Réanimation

, Volume 24, Issue 3, pp 328–336 | Cite as

Comment utiliser les aminosides en réanimation

  • A. Boyer
  • B. Clouzeau
  • F. M’zali
  • M. Kann
  • D. Gruson-Vescovali
Mise au Point / Update
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Résumé

L’administration des aminoglycosides (AG) chez les patients en choc septique doit respecter une haute dose unique quotidienne (7–9 mg/kg de gentamicine/tobramycine et 25–30 mg/kg d’amikacine) en perfusion de 30 minutes et pour une durée <5 jours. Le poids réel actuel est utilisé, sauf chez les obèses. Leur administration n’est pas aisée chez les patients en choc septique du fait de l’extrême variabilité intra-et interindividuelle des caractéristiques pharmacocinétiques : le volume de distribution est souvent augmenté, alors que la constante d’élimination peut être abaissée ou augmentée. Le cas particulier des patients en épuration rénale continue ou discontinue est décrit dans cette revue. Sur le plan pharmacodynamique, l’objectif est d’obtenir un rapport pic/CMI à 8-10 : cet objectif de pic est essentiellement théorique, la CMI bactérienne n’étant souvent obtenue qu’après la fin du traitement AG. Plusieurs schémas de monitorage ont été testés en réanimation, du simple ajustement linéaire des doses selon le dosage sérique pic/vallée, jusqu’aux modèles pharmacologiques de type bayésiens, en passant par l’utilisation de normogrammes ou de méthodes pharmacologiques reposant sur un ou plusieurs dosages intermédiaires. La traduction clinique de ces différents monitorages est incertaine. Par contre, les modèles les plus complexes pourraient diminuer la néphrotoxicité. Mais en réanimation, l’urgence des soins et la charge de travail sont des obstacles à leur application. L’ajustement linéaire des doses selon le dosage des pics et vallées reste donc de mise. L’ensemble de ces mesures a permis une décroissance de la néphrotoxicité ces derniéres années, y compris dans le choc septique.

Mots clés

Aminoglycoside Néphrotoxicité Choc septique 

How to use aminoglycosides in the intensive care unit

Abstract

The aminoglycosides (AG) schedule of administration in patients with septic shock consists in a high dose once daily (7–9 mg/kg of gentamicin/tobramycin; 25–30 mg/kg of amikacine) in a 30 minutes infusion and for a maximum of 5 days. The total body weight must be used except for obese patients. AG administration in critically ill septic patients is complicated by an extreme inter- and intraindividual variability in drug pharmacokinetic characteristics: the volume of distribution is frequently increased, while the elimination constant can be either increased or decreased. The case for patients needing continuous or discontinuous renal replacement therapy is addressed in this review. The Cmax objective is 8–10 fold the MIC then taper the dose as soon as the MIC has been provided, which unfortunately often takes longer than the AG-treatment duration. Several therapeutic drug monitoring (TDM) options have been proposed in critically ill patients: simple linear dose adjustment according to AG serum concentration to nomograms, other pharmacological method based on the determination of intermediate AG assay before Cmin, and Bayesian methods. The translation of these complex TDM methods into better clinical outcomes remains uncertain but these programs could reduce AG-associated NT in patients with septic shock. Therefore, the questions of the possible application of TDM to ICU setting remain unanswered. Indeed, high workload, often in situation of emergency, is a substantial obstacle to a sophisticated optimized AG administration. A simple linear adjustment of AG doses is recommended so far. All these recommendations have led to a global decrease of AG nephrotoxicity for the last decades.

Keywords

Aminoglycosides Nephrotoxicity Septic shock 
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Copyright information

© Société de réanimation de langue française (SRLF) and Springer-Verlag France 2015

Authors and Affiliations

  • A. Boyer
    • 1
    • 2
  • B. Clouzeau
    • 1
  • F. M’zali
    • 3
  • M. Kann
    • 3
  • D. Gruson-Vescovali
    • 1
    • 3
  1. 1.Service de réanimation médicale, CHU Bordeauxhôpital Pellegrin, place Amélie Raba LéonBordeaux cedexFrance
  2. 2.INSERM U657, pharmaco-épidémiologie et évaluation de l’impact des produits de santé sur les populationsUniversité de BordeauxBordeaux cedexFrance
  3. 3.UMR CNRS 5234, microbiologie cellulaire et moléculaire et pathogénicitéUniversité de BordeauxBordeaux cedexFrance

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