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. IP no.
258257
UNIT
Surgery 1
AGE
70 yrs
SEX
Male
WEIGHT
72 Kgs
Wednesday, February 19, 2014
2

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. 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. 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. 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. • 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. 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. 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. 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. 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. DAY 3
BP: 130/90 mmHg
O/E:
Pain in foot
CVS/RS: NAD
Surgery conducted
Wednesday, February 19, 2014
PULSE : 90BPM
12

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. 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. 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. 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. 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. 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. 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. DAY 6
BP: 130/90 mm Hg PULSE: 90 BPM
• O/E : No fresh complains
• Ortho opinion: Physiotherapy
Wednesday, February 19, 2014
20

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. 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. 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. PHARMACEUTICAL CARE
PLAN (SOAP)
Wednesday, February 19, 2014
24

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. 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. 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. 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. 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. PROBLEMS IDENTIFIED
• Untreated indication LVH.
• Monitoring error: continues use of salbutamol
even after potassium levels came to normal.
Wednesday, February 19, 2014
30

31. MONITORING PARAMETERS
•
•
•
•
•
Serum electrolytes
Renal function test
ECG
Blood pressure
Tissue culture
Wednesday, February 19, 2014
31

32. PATIENT COUNSELLING
Wednesday, February 19, 2014
32

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. 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. 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. Wednesday, February 19, 2014
36