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