title: Propylene glycol accumulation in critically ill patients receiving continuous intravenous lorazepam infusions.
abstract: BACKGROUND
  Lorazepam is recommended by the Society of Critical Care Medicine as the preferred agent for sedation of critically ill patients. Intravenous lorazepam contains propylene glycol, which has been associated with toxicity when high doses of lorazepam are administered.
  
  
  OBJECTIVE
  To evaluate the accumulation of propylene glycol in critically ill patients receiving lorazepam by continuous infusion and determine factors associated with propylene glycol concentration.
  
  
  METHODS
  A 6-month, retrospective, safety assessment was conducted of adults admitted to the medical intensive care unit who were receiving lorazepam by continuous infusion for 12 hours or more. Propylene glycol serum concentrations were obtained 24-48 hours after continuous-infusion lorazepam was initiated and every 3-5 days thereafter. Propylene glycol accumulation was defined as concentrations of 25 mg/dL or more. Groups with and without propylene glycol accumulation were compared and factors associated with propylene glycol concentration were determined using multivariate correlation regression analyses.
  
  
  RESULTS
  Forty-eight propylene glycol serum samples were obtained from 33 patients. Fourteen (42%) patients had propylene glycol accumulation, representing 23 (48%) serum samples. Univariate analyses showed the following factors were related to propylene glycol accumulation: baseline renal dysfunction, presence of alcohol withdrawal, sex, age, Acute Physiology and Chronic Health Evaluation (APACHE II) score, rate of lorazepam continuous infusion, and 24-hour lorazepam dose. Multivariate linear regression modeling demonstrated that propylene glycol concentration was strongly associated with the continuous infusion rate and 24-hour dose (adjusted r(2) > or = 0.77; p < 0.001). Independent correlation analyses showed that these 2 variables were so strongly associated with propylene glycol concentration (r(2) > or = 0.71; p < 0.001) that they alone predicted propylene glycol concentration. Seven (21%) patients developed renal dysfunction after continuous-infusion lorazepam was initiated, but associated causes were indeterminable. Other possible propylene glycol-associated adverse effects were not observed.
  
  
  CONCLUSIONS
  The continuous infusion rate and cumulative 24-hour lorazepam dose are strongly associated with and independently predict propylene glycol concentrations. Despite the absence of confirmed propylene glycol-associated adverse effects, clinicians should be aware that propylene glycol accumulation may occur with continuous-infusion lorazepam.
authors.affiliation: Department of Pharmacy, Sky Ridge Medical Center, Lone Tree, CO, USA.
authors.forename: Erica L
authors.initials: EL
authors.lastname: Horinek
authors.forename: Tyree H
authors.initials: TH
authors.lastname: Kiser
authors.forename: Douglas N
authors.initials: DN
authors.lastname: Fish
authors.forename: Robert
authors.initials: R
authors.lastname: MacLaren
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D016638:Critical Illness; D004305:Dose-Response Relationship, Drug; D005260:Female; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage*; D007262:Infusions, Intravenous; D007362:Intensive Care Units; D007674:Kidney Diseases / Q000209:etiology; D008140:Lorazepam / Q000008:administration & dosage*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D014677:Pharmaceutical Vehicles / Q000009:adverse effects / Q000493:pharmacokinetics*; D019946:Propylene Glycol / Q000009:adverse effects / Q000097:blood*; D012044:Regression Analysis; D012189:Retrospective Studies; D012307:Risk Factors; D012737:Sex Factors
chemical_list: D006993:Hypnotics and Sedatives; D014677:Pharmaceutical Vehicles; D019946:Propylene Glycol; D008140:Lorazepam