Drug points: Severe hypotension associated with netilmicin treatment

BMJ 1997; 315 doi: (Published 05 July 1997) Cite this as: BMJ 1997;315:31
  1. T Rygnestada
  1. a Department of Anaesthesiology, Regional and University Hospital, Trondheim, Norway

    Cardiovascular side effects from aminoglycosides are rarely reported,1 which might be the result of underreporting. I report a case of severe hypotension associated with netilmicin treatment in a critically ill patient.

    A 50 year old woman with pharyngeal cancer had an emergency tracheotomy. At operation she had no other known disease. She developed pneumonia and was artificially ventilated. Streptococcus milleri was found in cultures from the operation wound. She was given netilmicin 140 mg twice daily and metronidazole 500 mg and cefuroxime 1.5 g three times daily.

    From the third postoperative day she had short hypotensive episodes lasting 5-10 minutes. Her systolic blood pressure measured in an intra-arterial line fell from 110-120 mm Hg to 60-80 mm Hg, which was accompanied by a fall in peripheral oxygen saturation on pulse oximetry of about 5-8%. However, she did not develop reflex tachycardia or show electrocardiographic changes or changes in central venous pressure. Vascular resistance was not measured. Her cardiovascular condition deteriorated and an infusion of dopamine (8 μg/kg/minute) was started to increase cardiac contractility. The hypotensive episodes came immediately after the slow injection of netilmicin was started and lasted until about five minutes after it had finished. The same was observed when the regimen was changed to netilmicin 350 mg once daily, when the netilmicin was given as a slow intravenous infusion, and when it was given intravenously as three equal doses 10 minutes apart.

    The antibiotic regimen was continued because the episodes were short and diuresis was adequate. Creatinine clearance was normal and stable. Netilmicin concentrations were within the recommended range. From the 14th postoperative day sedation was stopped. She no longer needed dopamine and the hypotensive episodes almost disappeared. She gradually recovered and had normal kidney function one week after discharge from intensive care.

    This patient developed side effects when she was critically ill. In critically ill patients—for example, those with sepsis—many factors might cause hypotension. Side effects of netilmicin treatment might act in addition to factors such as septicaemia and heavy sedation. The lack of reflex tachycardia suggests a direct cardiodepressive effect. A direct vascular effect cannot be ruled out.


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