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A Case of Patient with CHF with Acute Chronic Renal Failure and Hyperkalaemia

MOHEMMAD REDZUAN BIN MOHEMMAD RIZAL

• • • • • •

Name R/N Age Gender Race Date of admission

: SM : 799231 : 69 : Female : Malay : 20th June 2013

CHIEF COMPLAINT

Referred from Hospital Muadzam Shah due to Acute on CRF 2° to UTI with Uremic Symptoms – Admitted to HMS on 17/6/2013.

HISTORY OF PRESENTING ILLNESSES
  

Bilateral pedal edema x 2/52 Poor oral intake Nausea and vomiting

Social and Family History   Mother of 2 children Housewife .Past Medical History    Diabetes Mellitus and Hypertension for past 10 years Congestive Heart Failure for past 5 years Under follow-up at Hospital Muadzam Shah.

Metformin 1g BD T. Potassium Chloride 1. Perindopril 8mg OD T.125mg OD T. Glicazide 160mg BD T. Frusemide 40mg OD T. Lovastatin 20mg OD .Past Medication History • • • • • • • T. Digoxin 0.2g OD T.

Vital Sign During Admission      Blood Pressure Pulse Rate Respiration Rate Temperature SpO2 : 104/54 mmHg : 92 pulse/minute : 20 breaths/minute : 37°C : 92% RA .

Diagnosis in Ward • • • • CHF with Acute Chronic Renal Failure Urinary Tract Infection Hyperkalaemia U/L Diabetes Mellitus and Hypertension .

Blood Pressure 21/6 22/6 .

5 37 36.Temperature 21/6 39 38.5 38 37.5 36 20/6/2013 9am 1pm 9pm 12mn 9am 12nn 2pm Tepid Sponging 22/6 Temperature IV Cefuroxime 750mg TDS .

LABORATORY RESULTS .

3 mmol/L 0.6 mmol/L 0.90 380 10.4 140 5.8 107 2.82 21/6 35.42 0.87 2.6 108 2.0 mmol/L 96-106mmol/L 2.BUSE/RENAL PROFILE Parameter Urea Na K Cl Ca Mg PO4 SCr ClCr Normal Range 1.5-5.90 2.24 0.3 mmol/L 135-145 mmol/L 3.97 22/6 36.8-1.7-8.1 142 6.37 289 14.7 106 2.7-1.9 143 5.38 0.90 2.73 330 12.45 mmol/L 64-122 mol/L 105-150 ml/min 20/6 31.1-2.84 .

0 189 .9 247 11.5 g/dL 150 – 400 x 109 /L 8.FULL BLOOD COUNT Parameter Normal Range 20/6 21/6 22/6 TWBC Hb Platelet 4 – 11 x 109 /L 11.5 – 16.32 16.4 200 11.91 16.02 16.

3 49 69 217 32 22/6 27.1 63 172 30 .LIVER PROFILE Normal range Albumin T. Bilirubin T.8 49. Protein ALP ALT 35-50 g/L < 20 mol/L 66-87 g/L 53-141 /L < 32 /L 21/6 31.

INPUT/OUTPUT CHART 20/6 21/6 Input Output 84 150 582 350 Balance -66 +232 .

9 7.7 17.3 13.7 13.DEXTROSE CHART 20/6 1am 3am 5am 7am 9am 12noon 2pm 4pm 6pm 11.4 11.2 6.8 - . 12.2 21/6 9.1 11.9 - 1030pm 11pm - 11.4 22/6 .0 8.

179 68.45 35-45 80-100 CnS Result Date Sample 20/6 Date Result Pending Source Sample Urine C+S Microorganism Sensitivity Resistance - .35-7.5 Normal Range pH pCO2 pO2 7.Metabolic Acidosis ABG 20/6 7.4 251 21/6 7.8 104.311 45.

MEDICATION IN WARD .

Metformin 1g BD Oral kalimate 10g TDS S/C Actrapid 6u Fluid Overload Prevention CVD Prophylaxis of Peptic Ulcer Type 2 DM Hyperkalaemia 20/6/13 20/6/13 22/6/13 Type 2 DM . Lovastatin 20mg ON IV Omeprazole 40mg OD T. Perindopril 8mg OD Hyperkalaemia CHF 22/6/13 20/6/13 20/6/13 20/6/13 20/6/13 20/6/13 22/6/13 21/6/13 21/6/13 Ongoing Ongoing 21/6/13 21/6/13 Ongoing Ongoing Others IV Frusemide 40mg BD T. Glicazide 160mg BD T.Drug Indication Date start Date stop Antibiotics IV Cefuroxime 750mg TDS Drug Urinary Tract Infection Indication 20/6 Ongoing Date start Date stop IV Lytic Cocktail Stat T.

2. Congestive Heart Failure Hyperkalaemia .PHARMACEUTICAL CARE ISSUE 1.

• Decreased cardiac output and ejection fraction. 2) Management of Heart Failure. . ECG. Management Recommended management2: (Refer to Algorithm treatment for Heart Failure) Management in the ward • T. it appears in a variety of conditions such as acute myocardial infarction. Congestive Heart Failure: Diagnosis. Jay I Peter. April 2004. vol 51 no 4. Perindopril 8mg OD • IV Frusemide 40mg BD Comment: Plan The was an inappropriate management of Congestive Heart failure for this patient. chronic uncontrolled hypertension and valvular disease. RP 1) Micheal S. Ministry of Health Malaysia. Therapy. Monitor Blood Pressure. Pathophysiology. increased renin released and increased peripheral arteriolar and venous constriction – this effects increase the cardiac work load and eventually lead for further decompesation.1) Management of Congestive Heart Failure Description Pathophysiology1 • Decreased cardiac contractility. and Implications for Respiratory Care Unit. • Autonomic compensatory mechanism: increased sympathetic discharge results from inadequate tissue perfusion and hypotension and causes tachycardia.

Flowchart: Optimizing Drug Therapy in CHF. Management of Heart Failure .

medscape. ECG Sign and Symptoms • Weakness. blood.12 . Available at: http://emedicine. Medscape. Potassium is an 2) To shift K from ECF to ICF important electrolyte 3) To reduce total body K in the body and high levels can cause the (Refer to Sarawak Handbook of heart and muscles to Medical Emergencies) function improperly and result in death. Management in the ward Common causes are • IV Lytic Coctail •Oral Kalimate 10mg TDS kidney failure and medications. Monitor Renal Profile.2) Management of Hyperkalaemia Description Pathophysiology3 • Management Recommended management4: Plan Comment: Goals: An abnormally high 1) To protect the heart from effects of K concentration of by antagonizing its effect on cardiac potassium in the conduction . slow heart rate. breathing problem 3) Hyperkalemia.com/article/240903medication#5 4) Sarawak Handbook of Medical Emergencies 3rd Edition Section 7. The was Inappropriate management of hyperkalaemia. fainting.

5 mmol/L) with no ECG changes Low potassium diet Stop drugs which may cause hyperkalemia Cation exchange. Severe Hyperkalaemia (K>6.Recommendation: 1. Immediate calcium administration Glucose and insulin Infusion Sodium bicarbonate Infusion Beta-agonist therapy Dialysis (Refer to Sarawak Handbook of Medical Emergencies) 2.5-6. 5.Glucose and insulin infusion\ Above treatments.resin Correction of acidosis in patient with metabolic acidosis +/.5 mmol/L) or with ECG changes: • • • • • • . • • • • • Mild to moderate Hyperkalaemia (K.

Drug Related Problem 1. 3. 2. 4. TDM for Digoxin Inappropriate Use of Drug Causing Hyperkalemia Late Administration of Lytic Cocktail Inappropriate use of Metformin and Glicazide on Acute CRF .

5-2 mcg/L Justifications4 • • • Digoxin MOA: Direct inhibition of membranebound Na+/K+ -ATPase1. Additional symptoms2.25 mcg/L Recommendation/ Outcome Recommendation • Suggest to withold T. difficulty breathing when lying down and overall swelling.Pg 482 2) Digoxin Toxity. Sign and symptoms .Inc. TDM sample for Digoxin was sent. •On 21/6/2013. Sign and symptoms of digoxin toxity2.nih. 2011. nausea. confusion.. Digoxin 0. vomiting. T.gov/medlineplus/ency/article/000165. Hyperkalemia. Lexi-Comp. Digoxin 0. palpitations.125mg OD • Suggest to reassay sample on 22/6/13 • Suggest to monitor potassium level 4-5mmol/l Outcome • T. diarrhea.125mg OD is withold • No sample was sent to TDM • Potassium level: 6. irregular pulse. 3.125mg OD upon admission to HTAA from HMS.1) TDM Digoxin Description of problem Patient on 1.125mg OD Result Normal Therapeutic Level 0. Digoxin 0. decreased urine output.htm .8 mmol/L 1 ) Lexicomp. 20th Ed. decreased consciousness.6 mmol/l • Potassium Level: 5.nlm. Drug Analysis T. Drug Information Handbook. loss of appetite. Available at: http://www. Digoxin 0.

However.html#afp20060115p283-t5 4) Lexicomp.. ACE inhibitor may further raise serum potassium level3. especially that associated with renal impaired or congestive heart failure. Frusemide 40mg OD is off 3) Hyperkalemia. Available at: http://www. • Justifications4 Patient with hyperkalaemia.2) Inappropriate Use of Drug Causing Hyperkalaemia Description of problem On 20/6. for this patient IV Frusemide is off on 21/6 • Recommendation/ Outcome Recommendation • Suggest to withhold T. Loop diuretic will help to increases renal excretion of potassium4.7 mmol/l was noted. IV. T.Frusemide 40mg OD Outcome • T. Page 736 .org/afp/2006/0115/p283. Frusemide 40mg OD • On 20/6. Potassium level = 5. Perindopril 8mg OD • Continue IV.aafp. Perindopril 8mg OD is off • IV. patient was given: 1. Drug Information Handbook 19th Edition . Perindopril 8mg OD 2.

1 mmol/l. 5) Sarawak Handbook of Medical Emergencies 3rd Edition. there are no administration of lytic coctail to the patient. 2.org/afp/2006/0115/p283. Glucose and insulin infusion.6 Lytic cocktail: 1.8 Justifications5.12 6) Hyperkalemia. • Continue Oral Kalimate 10g TDS mmol/l. However. •On 22/6 – Potassium level = 6.3) Late Administration of Lytic cocktail Description of problem • On 21/6 – Potassium level =5. Lytic cocktail stat was prescribed by doctor.html#afp20060115p283-t5 . Section 7. Calcium administration (10ml of 10% IV Calcium Gluconate or 3-10ml of 10% calcium chloride over 2-5 minutes. Rapid acting insulin 10 U + 50ml of 50% dextrose infused 30-60min Oral Kalimate – remove potassium via the digestive tract Recommendation/ Outcome Recommendation • Suggest to start IV Lytic cocktail stat on 22/6 • Continue Oral kalimate 10g TDS Outcome • IV Lytic cocktail stat x 1 was given to the patient. there are no lytic cocktail was given to the patient. However. Available at: http://www.aafp.

West J Med 1992. Glicazide 160mg BD • • The use of T.9 Metformin • Should not be given to the patient with renal impairment even if it is mild. Metformin 1g BD • Suggest to withold T. Am J Kidney Dis 2003.4) Inappropriate Use of Metformin and Glicazide on Acute CRF Description of problem Patient on: 1. Hepatic Drug Metabolism and transport in patient with kidney disease. Price DW. T. CMAJ 2002.Glicazide was inappropriate Noted Clcr: Justifications4 Glicazide • Severe renal impairment: Avoid if possible. Glicazide 160mg BD is withold . Glicazide 160mg BD Outcome • T. if no alternative reduce dose and monitor closely7. 38: 853-858 10) Swan SK. • Clcr < 50 ml/min: Avoid. 156. Frye RF. Metformin 1g BD 2.. Recommendation/ Outcome 7) Nolin TD. Recommendation • Suggest to withold T. Drug dosing guidelines in patients with renal failure. Matzke GR. increased risk of lactic acidosis10. Raebel MA. Safe drug prescribing for patients with renal insufficiency. 164(4): 473-477 9) Long CL.Metformin and T. as it may predispose patients to lactic acidosis7. 42(5): 906-925 8) Kappel J. 633-638. Calissi P. Bennett WM. Compliance with dosing guidelines in patients with chronic kidney disease. Magid DJ. • Contraindicated in severe impairment8 • Clcr <50 ml/min: Avoid. Pharmacother 2004. Metformin 1g BD is withold • T. T.

Ensure safe usage of medication in ward Pharmacist involve in Therapeutic Drug Monitoring Counsel patient on taking proper diet of potassium and herbal medication. 3.EMPHASIS ON PHARMACIST’S ROLE 1. . 2.

30pm • Cause of death: Urosepsis .CONCLUSION Patient is passed away on 22/6/2013 at 8.

Available at: http://emedicine.Reference 1. vol 51 no 4. Drug dosing guidelines in patients with renal failure. Compliance with dosing guidelines in patients with chronic kidney disease. Therapy.htm Nolin TD. West J Med 1992. 5.Inc. Sign and symptoms . Medscape. 633-638. 164(4): 473-477 Long CL. Raebel MA. Lexi-Comp. 10. Bennett WM. April 2004. Management of Heart Failure. Matzke GR.gov/medlineplus/ency/article/000165. 6. Frye RF. 8. 2011. Jay I Peter. Available at: http://www. Ministry of Health Malaysia. Calissi P.nih.12 Lexicomp.nlm. 38: 853-858 Swan SK. 2. 42(5): 906-925 Kappel J. Price DW.medscape. Hyperkalemia. Micheal S.Pg 482 Digoxin Toxity. Congestive Heart Failure: Diagnosis. Am J Kidney Dis 2003. Safe drug prescribing for patients with renal insufficiency. and Implications for Respiratory Care Unit.. 7. 156. Drug Information Handbook. Pathophysiology. 9. 4. Hepatic Drug Metabolism and transport in patient with kidney disease. . 3. 20th Ed. Magid DJ.com/article/240903-medication#5 Sarawak Handbook of Medical Emergencies 3rd Edition Section 7. Pharmacother 2004. CMAJ 2002.

Management Recommended management4: Plan Comment: The was appropriate (Refer to National Antibiotic Guideline management of 2008 for Antibiotic Regime UTI) urinary tract infection. Once in the bladder. Dipiro. Wells.2) Management of Urinary Tract Infection Description Pathophysiology3 • • The bacteria causing UTI usually originate from bowel flora of the host. In females. Patient who are unable to void urine completely are at greater risk of developing UTI and frequently have recurrent infection.Dipiro. Temperature. • • 3) Barbara G. MOH . Terry L. Cecily V. Joseph T. Management in the ward • IV Cefuroxime 750mg TDS Monitor CnS. TWBC. 4) National Antibiotic Guidelines 2008. Schwinghammer. Pharmacotherapy Handbook 7th Edition. Bacteria are then enter the bladder from urethra. the short length of the urethra and proximity to the perirectal area make colonization of the urethra likely. the organisms multiply quickly and can ascend the ureters to the kidney.

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gov/pmc/articles/PMC2652237/) . Available at: http://www.ncbi.What and which level of Hemoglobin require for blood transfusion in anemia?? (Refer from Recommendation for the transfusion of RBC.nih.nlm.