TDM Case Presentation

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)

End-Stage Renal Failure on IV Vancomycin (Line related sepsis with MRSA)

CASE 1

Patient Description

Name : AAG R/N : 8051180Ward :C7-B27Gender : 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 2010Benign Prostatic HyperplasiaSuspected Pulmonary TB

Past Medical History

DMHTNUrosepsisESRF

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 positiveSensitive to Vancomycin

Medication Plan:a.IV Vancomycin 1g BDb.Stop IV Cefepime

Essential vital sign &

Laboratory values

White Blood Cell test

Dates Volume (µL) Comments

14/10/10 19.9x103•Normal value 4,300 - 10,800 cells/µL.

•High than normal value

16/10/10 13.3x103

Renal test

Dates Concentration (mg/dL) comments

14/10/10 19.5 •Normal value 8-18 mg/dL.•Slightly high

19/10/10 17.5 •normal

Blood urea nitrogen concentration

Dates Concentration (µmol/L) comments

14/10/10 374 •Normal value 53-115 µmol/L•High

16/10/10 385 •same

Serum creatinine concentration

Liver function testdate 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 5-40 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

On 16/10/2010

Drug Dose & Frequency

Date & Time Started

Last dose taken/ administered Sampling

Date Time Date Time

IV Vancomycin 1g BD 14/10/10 5.30PM 16/10 8 am

16/10 7.30 am

16/10 12.00pm

Drug Dose & Frequency

Date & Time Started

Last dose taken/ administered Sampling

Date Time Date Time

IV Vancomycin 750 mg BD 14/10/10 5.30PM 18/10 8 am

19/10 7.30 am

19/10 10.30pm

On 19/10/2010

Laboratory Data (14/10/2010)

Laboratory Data (19/10/2010)

TDM Request Form

Therapeutic level on 16/10/2010

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

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

• Oral1.Vitamin B complex I/I OD – Starts on 15/102.Fe Fumarate II/II OD – Starts on 18/103.Mist KCl 2g TDS – Starts on 18/104.NaHCO3

2g BD – Starts on 19/10

Current Drug Therapy

• Parenteral1.IV Ranitidine 15 mg TDS – Start on 19/102.IV Vancomycin 1 g Stat BD – Start on 14/10