cellulitis with acute kidney injury
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TRANSCRIPT
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Monday 10 April 2023 1
Case presentation on Lower limb Cellulitis with NSAID’s induced
Acute Kidney Injury
By: Abhimanyu Parashar Pharm D
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Monday 10 April 2023 2
IP no. 258257
UNIT Surgery 1
AGE 70 yrs
SEX Male
WEIGHT 72 Kgs
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Monday 10 April 2023 3
Reasons for admission :
c/o: Ulcer on Right foot since 10 daysc/o: Pain in both limbs since 2 years10 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, TBSHx: NS
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Monday 10 April 2023 4
General Examination• Elderly male patient• Conscious oriented• BP: 170/100 mmHg• Pulse: 85 BPM• Pallor +• Cataract +
• Swelling of Rt Lower limb from knee to toes
• Small ulcer +• Discharge +• Left leg normal• CVS: S1S2 +• RS: B/L NVBS +
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Monday 10 April 2023 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
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Monday 10 April 2023 6
LAB REPORTS :HEMATOLOGY
Hb 9.4 g%
WBC 7000 Cells/ cumm
DLC N: 87 % , L: 11 %, M: 02 %E: 00 %, B: 02 %
PLT 4.82 L/ cumm
BT 3 min
CT 6 min
ELECTROLYTES
Sodium 144 mmol/l
Potassium 6.5 mmol/l
Chloride 115 mmol/l
BIOCHEMISTRY
RBS 117 mg/dl
Urea 57 mg/dl
S. Cr 2.5 mg/dl
MICROBIOLOGYAFB: -veHIV: -veHBS Ag: -ve
GFR: 28 ml/minUrine Culture
Pus cells +
Gram –ve bacilli +
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Monday 10 April 2023 7
• Physician opinion:Not a k/c/o DM, HTNCVS: S1S2 +, TachycardiaECG: Tachycardia, mild LVHC- X-ray Pul. EdemaIMP: 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 parametersIf surgery is necessary then it should be done after the
consent of the patient.
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Monday 10 April 2023 8
TREATMENT CHART
DRUG DOSE R F 1
Inj. Ceftriaxone 1 g 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 +
Calcium Gluconate PO 6hrly +
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Monday 10 April 2023 9
DAY 2
BP :130/90mm Hg PULSE :90 BPMNephrologists' opinion: H/O NSAID’s Abuse since 6
monthsCVS/ RS: NADIMP: Cellulitis with Hypertension with ? NSAID Induced
CKDADV: 2 pints of NS at 75 ml/hrAvoid NSAIDS, Rpt U/C, USG abdomen + KUB,Low potassium diet, salbutamol, Calcium gluconate, H.
actrapid 8 units with 25% dextrose
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Monday 10 April 2023 10
LAB REPORTS :
ELECTROLYTES
Sodium 134 mmol/l
Potassium 5.6 mmol/l
Chloride 106 mmol/l
BIOCHEMISTRY
RBS 96 mg/dl
HbA1C 5.2 g%
Urea 55 mg/dl
S. Cr 3.0 mg/dl
GFR: 23.5 ml/min
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Monday 10 April 2023 11
TREATMENT CHART
DRUG DOSE R F 1 2
Inj. Ceftriaxone 1 g 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 8 U SC +
K check powder PO 6hrly + +
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Monday 10 April 2023 12
DAY 3
BP: 130/90 mmHg PULSE : 90BPMO/E: Pain in footCVS/RS: NADSurgery conducted
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Monday 10 April 2023 13
LAB REPORTS :
ELECTROLYTES
Sodium 138 mmol/l
Potassium 3.3 mmol/l
Chloride 88 mmol/l
BIOCHEMISTRY
Urea 53 mg/dl
S. Cr 3.0 mg/dlGFR: 23.5 ml/min
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Monday 10 April 2023 14
TREATMENT CHART
DRUG DOSE R F 1 2 3
Inj. Ceftriaxone 1 g 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 + + +
K check powder PO 6hrly + + +
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Monday 10 April 2023 15
DAY 4
BP:130/90 mmHg PULSE: 90 BPMO/E: No fresh complainsOphthalmologist opinion: RE: Leucomatous opacity, No viewLE: NormalIMP: No DR, Hypertensive retinopathy
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Monday 10 April 2023 16
TREATMENT CHART
DRUG DOSE R F 1 2 3 4
Inj. Ceftriaxone 1 g 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 + + + +
K check powder PO 6hrly + + + +
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Monday 10 April 2023 17
DAY 5
BP : 130/90 mmHg PULSE :80 BPM Nephrologists opinion: No edemaCVS/ RS: NADRFT: improvingADV: Rpt U/C after 5 days
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Monday 10 April 2023 18
LAB REPORTS :
ELECTROLYTES
Sodium 140 mmol/l
Potassium 4.8 mmol/l
Chloride 100 mmol/l
BIOCHEMISTRY
Urea 34 mg/dl
S. Cr 2.0 mg/dlGFR: 35 ml/min
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Monday 10 April 2023 19
TREATMENT CHART
DRUG DOSE R F 1 2 3 4 5
Inj. Ceftriaxone 1 g 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 + + + +
K check powder PO 6hrly + + + + +
Inj Cefoperazone + Sulbactum 1.5 g IV 1-0-1 +
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Monday 10 April 2023 20
DAY 6
BP: 130/90 mm Hg PULSE: 90 BPM• O/E : No fresh complains • Ortho opinion: Physiotherapy
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Monday 10 April 2023 21
TREATMENT CHART
DRUG DOSE R F 1 2 3 4 5 6
Inj. Ceftriaxone 1 g 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 + + + +
Calcium Gluconate PO 6hrly + + + + + +
Inj Cefoperazone + Sulbactum 1.5 g IV 1-0-1 + +
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Monday 10 April 2023 22
DAY 7
BP: 130/80 mm Hg PULSE: 84 BPMO/E : No fresh complains CVS/ RS: NADAfebrileADV: CST
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Monday 10 April 2023 23
TREATMENT CHART
DRUG DOSE R F 1 2 3 4 5 6 7
Inj. Ceftriaxone 1 g 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 + + + +
Calcium Gluconate PO 6hrly + + + + + +
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 +
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Monday 10 April 2023 24
PHARMACEUTICAL CARE PLAN (SOAP)
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Monday 10 April 2023 25
SUBJECTIVE EVIDENCE
• Ulcer on Right foot since 10 days• Pain in both limbs since 2 years• H/O NSAID’s abuse
OBJECTIVE EVIDENCE
• Elevated Serum creatinine• Elevated Blood Urea levels• Elevated Potassium Levels• ECG: Tachycardia, Mild LVH
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Monday 10 April 2023 26
FINAL DIAGNOSIS
Based on subjective and objective evidence the patient was diagnosed as Lower limb Cellulitis
with NSAID’s induced Acute Kidney Injury
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Monday 10 April 2023 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.
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Monday 10 April 2023 28
TREATMENT OPTIONSCELLULITIS:• Beta lactam Antibiotics• Macrolides• Clindamycin • Vancomycin
HYPERKALEMIA:• Insulin• Salbutamol• Calcium gluconate• Calcium polysterate• Hemodialysis (in rare cases)
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Monday 10 April 2023 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
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Monday 10 April 2023 30
PROBLEMS IDENTIFIED
• Untreated indication LVH.• Monitoring error: continues use of salbutamol
even after potassium levels came to normal.
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Monday 10 April 2023 31
MONITORING PARAMETERS
• Serum electrolytes• Renal function test• ECG• Blood pressure• Tissue culture
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Monday 10 April 2023 32
PATIENT COUNSELLING
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Monday 10 April 2023 33
About Disease
• What is cellulitis?• What are the symptoms?• How do you get cellulitis?• How can you prevent cellulitis?
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Monday 10 April 2023 34
About Medications
– Name and purpose
– Dose and frequency
– Medication adherence
– Possible adverse effects
– Missed dose
– Avoid use of OTC drugs (NSAID’s)
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Monday 10 April 2023 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.
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