How to manage a patient experiencing chest pain, palpitations, and burning sensations in hands and feet after an amikacin (antibiotic) injection?

Management of Suspected Amikacin Toxicity

This patient requires immediate discontinuation of amikacin and urgent evaluation for life-threatening cardiac complications, as chest pain and palpitations may represent acute cardiotoxicity, while the burning sensations in hands and feet suggest peripheral neurotoxicity—both serious adverse effects requiring immediate intervention. 1, 2, 3

Immediate Actions

Discontinue Amikacin Immediately

• Stop all amikacin administration immediately upon development of these symptoms, as aminoglycosides carry the highest risk of permanent ototoxicity and neurotoxicity that can progress if exposure continues 2, 3
• The burning sensation in extremities represents peripheral neurotoxicity (circumoral and peripheral paresthesias), which is a recognized adverse effect of aminoglycosides 1
• Do not wait for confirmatory testing before stopping the drug 2

Urgent Cardiac Evaluation

• Place the patient on continuous cardiac monitoring immediately with emergency resuscitation equipment and defibrillator nearby 1
• Obtain a 12-lead ECG within 10 minutes to evaluate for acute coronary syndrome, arrhythmias, or conduction abnormalities 1
• Measure cardiac biomarkers (troponin, BNP) to assess for myocardial injury 1
• The chest pain and palpitations require urgent evaluation as they may represent acute cardiac toxicity, though this is rare with aminoglycosides 1

Rule Out Acute Coronary Syndrome

• While amikacin-induced cardiotoxicity is uncommon, chest pain with palpitations in a 45-year-old female requires exclusion of acute coronary syndrome as the primary differential 1
• If ECG shows ST-segment elevation or other acute changes, activate acute coronary syndrome protocols immediately 1
• Consider immediate cardiology consultation if diagnosis is unclear or if cardiac symptoms persist 1

Comprehensive Toxicity Assessment

Evaluate for Nephrotoxicity

• Measure serum creatinine, BUN, and calculate creatinine clearance immediately 1, 3
• Obtain urinalysis to assess for casts, white cells, red cells, or albumin—signs of renal tubular irritation 3
• Nephrotoxicity occurs in approximately 2% of patients receiving aminoglycosides, though less commonly with streptomycin than amikacin 1
• Check serum amikacin trough level if the patient received multiple doses—trough levels >10 mcg/mL are associated with toxicity 3

Assess for Ototoxicity

• Question the patient specifically about tinnitus, hearing loss, vertigo, or balance disturbances 1, 2
• Perform baseline audiometry and vestibular testing urgently if not previously done 1, 2
• Aminoglycoside-induced hearing loss is typically permanent and irreversible, making early detection critical 2
• Ototoxicity risk increases with cumulative doses above 100-120 grams, advanced age, and concurrent use of loop diuretics 1

Evaluate Neuromuscular Function

• Assess for signs of neuromuscular blockade, including muscle weakness, respiratory difficulty, or decreased deep tendon reflexes 1, 3
• This is particularly important in patients with underlying neuromuscular disorders (myasthenia gravis, Parkinson's disease) 3
• Check serum electrolytes including calcium, magnesium, and potassium, as aminoglycosides can cause hypocalcemia, hypomagnesemia, and hypokalemia 4

Supportive Management

Hydration and Enhanced Elimination

• Administer intravenous fluids generously to maintain diuresis and facilitate renal excretion of amikacin 3, 5
• In patients with normal renal function who received an overdose, careful hydration with maintenance of generous diuresis is the primary management strategy 5
• Monitor urine output closely and maintain adequate hydration to minimize chemical irritation of renal tubules 3

Consider Dialysis for Severe Toxicity

• In cases of severe overdose or toxic reaction, peritoneal dialysis or hemodialysis can aid in removal of amikacin from the blood 3
• However, in one case report of massive overdose (18g over 4 hours), peritoneal dialysis did not effectively remove amikacin, and hydration alone was sufficient 5
• Hemodialysis is more effective than peritoneal dialysis for aminoglycoside removal if needed 3

Alternative Antibiotic Selection

Switch to Non-Ototoxic/Non-Nephrotoxic Agents

• For respiratory infections, switch to amoxicillin, amoxicillin-clavulanate, or cephalosporins which provide adequate coverage without ototoxicity risk 2
• For serious gram-negative infections, consider combination therapy with high-dose beta-lactams or fluoroquinolones 2
• Never restart aminoglycosides after development of neurotoxicity or ototoxicity without expert infectious disease consultation and compelling indication 2

Avoid Concurrent Ototoxic/Nephrotoxic Agents

• Do not combine with loop diuretics (furosemide, ethacrynic acid) which increase ototoxicity risk 1, 4
• Avoid concurrent nephrotoxins including capreomycin, cephalosporins, cyclosporine, colistimethate sodium, or tacrolimus 4, 3
• Discontinue any bisphosphonates due to increased risk of hypocalcemia 4

Critical Pitfalls to Avoid

• Never continue aminoglycosides after development of neurologic symptoms without expert consultation, as toxicity can be permanent and irreversible 2, 3
• Do not assume chest pain is benign—acute coronary syndrome must be excluded first in any patient presenting with chest pain and palpitations 1
• Do not delay cardiac monitoring or ECG while pursuing other diagnostic workup 1
• Avoid attributing all symptoms to anxiety or non-cardiac causes without objective cardiac evaluation 1
• Do not restart amikacin even if symptoms improve, as cumulative toxicity increases with repeated exposure 1, 2

Monitoring After Discontinuation

• Continue monitoring renal function for at least 2 weeks after discontinuation, as nephrotoxicity can progress even after stopping the drug 1, 3
• Arrange follow-up audiometry in 2-4 weeks to assess for delayed ototoxicity 1, 2
• Document the adverse reaction clearly in the medical record and ensure the patient is counseled about permanent avoidance of aminoglycosides 2, 3
• Report the adverse event to institutional pharmacovigilance systems 3