The correct management of chronic medications not related with surgical procedures in the perioperative period has a relevant place because each year millions of patients around the world undergo surgical procedures. For this reason the assistencial team should be aware of the importance of continuate or discontinuate determinate drugs during perioperative period because some of them are considered an important risk factor in the development of complications. The key is to differentiate necessary from unnecessary medication. This is a complex aspect, little studied, which difficult clinical decisions and favours the coexistence of several trends of clinical practice. The purpose of this review is to describe the factors that determinate the continuity or suspension of chronic medications which are not related with surgery in the perioperative period and to provide practice recommendations in lights of available publications.

Background The pharmacokinetics (PK) of antibiotics change during sepsis and continuous renal replacement therapies in critically ill patients. Limited evidence exists on the use of the oXiris® high-adsorbent membrane. Objectives To develop a PK/pharmacodynamic (PD) model for meropenem in critically ill sepsis patients undergoing continuous venovenous haemodiafiltration (CVVHDF) with the oXiris® membrane, and to design an optimal dosing regimen assessed according to the PTA. Methods A prospective, open-label, observational PK trial was performed (EUDRACT 2011-005902-30). We conducted PK studies (plasma and ultrafiltrate) for at least 24 h after concomitant administration of CVVHDF and meropenem 1 g q8h. We constructed a PK model using the non-linear mixed-effects approach (NONMEM 7.3). We evaluated the suitability of different dosage regimens using Monte Carlo simulations and calculated the PTA as the percentage of subjects achieving a given percentage of time above the MIC (fT>MIC). Results The PK of meropenem was best captured by a two-open-compartment model with zero-order input kinetics and first-order elimination. Extracorporeal CL was 7.78 L/h [relative standard error (RSE) 16.45 L/h] and central compartment V (Vc) was 24.9 L (RSE 13.73 L). Simulations showed that, for susceptible Pseudomonas aeruginosa isolates (EUCAST MIC ≤2 mg/L) and attainment of 100%fT>MIC, 500 mg q8h given as extended (EI) or continuous infusion (CI) would be sufficient. For a target of 100%fT>4×MIC, CI of 3000 mg q24h or 2000 mg q8h administered as EI or CI would be required. Conclusions We have constructed a PK model of meropenem in sepsis patients undergoing CVVHDF using the oXiris® membrane. This tool will support physicians when calculating the optimal initial dose.

The Kardex system optimises the speed of trolley filling with regard to the manual system, provided that the trolleys are grouped at the time of starting the preparation. The check of the cabinet contents shows that possibilities of error exist, related to its handling, which can be minimised by incorporating bar codes into the system s replenishment process.

BackgroundLevetiracetam (LEV) is a second-generation antiepileptic drug used as a unique or adjunctive therapy for treating partial or generalised epilepsy. Its maximum dose according to the summary product is 3000 mg/day. In patients with resistant epilepsy sometimes it is used at doses higher than recommended. A recent report suggests that high doses may still be possible without toxicity.1 PurposeTo describe the importance of therapeutic drug monitoring (TDM) of LEV for minimising toxicity when it is used at doses higher than recommended.Material and methodsCase report of 57-years-old male diagnosed with symptomatic focal epilepsy and human immunodeficiency virus (HIV). Antiepileptic treatment consists of LEV 4000 mg/day, topiramate 300 mg/day and clonazepam 4 mg/day since 2010 plus lacosamide 200 mg/day added in 2015. In September 2016 he had a new neurological crisis and dosage was increased to 4500 mg/day. Antiretroviral medication (AM) was changed in 2013 from tenofovir/efavirenz/emtricitabine to abacavir/lamivudine plus efavirenz. In January 2017 AM medication was simplified to dolutegravir/abacavir/lamivudine.ResultsLEV trough plasma levels (LEVTPL) were 35.9 µg/mL (therapeutic range is 10–40 µg/mL) at the beginning of 2016, 6 years after treatment with LVT 4000 mg/day, glomerular filtration (GFR) calculated by CKD-EPI was >60 ml/min/1.73 m2 and the patient did not have clinical signs of toxicity. Three months after increasing LEV dose to 4500 mg/day the patient presented symptoms of intoxication, felt tired and sleepy. TDM confirmed supratherapeutic LEVTPL of 67.1 µg/mL accompanied by a slight deterioration of renal function (GFR: 50 ml/min/1.73 m2). Concomitant medication seemed not to interact with LEV. LEV dose was reduced to 3500 mg/day. Three months’ later, LEVTPL values returned to normal (36.3 µg/mL) and clinical signs of toxicity disappeared.ConclusionLEV at doses higher than recommended could be used safely if there is a close TDM programme to ensure treatment effectiveness and minimise adverse effects.References and/or Acknowledgements1. Stepanova D, Beran R. Measurement of levetiracetam drug levels to assit with seizure control and monitoring of drug interactions with other Anti-Epileptic Medication (AEMs). Seizure2014;23:371–376.No conflict of interest

Background Digoxin, the oldest cardiovascular drug, has been used for the treatment of heart failure and in frequency control strategies in atrial fibrillation (AF) patients. American College of Cardiology/American Heart Association (ACC/AHA) guidelines from 2009 and European Society of Cardiology (ESC) guidelines from 2012, on the management of acute and chronic heart failure (CHF), recommend digoxin for symptom relief and reducing hospital admissions. The ESC-recommended serum digoxin levels used for treating of CHF are 0.8–1.5 nmol/l (0.6–1.2 ng/ml) and equivalent ACC/AHA guidelines recommend 0.64–1.2 nmol/l (0.5–0.9 ng/ml). A serum digoxin level ≥3.0 nmol/l (2.5 ng/ml) is considered to be toxic. Purpose The aim of our study was to analyse a patient population admitted to emergencies for digoxin intoxications in a third-level hospital. Materials and methods This was a retrospective single-centre study of patients admitted to Emergencies with the diagnosis of digoxin intoxication from January 2010 to May 2012. Variables collected from medical records: demographic data (sex, age), antecedents (diabetes, acute (ARF) and chronic (CRF) renal failure, hypertension, dyslipidaemia, CHF), digoxin treatment data, reason for intoxication, test results at admission and treatment at discharge. All categorical variables are reported as frequency and percentage, while the continuous variables were reported as mean ± standard deviation. Results 136 out of 237,068 patients admitted to hospital as emergencies had digoxin intoxication (106 women, 81.8 ± 8.7 years). 36.1% diabetic, 53.5% and 35.6% suffered ARF and CRF, 86.7% hypertensive, 45.9% dyslipidaemia and 69.2% CHF). 47.8% were treated with digoxin for AF and 47% for CHF and AF. The mean daily dose of digoxin was 0.163 ± 0.050 mg. The main reasons for digoxin intoxication were ARF (34.5%), acute kidney injury in CRF (22.7%) and no dosage adjustment (21.8%). The mean digoxin serum levels were 3.36 ± 1.29 mcg/L and creatinine 167.9 ± 121.4 μmol/L. Two patients required treatment with anti-digoxin antibody and three were admitted to the ICU. At discharge, digoxin treatment was stopped (53.2%), dose adjusted (23.4%) or changed to another drug (12.9%) in most of the cases. Conclusions According to the results published, we have found that elderly women with impaired renal function are at the greatest risk. Therefore, early recognition is important for close monitoring and to reduce admissions. No conflict of interest.