Transcript Slide 1

TDM Case Presentation
End-Stage Renal Failure on IV Vancomycin
(Line related sepsis with MRSA)
CASE 1
By :
Group B
STUDENT
LIM KOK HAN (95298)
MD HASHIMIE BARUDDIN BIN MAT HASSAN (95304)
SURESKUMAR A/L HARISKRISHANAN (95369)
MOHAMAD SYAHIR BIN FADZIL (UF070007)
MOHD JAUZE BIN KOMARUDIN (UF070008)
MUHAMMAD IMADUDDIN BIN CHE MOHD NASIR (UF070014)
Patient Description
 Name
: AAG
 R/N
: 8051180
Ward
:C7-B27
Gender : Male
 Ethnic
: Indian
 Age
: 88 yo
 Weight : 55 kg
 Admission: 8/10/10
Chief Complains
Regards from Hospital Sg.Bakap for further
examination. He got fever (5/7), chills, tremor
which cannot relieve by PCM ,cough, dysuria,
no chest pain/shortness of breath, no vomit,
and no diarrhea.
History of Present Illness
Urosepsis in July 2010
Benign Prostatic Hyperplasia
Suspected Pulmonary TB
Past Medical History
DM
HTN
Urosepsis
ESRF
Family History
Most of his family are smoking and
consume alcohol except him.
On Admission
8/10/10 [ 8.35 pm]
Diagnosis
Acute CRF 2° Urosepsis
BPH
Suspected Pulmonary TB
Medication Plan:
 IV Unasyn® 1.5g BD
 IVD 4ʘ NS 24 hr
On 14/10/10 [3.40 pm]
Result from Pathology Dept.
Noted MRSA positive
Sensitive to Vancomycin
Medication Plan:
a. IV Vancomycin 1g BD
b. Stop IV Cefepime
Essential vital sign
&
Laboratory values
White Blood Cell test
Dates
14/10/10
16/10/10
Volume (µL)
Comments
19.9x103
•Normal value
4,300 - 10,800
cells/µL.
13.3x103
•High than
normal value
Renal test
Blood urea nitrogen concentration
Dates
Concentration (mg/dL)
comments
14/10/10
19.5
•Normal value 8-18 mg/dL.
•Slightly high
19/10/10
17.5
•normal
Serum creatinine concentration
Dates
Concentration (µmol/L)
comments
14/10/10
374
•Normal value 53-115 µmol/L
•High
16/10/10
385
•same
Liver function test
date
test
concentration
comments
16/10/10
Alanine
Aminotransferase
(ALT)
98 IU/L
High than normal
value 5-35 IU/L
Aspartate
Aminotransferase
(AST)
82 IU/L
High than value 540 IU/L
Albumin
16 g/L
Less than normal
value 36-50 g/L
Input / output
In
2860 cc
Out
2700 cc
Balance
160 cc
TDM Request Form
Name
AAG
Diagnosis
Acute on CFR, 2° Urosepsis (MRSA)
Ward/Unit
C7-27
R/N
8051180
Age
88 years old
Sex
Male
Race
Indian
Weight (kg)
55 kg
Pregnant
No
Smoking
No
Alcohol
No
On 16/10/2010
Drug
IV
Vancomycin
Dose &
Frequency
1g BD
Date & Time
Started
14/10/10 5.30PM
Last dose taken/
administered
Date
16/10
Time
8 am
Sampling
Date
Time
16/10
7.30 am
16/10
12.00pm
On 19/10/2010
Drug
IV
Vancomycin
Dose &
Frequency
750 mg BD
Date & Time
Started
14/10/10 5.30PM
Last dose taken/
administered
Date
18/10
Time
8 am
Sampling
Date
Time
19/10
7.30 am
19/10
10.30pm
Laboratory Data (14/10/2010)
Lab Data
Value
K+
3.0
Na+
134
BUN
19.5
Serum Creatinine
374
SGPT/SGOT
Alk Phos
Laboratory Data (19/10/2010)
Lab Data
Value
K+
2.6
Na+
140
BUN
17.5
Serum Creatinine
385
SGPT/SGOT
Alk Phos
82
TDM Request Form
Therapeutic level on 16/10/2010
Drug
Vancomycin
Therapeutic Range
Trough: 15-20 μg/mL
Peak: 20-50 μg/mL
Measured level
Pre : 27.69 μg/mL
Post: 44.64 μg/mL
Comment:
-measured prelevel(trough level) is higher than recommended therapeutic
range
-the measured postlevel is at higher end of the recommended range
-withhold the dose on 16/10 8pm , and restart with a low dose of 750 mg BD
IV vancomycin on 17/10
-recheck the level on 19/10
TDM Request Form
Therapeutic level on 19/10/2010
Drug
Vancomycin
Therapeutic Range
Trough: 15-20 μg/mL
Peak: 20-50 μg/mL
Measured level
Pre : 71.89 μg/mL
Post: 86.59 μg/mL
Blood Pressure - mmHg
Blood Pressure Fluctuation
• Blood Pressure Rise – accumulation of waste
material in the body due to kidney failure
• During dialysis, blood pressure decrease –
remove of waste and extra fluid
Pulse Rate (beats per minute)
Body Temperature
Respiratory Rate – Breaths/minute
Diagnoses/ Chronic Medical Problems
• End Stage Renal Failure
- CrCl < 10ml/min
- The kidneys can no longer remove wastes,
concentrate urine, and regulate many other
important body functions
• Secondary Urosepsis (MRSA)
- infection in the urinary tract spreads to the
bloodstream
Current Drug Therapy
• Oral
1. Vitamin B complex I/I OD – Starts on 15/10
2. Fe Fumarate II/II OD
– Starts on 18/10
3. Mist KCl 2g TDS
– Starts on 18/10
4. NaHCO3 2g BD
– Starts on 19/10
Current Drug Therapy
• Parenteral
1. IV Ranitidine 15 mg TDS – Start on 19/10
2. IV Vancomycin 1 g Stat BD – Start on 14/10