title: Acute tubular necrosis associated with propylene glycol from concomitant administration of intravenous lorazepam and trimethoprim-sulfamethoxazole.
abstract: A 46-year-old morbidly obese man was admitted to the medical intensive care unit with respiratory failure. He required pressure-control ventilation and high levels of sedation with continuous-infusion lorazepam. He developed Stenotrophomonas maltophilia pneumonia; treatment included scheduled intravenous trimethoprim-sulfamethoxazole. Each of these drugs contain several hundred milligrams/milliliter of propylene glycol. On day 17 of his hospital course, 3 days after starting the trimethoprim-sulfamethoxazole, the patient developed acute renal failure consistent with acute tubular necrosis. Propylene glycol toxicity was suspected; therefore, all drugs containing propylene glycol were discontinued, and laboratory data were collected. A marked osmol gap, metabolic acidosis, and renal toxicity were attributed to both continuous and large intermittent doses of intravenous propylene glycol. Particular attention should be paid to the total amount of propylene glycol provided to patients from administered drugs. Patients in the intensive care setting who require high doses of intravenous lorazepam for sedation, as well as antimicrobial therapy with trimethoprim-sulfamethoxazole for treatment of either Stenotrophomonas maltophilia or Pneumocystis carinii pneumonia, may be at increased risk for propylene glycol toxicity and should be monitored closely.
authors.affiliation: Department of Pharmacy, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA. mhayman@emh.org
authors.forename: Marybeth
authors.initials: M
authors.lastname: Hayman
authors.forename: Edward C
authors.initials: EC
authors.lastname: Seidl
authors.forename: Median
authors.initials: M
authors.lastname: Ali
authors.forename: Khalid
authors.initials: K
authors.lastname: Malik
mesh_terms: D058186:Acute Kidney Injury / Q000139:chemically induced* / Q000150:complications; D003428:Cross Infection / Q000150:complications / Q000188:drug therapy; D006801:Humans; D007275:Injections, Intravenous; D008140:Lorazepam / Q000008:administration & dosage / Q000493:pharmacokinetics / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D019999:Pharmaceutical Solutions / Q000008:administration & dosage / Q000633:toxicity; D045363:Pneumocystis carinii; D018410:Pneumonia, Bacterial / Q000150:complications / Q000188:drug therapy*; D011409:Propylene Glycols / Q000008:administration & dosage / Q000097:blood / Q000633:toxicity*; D012997:Solvents / Q000008:administration & dosage / Q000633:toxicity; D020615:Stenotrophomonas maltophilia; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000008:administration & dosage / Q000493:pharmacokinetics / Q000627:therapeutic use*
chemical_list: D019999:Pharmaceutical Solutions; D011409:Propylene Glycols; D012997:Solvents; D015662:Trimethoprim, Sulfamethoxazole Drug Combination; D008140:Lorazepam