What is the management for shortness of breath during vancomycin infusion?

Management of Shortness of Breath During Vancomycin Infusion

For shortness of breath during vancomycin infusion, immediately stop the infusion, administer supplemental oxygen if hypoxemic, and consider antihistamine pretreatment before any rechallenge at a slower infusion rate. 1, 2

Understanding the Reaction

Shortness of breath during vancomycin administration is typically part of an infusion-related reaction that can range from mild to severe. According to the FDA drug label, these reactions are characterized as "anaphylactoid reactions" that may include:

• Shortness of breath (dyspnea)
• Wheezing
• Hypotension
• Urticaria or pruritus
• Flushing of the upper body ("red neck")
• Chest and back pain/muscle spasm 2

These reactions are primarily related to the rate of infusion rather than true allergic (IgE-mediated) hypersensitivity.

Immediate Management

1. STOP the infusion immediately when shortness of breath occurs 1
2. Notify the physician and perform physical assessment of symptoms
3. Switch IV line to normal saline at KVO (keep vein open) rate
4. Monitor vital signs (BP, pulse, respiratory rate, O₂ saturation, temperature)
5. Administer oxygen by mask or nasal cannula if hypoxemic 1

Classification and Treatment Based on Severity

Moderate Hypersensitivity Reaction (with shortness of breath)

• Shortness of breath
• Transient cough
• Possible tachycardia
• Possible hypotension (drop in SBP ≥30 mmHg from baseline or SBP ≤90 mmHg)

Treatment:

• Monitor for ≥15 minutes
• Maintain IV normal saline at KVO
• Consider IV corticosteroid (Hydrocortisone 100-500 mg IV)
• Consider IV H₂ antagonist (Famotidine 20 mg IV) 1

Severe/Life-threatening Reaction (including anaphylaxis)

• Sudden onset and rapid intensification of symptoms
• Respiratory distress with stridor or bronchospasm
• Hypotension
• Involvement of multiple organ systems

Treatment:

• Call emergency services or resuscitation team immediately
• Administer EPINEPHRINE (1 mg/mL) 0.3 mg IM into the anterolateral mid-third portion of the thigh
• May repeat epinephrine once if needed
• Consider β₂ agonist nebulizer (Albuterol 0.083% via nebulizer) 1

Prevention and Rechallenge Strategies

Prevention:

1. Slow infusion rate: Vancomycin should be administered over at least 60 minutes to avoid infusion-related reactions 2
2. Antihistamine pretreatment: Consider pretreatment with diphenhydramine (1 mg/kg) and cimetidine (4 mg/kg) before vancomycin administration in patients with previous reactions 3
3. Proper dilution: Ensure vancomycin is properly diluted according to guidelines

Rechallenge (if clinically necessary):

1. Discuss rechallenge with patient and provide reassurance
2. If accepted, restart infusion ~15 minutes after resolution of symptoms
3. Restart at slower infusion rate (50% of initial rate)
4. If well tolerated, increase slowly after 15 minutes
5. Stop infusion if symptoms recur 1

Important Considerations

• Infusion-related events occur most commonly during rapid infusion and usually resolve within 20 minutes but may persist for several hours 2
• Studies show these reactions are infrequent if vancomycin is given by slow infusion over 60 minutes 2
• In studies of normal volunteers, infusion-related events did not occur when vancomycin was administered at a rate of 10 mg/min or less 2
• Antihistamine pretreatment has been shown to permit more rapid vancomycin administration in 89% of treated patients 3

Pitfalls to Avoid

1. Don't restart infusion at the same rate - always use a slower infusion rate after a reaction
2. Don't confuse infusion reactions with true allergic reactions - most vancomycin reactions are rate-related, not true allergies
3. Don't overlook the possibility of concomitant nephrotoxicity or ototoxicity - monitor for these adverse effects, especially in patients with renal impairment
4. Don't continue vancomycin if severe reactions occur - consider alternative antibiotics if appropriate

By following this algorithmic approach to managing shortness of breath during vancomycin infusion, clinicians can effectively address this adverse reaction while minimizing patient risk and discomfort.