23/11/2016

AMINOGLYCOSID

Liu khi u - 1 ln/ngy

Phng php HARTFORD nomogram
o Khi BN khng c bnh l lm thay i Vd
o Ch hiu chnh da trn 2 yu t: cn nng v CrCl

Chc nng thn bnh thng

o Gentamicin / Tobramycin / Neltimicin : 5 7 mg/kg/ngy *
o Amikacin : 15 mg/kg/ngy

Suy thn :
eCrCl (mL/pht)

Khong cch liu

> 60 mL/pht

Mi 24 h

40 59 mL/pht

Mi 36 h

20 39 mL/pht

Mi 48 h

< 20 mL/pht

Theo di nng thuc lin tc, dng liu tip

theo khi trough < 1 g/mL *

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Liu khi u - 1 ln/ngy

Suy thn :
o Chnh liu da vo HARTFORD nomogram

Liu khi u - 1 ln/ngy

Suy thn :
o Chnh liu da vo HARTFORD nomogram
Da vo liu gentamicin 7 mg/kg/ngy
Nu dng amikacin: hiu chnh bng x nng thuc/mu
Nu dng liu khi u khc 7 mg/kg/ngy: hiu chnh nng
theo liu dng thc t
Nu nng thuc/mu nm ngay trn ng k chn
khong cch dng xa hn
Nu nng thuc/mu nm ngoi ton theo di lin tc
nng thuc/mu, dng liu tip theo khi trough < 1 g/mL *

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Liu khi u - 1 ln/ngy

V d 1:
o BN nam 50 tui, cao 178 cm, nng 70 kg
o Chn on: vim phi do nhim khun Gram (-)
o SCr 0,9 mg/dL, n nh trong 5 ngy k t lc nhp vin
o Tnh liu gentamicin dng theo cch 1 ln/ngy.
o 10h sau khi bt u truyn, nng gentamicin trong mu
l 3 g/mL
o Xc nh khong cch liu.

Liu khi u - 1 ln/ngy

V d 1:
o Bc 1: c tnh CrCl. BN khng bo ph.

o Bc 2: Tnh liu khi u v khong cch liu

Tnh liu khi u
7 mg/kg x 70 kg = 490 mg
Dng mi 24 gi khi u 500 mg/ 24h
Xc nh khong cch liu : theo HARTFORD nomogram
Mi 24 gi
Khng cn chnh liu khi u

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Liu khi u - 1 ln/ngy

V d 2:
o BN nam 50 tui, cao 178 cm, nng 70 kg
o Chn on: vim phi do nhim khun Gram (-)
o SCr 3,5 mg/dL, n nh trong 5 ngy k t lc nhp vin
o Tnh liu gentamicin dng theo cch 1 ln/ngy.
o 13h sau khi bt u truyn, nng gentamicin trong mu
l 9 g/mL
o Xc nh khong cch liu.

Liu khi u - 1 ln/ngy

V d 2:
o Bc 1: c tnh CrCl. BN khng bo ph.

o Bc 2: Tnh liu khi u v khong cch liu

Tnh liu khi u
7 mg/kg x 70 kg = 490 mg
Dng mi 48h khi u 500 mg/ 48h

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Liu khi u - 1 ln/ngy

V d 2:
o Bc 2: Tnh liu khi u v khong cch liu
Xc nh khong cch liu : theo HARTFORD nomogram
Ngoi ton theo di nng thuc/mu lin tc
c tnh hng s tc thi tr ke v t1/2
ke = 0,00293 x CrCl + 0,014 = 0,087 h-1
t1/2 = 0,693 / ke = 8 h
Sau 4 ln t1/2 (32h) th trough < 1 g/mL
Khong cch liu = 13 + 32 = 45 h

10

Liu khi u - Cch thng thng

Phng php Hull & Sarubbi nomogram
o Khi BN khng c tnh trng/ bnh l lm thay i Vd
o 2 yu t hiu chnh c : Cn nng & CrCl
o Liu khi u theo kinh nghim
Thuc

Loading dose

Peak (mong mun)

1,5 2,0 mg/kg

4 10 g/mL

5,0 7,5 mg/kg

15 30 g/mL

Gentamicin
Tobramycin
Neltimicin
Amikacin
Kanamycin

o Liu duy tr : tnh theo % loading dose, khong cch dng thuc
v CrCl

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12

Liu khi u - Cch thng thng

Nng tr liu vi mt s loi nhim trng
Tnh trng bnh

Peak

Trough

Gentamicin / Tobramycin / Neltimicin

Hip ng iu tr G(+), nhim trng ng tiu

35

<1

Vim thn m k, lc ni mc t cung

46

<1

Vim phi, nhim trng huyt

8 10

<2

10 12

<1

Hip ng iu tr G(+), nhim trng ng tiu

12 15

<5

Nhim trng trung bnh (VD: nhim trng

bng)

15 25

<5

Nhim trng nng (VD: vim phi do

Pseudomonas, nhim trng huyt)

25 30

< 10

X nang
Amikacin

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13

Liu khi u - Cch thng thng

V d 1:
o BN nam 50 tui, cao 178 cm, nng 70 kg
o Chn on: vim phi do nhim khun Gram (-)
o SCr 0,9 mg/dL, n nh trong 5 ngy k t lc nhp vin
o Tnh liu gentamicin dng theo cch thng thng.

14

Liu khi u - Cch thng thng

V d 1:
o Bc 1: c tnh CrCl. BN khng bo ph.

o Bc 2: Tnh liu
BN vim phi do VK G(-): Cmaxss ~ 8 10 g/mL
Tnh liu khi u
2 mg/kg x 70 kg = 140 mg
Tnh liu duy tr : theo HULL & SARUBBI nomogram
0,9 x 140 mg = 126 mg / 8h 125 mg/ 8h

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15

Liu khi u - Cch thng thng

V d 2:
o BN nam 50 tui, cao 178 cm, nng 70 kg
o Chn on: vim phi do nhim khun Gram (-)
o SCr 3,5 mg/dL, n nh trong 5 ngy k t lc nhp vin
o Tnh liu gentamicin dng theo cch thng thng.

16

Liu khi u - Cch thng thng

V d 2:
o Bc 1: c tnh CrCl. BN khng bo ph.

o Bc 2: Tnh liu
BN vim phi do VK G(-): Cmaxss ~ 8 10 g/mL
Tnh liu khi u
2 mg/kg x 70 kg = 140 mg
Tnh liu duy tr : theo HULL & SARUBBI nomogram
0,81 x 140 mg = 113 mg / 24h 115 mg/ 24h

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Liu khi u - Cch thng thng

V d 3:
o BN n 35 tui, cao 165 cm, nng 150 kg
o Chn on: nhim trng bng
o SCr 1,1 mg/dL, n nh
o Tnh liu tobramycin dng theo cch thng thng

18

Hiu chnh liu DH tuyn tnh

V d :
o BN nam 50 tui, cao 178 cm, nng 70 kg
o Chn on: vim phi do nhim khun Gram (-)
o SCr 0,9 mg/dL, n nh trong 5 ngy k t lc nhp vin
o Ch nh gentamicin 170 mg/ 8h
Mong mun: Cmaxss = 9 g/mL; Cminss = 1 g/mL

o Sau liu th 3, o nng thuc:

Cmaxss = 12 g/mL; Cminss = 1,4 g/mL

o Tnh li liu gentamicin t Cmaxss = 9 g/mL

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Hiu chnh liu DH tuyn tnh

V d :
o Bc 1: c tnh CrCl. BN khng bo ph.

o Bc 2: c tnh hng s tc thi tr (ke) v thi gian

bn thi (t1/2)
ke = 0,00293 x CrCl + 0,014 = 0,298 h-1
t1/2 = 0,693 / ke = 2,3 h
Thi im ly mu thuc t trng thi n nh

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Hiu chnh liu DH tuyn tnh

V d :
o Bc 3: tnh liu mi t nng nh mong mun
Dmi = (Css, mi / Css, c) x Dc = (9 / 12) x 170 = 128 mg
Liu tip theo : 130 mg / 8h

o Bc 4: kim tra nng y ca liu hiu chnh

Css, mi = (Dmi / Dc) x Css, c = (130 / 170) x 1,4 = 1,1 g/mL
An ton

10

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21

VANCOMYCIN

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Liu khi u Matzke nomogram

Cch tin hnh
o Tnh CrCl
o Tnh liu np (25 mg/kg)
o Tnh liu duy tr (19 mg/kg) v khong cch liu

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Liu khi u Matzke nomogram

V d 1:
o BN nam 50 tui, cao 178 cm, nng 70 kg
o Chn on: nhim trng vt thng do MRSA
o SCr 0,9 mg/dL, n nh trong 5 ngy k t lc nhp vin
o Tnh liu vancomycin.

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Liu khi u Matzke nomogram

V d 1:
o Bc 1: c tnh CrCl. BN khng bo ph.

o Bc 2: Tnh liu np
D = 25 x 70 = 1750 mg

o Bc 3: Tnh liu duy tr v khong cch liu

= 0,6 ngy khong 12h
D = 19 x 70 = 1330 mg
1250 mg/ 12h

12

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Liu khi u Matzke nomogram

V d 2:
o BN nam 50 tui, cao 178 cm, nng 70 kg
o Chn on: nhim trng vt thng do MRSA
o SCr 3,5 mg/dL, n nh trong 5 ngy k t lc nhp vin
o Tnh liu vancomycin.

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Liu khi u Matzke nomogram

V d 2:
o Bc 1: c tnh CrCl. BN khng bo ph.

o Bc 2: Tnh liu np
D = 25 x 70 = 1750 mg

o Bc 3: Tnh liu duy tr v khong cch liu

= 2 ngy
D = 19 x 70 = 1330 mg
1250 mg/ 48h

13

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Hiu chnh liu DH tuyn tnh

V d :
o BN nam 50 tui, cao 178 cm, nng 70 kg
o Chn on: vim phi do MRSA
o SCr 0,9 mg/dL, n nh trong 5 ngy k t lc nhp vin
o Ch nh vancomycin 1000 mg/ 12h
Mong mun: Cmaxss = 35 g/mL; Cminss = 15 g/mL

o Sau liu th 3, o nng thuc:

Cmaxss = 22 g/mL; Cminss = 10 g/mL

o Tnh li liu vancomycin t Cminss = 15 g/mL

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Hiu chnh liu DH tuyn tnh

V d :
o Bc 1: c tnh CrCl. BN khng bo ph.

o Bc 2: c tnh hng s tc thi tr (ke) v thi gian

bn thi (t1/2)
Cl = 0,695 x CrCl (mL/pht/kg) + 0,05 = 1,013 mL/pht/kg
Vd = 0,7 x 70 = 49 L
ke = Cl / Vd = 0,0868 h-1
t1/2 = 0,693 / ke = 8 h
Lc ly mu (~ 3 x t1/2) thuc c th t trng thi n nh

14

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Hiu chnh liu DH tuyn tnh

V d :
o Bc 3: tnh liu mi t nng y mong mun
Dmi = (Css, mi / Css, c) x Dc = (15 / 10) x 1000 = 1500 mg
Liu tip theo : 1500 mg / 12h

o Bc 4: kim tra nng nh ca liu hiu chnh

Css, mi = (Dmi / Dc) x Css, c = (1500 / 1000) x 22 = 33 g/mL
An ton

30

Hiu chnh liu Nng y

V d:
o BN nam 55 tui, cao 185 cm, nng 78 kg
o Chn on: vim phi do MRSA
o SCr 1,5 mg/dL, n nh trong 3 ngy cui nay
o Ch nh vancomycin 1000 mg/ 24h
Mong mun: Cminss = 15 g/mL

o Sau liu th 2, o nng thuc: Cminss = 10 g/mL

o Tnh li liu vancomycin t Cminss = 15 g/mL

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Hiu chnh liu Nng y

V d :
o Bc 1: c tnh CrCl. BN khng bo ph.

o Bc 2: c tnh hng s tc thi tr (ke) v thi gian

bn thi (t1/2)
Cl = 0,695 x CrCl (mL/pht/kg) + 0,05 = 0,594 mL/pht/kg
Vd = 0,7 x 78 = 55 L
ke = Cl / Vd = 0,0509 h-1
t1/2 = 0,693 / ke = 13,6 h
Lc ly mu thuc t trng thi n nh (> 3 x t1/2)

32

Hiu chnh liu Nng y

V d :
o Bc 3: Tnh li khong liu mi
mi = (Css, c / Css, mi) x c = (7 / 15) x 24 = 11h
Liu tip theo : 1000 mg / 12h

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