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Antibiotics
Case Synopsis
A 23-year-old man presents for reduction and fixation of an open tibial fracture after falling off a horse. During the presurgical briefing/time-out, the surgeon requests that the patient be given vancomycin, 1 g, before incision. After propofol and succinylcholine administration and successful endotracheal intubation, anesthesia is maintained with sevoflurane, N 2 O 50%/O 2 50%, and fentanyl, 2 μg/kg/h. Four minutes after vancomycin is given, the patient suffers cardiovascular collapse.
Problem Analysis
Definition
Anesthesiologists frequently administer antibiotic prophylaxis to surgical patients to ensure patient benefits related to the Surgical Care Improvement Project (i.e., SCIP-Inf 1). For this reason, anesthesiologists should be knowledgeable regarding indications, dosage, complications, and interactions of antibiotics with anesthetics and other medications used in the perioperative period. Antibiotics possess a diverse spectrum of side effects and interact with a number of anesthetic adjuvants ( Table 82.1 ). Antibiotics also account for the majority of self-reported drug-allergy entries. For these reasons, anesthesiologists must understand and anticipate possible complications associated with antibiotic administration.
TABLE 82.1
Complications of Antibiotics Commonly Used for Prophylaxis
Adapted from Cheng, EY, Nimphius N, Hennen ER: Antibiotic therapy and the anesthesiologist. J Clin Anesth 7:425-439, 1995.
| Complications | |||
|---|---|---|---|
| Antibiotic | Common | Occasional | Rare |
| Aminoglycosides | Nephrotoxicity Ototoxicity |
Rash Nausea, vomiting Potentiation of neuromuscular blockade |
Peripheral neuritis Anaphylaxis Electrolyte disturbances |
| Cephalosporins | Painful when given intramuscularly (IM) | Nausea Drug fever Diarrhea Phlebitis |
Anaphylaxis Hypotension Bronchospasm Angioedema Urticaria |
| Clindamycin | Diarrhea Pseudomembranous colitis Rash Metallic taste Inhibition of neuromuscular transmission Potentiation of neuromuscular blockade |
Anaphylaxis Cardiac arrest Erythema Granulocytopenia Thrombocytopenia |
|
| Erythromycin | Phlebitis when given intravenously Painful when given IM |
Nausea, vomiting Diarrhea Pseudomembranous colitis |
Long QT syndrome Fever Rash Eosinophilia |
| Metronidazole | Nausea, vomiting Metallic taste Disulfiram-like reaction if alcohol consumed |
Burning tongue Urethral/vaginal burning Dark urine Rash |
Convulsions Ataxia Peripheral neuropathy Encephalopathy Cerebellar dysfunction |
| Penicillin G, ampicillin | Rash Drug fever Diarrhea Leukopenia |
Anaphylaxis Bronchospasm Angioedema Electrolyte disturbances Interstitial nephritis |
|
| Trimethoprim-sulfamethoxazole | Rash | Erythema multiforme Diarrhea Aplastic anemia Neutropenia Thrombocytopenia |
|
| Vancomycin | Phlebitis Severe pain when given IM |
“Red man” syndrome “Pain and spasm” syndrome Hypotension Anaphylaxis Nephrotoxicity Ototoxicity |
Neutropenia |
Vancomycin is a glycopeptide antibiotic commonly used for bacterial prophylaxis in orthopedic, neurologic, and vascular surgery and as an alternative antibiotic for patients allergic to penicillin-based antibiotics and cephalosporins or for patients harboring drug-resistant organisms. When a life-threatening reaction occurs after the initiation of vancomycin, the possibility of a hypersensitivity reaction must be considered. Vancomycin administration can lead to multiple types of hypersensitivity reactions, two of which are (1) “red man” syndrome (RMS) and (2) anaphylaxis.
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