so-called red man syndrome) also can occur. These events are much less frequent with a slower infusion rate. 

A man recovering from neuromuseular bloekade with suxamethonium (with some evidence of residual Phase II bloek) developed almost total muscle paralysis and apnoea when given an intravenous infusion of vancomycin. He recovered spontaneously when the vancomycin was stopped, but it took several hours. The neuromuseular blockade due to vecuronium was increased in a patient when given an infusion of vancomycin (I g in 250 mL of saline over 35 minutes). Transient apnoea and apparent cardiac arrest have also been described in a patient following a I-g intravenous injection of vancomycin given over 2 minutes. However, in both of these cases the vancomycin was given more rapidly than the current recommendations. It is now known that rapid infusion of vancomycin can provoke histamine release, which can result in apnoea, hypotension, anaphylaxis and muscular spasm, effects similar to those seen in these two patients. 

An isolated case report su ests that the hypotensive effects of the rapid infusion of vancomycin may occur more readily in those who are already vasodilated with nifedipine, but it seems likely that the effects seen were due to the rapid infusion alone. 

Comment Rapid infusions of vancomycin carry the risk of reactions, such as severe hypotension (including shock and cardiac arrest) and flushing of the upper body. 

The most commonly occurring adverse effects caused by vancomycin are referred to collectively as red man syndrome. Reactions may range from mild pruritus, erythema, and flushing of the upper body to angioedema and rarely hypotension and cardiovascular collapse. Reactions may be prevented or their severity decreased by extending the infusion time and/or premedication with histamine H, and H2 receptor antagonists. 

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