cellulitis with Acute Kidney Injury

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cellulitis with Acute Kidney Injury

  1. 1. Case presentation on Lower limb Cellulitis with NSAID’s induced Acute Kidney Injury By: Abhimanyu Parashar Pharm D Wednesday, February 19, 2014 1
  2. 2. IP no. 258257 UNIT Surgery 1 AGE 70 yrs SEX Male WEIGHT 72 Kgs Wednesday, February 19, 2014 2
  3. 3. Reasons for admission : c/o: Ulcer on Right foot since 10 days c/o: Pain in both limbs since 2 years 10 days back got injured on right leg due to thorn prick and developed into an ulcer 2x2 cm PMHx: Not a k/c/o HTN, DM, TB SHx: NS Wednesday, February 19, 2014 3
  4. 4. General Examination • • • • • • Elderly male patient Conscious oriented BP: 170/100 mmHg Pulse: 85 BPM Pallor + Cataract + Wednesday, February 19, 2014 • Swelling of Rt Lower limb from knee to toes • Small ulcer + • Discharge + • Left leg normal • CVS: S1S2 + • RS: B/L NVBS + 4
  5. 5. DAY 1 • • • • BP : 170/100 mm Hg RBS: 117 mg/dl Imp: Rt Leg Cellulites Investigations: Hb, TC, DC, ESR, Plt, INR, CT, BT, RBS, RBS, U/C, SE, HIV, HBS Ag, ECG • ADV: Limb elevation, Physician opinion, Anesthetic opinion Provisional Diagnosis: ? Diabetic Foot Wednesday, February 19, 2014 5
  6. 6. LAB REPORTS : HEMATOLOGY ELECTROLYTES Hb 9.4 g% Sodium 144 mmol/l WBC 7000 Cells/ cumm Potassium 6.5 mmol/l DLC N: 87 % , L: 11 %, M: 02 % E: 00 %, B: 02 % Chloride 115 mmol/l PLT 4.82 L/ cumm BT CT BIOCHEMISTRY RBS 117 mg/dl 3 min Urea 57 mg/dl 6 min S. Cr 2.5 mg/dl MICROBIOLOGY AFB: -ve HIV: -ve HBS Ag: -ve Wednesday, February 19, 2014 Urine Culture Pus cells + Gram –ve bacilli GFR: 28 ml/min + 6
  7. 7. • Physician opinion: Not a k/c/o DM, HTN CVS: S1S2 +, Tachycardia ECG: Tachycardia, mild LVH C- X-ray Pul. Edema IMP: Cellulitis with AKI with Hyperkalemia ADV: salbutamol neb, Rpt U/C, HbA1C, USG abdomen, Fundoscopy • Anesthetic opinion: In view of BP, Hyperkalemia & ECG, it is advisable to take to surgery after controlling parameters If surgery is necessary then it should be done after the consent of the patient. Wednesday, February 19, 2014 7
  8. 8. TREATMENT CHART DRUG DOSE R F 1 Inj. Ceftriaxone 1g IV 1-0-1 + Inj. Metronidazole 500 mg IV 1-1-1 + Inj. pantoprazole 40 mg IV 1-0-0 + Salbutamol 100 mcg INH 4 hrly + PO 6hrly + Calcium Gluconate Wednesday, February 19, 2014 8
  9. 9. DAY 2 BP :130/90mm Hg PULSE :90 BPM Nephrologists' opinion: H/O NSAID’s Abuse since 6 months CVS/ RS: NAD IMP: Cellulitis with Hypertension with ? NSAID Induced CKD ADV: 2 pints of NS at 75 ml/hr Avoid NSAIDS, Rpt U/C, USG abdomen + KUB, Low potassium diet, salbutamol, Calcium gluconate, H. actrapid 8 units with 25% dextrose Wednesday, February 19, 2014 9
  10. 10. LAB REPORTS : ELECTROLYTES Sodium 134 mmol/l Potassium 5.6 mmol/l Chloride 106 mmol/l BIOCHEMISTRY RBS 5.2 g% 55 mg/dl S. Cr Wednesday, February 19, 2014 HbA1C Urea GFR: 23.5 ml/min 96 mg/dl 3.0 mg/dl 10
  11. 11. TREATMENT CHART DRUG DOSE R F 1 2 Inj. Ceftriaxone 1g IV 1-0-1 + + Inj. Metronidazole 500 mg IV 1-1-1 + + Inj. pantoprazole 40 mg IV 1-0-0 + + Salbutamol 100 mcg INH 4 hrly + + Inj. INSULIN with 25% Dextrose 8U SC K check powder Wednesday, February 19, 2014 PO + 6hrly + + 11
  12. 12. DAY 3 BP: 130/90 mmHg O/E: Pain in foot CVS/RS: NAD Surgery conducted Wednesday, February 19, 2014 PULSE : 90BPM 12
  13. 13. LAB REPORTS : ELECTROLYTES Sodium 138 mmol/l Potassium 3.3 mmol/l Chloride 88 mmol/l BIOCHEMISTRY Urea GFR: 23.5 ml/min Wednesday, February 19, 2014 53 mg/dl S. Cr 3.0 mg/dl 13
  14. 14. TREATMENT CHART DRUG DOSE R F 1 2 3 Inj. Ceftriaxone 1g IV 1-0-1 + + + Inj. Metronidazole 500 mg IV 1-1-1 + + + Inj. pantoprazole 40 mg IV 1-0-0 + + + Inj. Tramadol 50 mg IV 1-1-1 Salbutamol 100 mcg INH 4 hrly + + + PO 6hrly + + + K check powder Wednesday, February 19, 2014 + 14
  15. 15. DAY 4 BP:130/90 mmHg PULSE: 90 BPM O/E: No fresh complains Ophthalmologist opinion: RE: Leucomatous opacity, No view LE: Normal IMP: No DR, Hypertensive retinopathy Wednesday, February 19, 2014 15
  16. 16. TREATMENT CHART DRUG DOSE R F 1 2 3 4 Inj. Ceftriaxone 1g IV 1-0-1 + + + + Inj. Metronidazole 500 mg IV 1-1-1 + + + + Inj. pantoprazole 40 mg IV 1-0-0 + + + + Inj. Tramadol 50 mg IV 1-1-1 + + Salbutamol 100 mcg INH 4 hrly + + + + PO 6hrly + + + + K check powder Wednesday, February 19, 2014 16
  17. 17. DAY 5 BP : 130/90 mmHg PULSE :80 BPM Nephrologists opinion: No edema CVS/ RS: NAD RFT: improving ADV: Rpt U/C after 5 days Wednesday, February 19, 2014 17
  18. 18. LAB REPORTS : ELECTROLYTES Sodium 140 mmol/l Potassium 4.8 mmol/l Chloride 100 mmol/l BIOCHEMISTRY Urea GFR: 35 ml/min Wednesday, February 19, 2014 34 mg/dl S. Cr 2.0 mg/dl 18
  19. 19. TREATMENT CHART DRUG DOSE R F 1 2 3 4 5 Inj. Ceftriaxone 1g IV 1-0-1 + + + + Inj. Metronidazole 500 mg IV 1-1-1 + + + + + Inj. pantoprazole 40 mg IV 1-0-0 + + + + + Inj. Tramadol 50 mg IV 1-1-1 + + + Salbutamol 100 mcg INH 4 hrly + + + + PO 6hrly + + + + IV 1-0-1 K check powder Inj Cefoperazone + Sulbactum Wednesday, February 19, 2014 1.5 g + + 19
  20. 20. DAY 6 BP: 130/90 mm Hg PULSE: 90 BPM • O/E : No fresh complains • Ortho opinion: Physiotherapy Wednesday, February 19, 2014 20
  21. 21. TREATMENT CHART DRUG DOSE R F 1 2 3 4 5 6 Inj. Ceftriaxone 1g IV 1-0-1 + + + + Inj. Metronidazole 500 mg IV 1-1-1 + + + + + + Inj. pantoprazole 40 mg IV 1-0-0 + + + + + + Inj. Tramadol 50 mg IV 1-1-1 + + + + Salbutamol 100 mcg INH 4 hrly + + + + PO 6hrly + + + + + + IV 1-0-1 + + Calcium Gluconate Inj Cefoperazone + Sulbactum Wednesday, February 19, 2014 1.5 g 21
  22. 22. DAY 7 BP: 130/80 mm Hg PULSE: 84 BPM O/E : No fresh complains CVS/ RS: NAD Afebrile ADV: CST Wednesday, February 19, 2014 22
  23. 23. TREATMENT CHART DRUG DOSE R F 1 2 3 4 5 6 Inj. Ceftriaxone 1g IV 1-0-1 + + + + Inj. Metronidazole 500 mg IV 1-1-1 + + + + + + Inj. pantoprazole 40 mg IV 1-0-0 + + + + + + Inj. Tramadol 50 mg IV 1-1-1 + + + + Salbutamol 100 mcg INH 4 hrly + + + + PO 6hrly + + + + + + + 7 + Calcium Gluconate + Inj Cefoperazone + Sulbactum 1.5 g IV 1-0-1 Tab. Cefoperazone + Sulbactum 1.5 g PO 1-0-1 + Tab. Pantoprazole 40 mg PO 1-0-0 + Wednesday, February 19, 2014 23
  24. 24. PHARMACEUTICAL CARE PLAN (SOAP) Wednesday, February 19, 2014 24
  25. 25. SUBJECTIVE EVIDENCE • Ulcer on Right foot since 10 days • Pain in both limbs since 2 years • H/O NSAID’s abuse Wednesday, February 19, 2014 OBJECTIVE EVIDENCE • • • • Elevated Serum creatinine Elevated Blood Urea levels Elevated Potassium Levels ECG: Tachycardia, Mild LVH 25
  26. 26. FINAL DIAGNOSIS Based on subjective and objective evidence the patient was diagnosed as Lower limb Cellulitis with NSAID’s induced Acute Kidney Injury Wednesday, February 19, 2014 26
  27. 27. GOALS OF TREATMENT • To prevent Progression of kidney disease and further insult to kidneys.. • To treat Hyperkalemia and prevent cardiac morbidity. • To treat cellulitis and retain mobility. Wednesday, February 19, 2014 27
  28. 28. TREATMENT OPTIONS CELLULITIS: • Beta lactam Antibiotics • Macrolides • Clindamycin • Vancomycin HYPERKALEMIA: • Insulin • Salbutamol • Calcium gluconate • Calcium polysterate • Hemodialysis (in rare cases) Wednesday, February 19, 2014 28
  29. 29. GOALS ACHIEVED • Patient’s potassium levels were brought to normal by day 3 • Patient’s Renal function was brought to normal by day 5 • Patient was symptomatically better by day 6 Wednesday, February 19, 2014 29
  30. 30. PROBLEMS IDENTIFIED • Untreated indication LVH. • Monitoring error: continues use of salbutamol even after potassium levels came to normal. Wednesday, February 19, 2014 30
  31. 31. MONITORING PARAMETERS • • • • • Serum electrolytes Renal function test ECG Blood pressure Tissue culture Wednesday, February 19, 2014 31
  32. 32. PATIENT COUNSELLING Wednesday, February 19, 2014 32
  33. 33. About Disease • • • • What is cellulitis? What are the symptoms? How do you get cellulitis? How can you prevent cellulitis? Wednesday, February 19, 2014 33
  34. 34. About Medications – Name and purpose – Dose and frequency – Medication adherence – Possible adverse effects – Missed dose – Avoid use of OTC drugs (NSAID’s) Wednesday, February 19, 2014 34
  35. 35. About Life style medications • Take good care of your skin. Keep it clean, and use lotion to prevent drying and cracking. • Check your feet and legs often. • Treat any skin infection right away. • Drink plenty of water. Wednesday, February 19, 2014 35
  36. 36. Wednesday, February 19, 2014 36

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