groupcase presentation

7/27/2019 Groupcase Presentation

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GROUP CASE

PRESENTATION

SATELLITE PHARMACY

CLERKSHIP2010/2011

GROUP B

CASE: UROSEPSIS


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PATIENT S CMR


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PATIENT PARTICULARS

NAME: MISS ABC BED/WARD: C1/17

AGE: 70

DIAGNOSIS : UROSEPSIS

DATE OF ADMISSION: 12/7/2010

DATE OF DISCHARGE : 8/8/2010


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Brief overview : UROSEPSIS

Definition: sepsis (septicaemia syndrome) caused by urinarytract infection

Urosepsis in adults comprises approximately 25% of all sepsiscases and in most cases is due to complicated urinary tract

infections (UTIs) Classic presentation: fever, chills, hypotension in somepatient

Patients who are more likely to develop urosepsis include:infant,elderly patients, diabetics, immunosuppressed

patients (such as transplant recipients), patients receivingcancer chemotherapy or corticosteroids and patientswith acquired immunodeficiency syndrome(HIV)


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Clinical diagnostic criteria of sepsis

Associated with Systemic Inflammatory

Response Syndrome(SIRS):

i) Temperature > 38 C or < 36 C

ii) Heart rate > 90 beats per minute

iii)Respiratory rate > 20 breaths or PaC02 < 32

mmHgiv) White blood cells > 12 x 10^9/L


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For therapeutic purposes, the diagnostic criteria

of sepsis should identify patients at an early stageof the syndrome, prompting urologists andintensive care specialists to search for and treatinfection, initiate appropriate therapy, and

monitor for organ failure and other complicationsIn the case of urosepsis the clinical evidence of

UTI is based on symptoms, physical examination,sonographic and radiological features, and

laboratory data, such as bacteriuria andleucocyturia.


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Pathophysiology of urosepsis

Micro-organisms reach the urinary tract by wayof the ascending, haematogenous or lymphaticroutes. For urosepsis to be established, from the

urinary tract the pathogens have to reach thebloodstream. The risk of bacteraemia is increasedin severe urogenital infections such aspyelonephritis and acute bacterial prostatitis, and

is facilitated by obstruction.systemicinflammatory response syndrome (SIRS) is thentriggered


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General Management of Urosepsis

Effective treatment eliminates the infectious sources, andimproves organ perfusion. Treatment of urosepsiscomprises four basic strategies:

i) supportive therapy (fluid replacement therapy for

stabilisation and maintaining blood pressure, manage fluidand electrolyte balance)

ii) antimicrobial therapy (initiate with broad spectrumantibiotic within in the first hour)

iii) control or manage of the complicating factor, &

iv) specific sepsis therapy(eg.corticosteroid, insulin, etc)

All four strategies need to be started as early as possible.


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Appropriate and early diagnosis of sepsis isimportant to enable commencement oftreatment without delay-if left untreated it

can cause severe sepsis & septic shock According to Kumar et al.s data [7],we have 1

h to administer broad-spectrum antibiotics.We have 6 h to stabilise haemodynamicsaccording to early goal-directed therapy. Wehave 24 h to apply adjunctive therapy


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Severe Sepsis association with organ

dysfunction, hypoperfusion or hypotension-

may include but are not limited to lacticacidosis, oliguria or an acute alteration of

mental status

Septic shock- Sepsis with hypotension

despite adequate fluid resuscitation


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DRUG THERAPY GIVEN(based on CMR)

HYDROCHLOROTHIAZIDE

NIFEDIPINE

AMLODIPINE

PCM

LOVASTATION

TAZOCIN

OMEPRAZOLE UNASYN

RANITIDINE

MAXOLON(

COLCHICINE

TICLIDOPINE

PREDNISOLONE

METOPROLOL

MIST KCL

NEUPOGEN ALBUMIN

SYPLACTULOSE


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Hydrochlorothiazide( HCTZ)

INDICATION: Management of mild tomoderate hypertension, treatment of edemain congestive heart failure, corticosteroid

therapy and nephrotic syndrome ACTION: Inhibits sodium reabsorption in the

distal tubules causing increased excretion ofsodium(&chloride) and water

Half life: 5.6-14.8 hour

Onset of action ~ 2hours (duration 6-12hours)


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DOSAGE

IN ADULT

EDEMA(25-100mg/day , max 200mg/day)

HTN(12.5-50mg/day)

In elderly patient : 12.5-25 mg once daily

(from the prescription dose given is 25mg po od)


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Warning /Precaution

Should avoid in renal disease(ineffective)

Electrolyte disturbance(hypokalemia, hyponatremia etc) can occur

May precipitate gout(cause hyperuricemia)

Use in caution with diabetes patient(may alter glucose control)

Use in caution in patient with high cholesterol ADR: 1-10% :orthostatic hypotension, photosensitivity,

hypokalemia, hyponatremia, anorexia, epigastric distress

ContraindicationsHypersensitivity to thiazides, related diuretics, orsulfonamide-derived drugs; anuria; renal decompensation

Hepatic impairment:Minor alterations of fluid and electrolytebalance may precipitate hepatic coma; use drug with caution


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DRP detected: Drug-drug interactions

1) Hydrochlorothiazide + prednisolone

Levels/effect of hydrochlorothiazide may beincreased by corticosteroid (prednisolone)

still can be used together2) Hydrochlorothiazide + amlodipine

The antihypertensive effect of amlodipine andthiazide diuretics may be additive. Management

consists of monitoring blood pressure duringcoadministration, especially during the first 1 to 3weeks of therapy.


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PATIENT CARE CONSIDERATIONS

Administration/Storage

If drug is administered as single dose, give in

morning.

Administer drug with food or milk to minimize

GI irritation.

Store tablets in tightly closed container at

room temperature


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Assessment/Interventions

Monitor patient's BP with patient lying down and standing.

Monitor serum potassium, calcium, magnesium, sodium, ABGs, uricacid.

Monitor renal ( BUN, creatinine) and liver (ALT, AST) function tests.

Monitor blood glucose levels in diabetic patients.

Observe closely for anaphylaxis (shortness of breath, rash, edema)after first dose.

Report muscle weakness, cramps, nausea, blurred vision, ordizziness to health care provider

Advise patient to limit sodium intake for optimal drug effect

Caution patient to avoid sudden position changes to preventorthostatic hypotension

Advise patient that drug may cause drowsiness and to use cautionwhile driving or performing other tasks requiring mental alertness

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