CASE STUDY

TDM
CLERKSHIP
Group D
Patient Profile
• Name : CEH
• Ward / Unit : C7-14
• R/N : 795080
• IC. No. : 610515-07-5047
• Age : 49 years old
• Gender : Male
• Weight : 60kg
• Race : Chinese
• Diagnosis : ESRF
Chief Complain
• Diarrhea for 9 days but not for the past 2
days
• Nausea
• Vomiting
History Of Present
Illness
• Fever for 3 days – High grade ,resolve by
PCM
• URTI sx. (cough for past few weeks),
– Nausea
– Vomiting
• Belching
• Tolerating orally minimal
– SOB
– Chest Pain
– Palpitation
– Dizziness
– Sweating
Past Medical
History
• DM
• HTN
• Renal Failure

Allergies
• Meropenam
Physical
Examination
Date 30/8 31/8 1/9
Temp (Co) 36.8 36.8 36.6
BP(mmHg) 115/68 118/73 125/66
Pulse (bpm) 70 66 70
SPO2 99% 98%

*blood pressure drops, resulting in shock.

 Laboratory Data
Date 30/8 31/8 1/9
WBC(1x103) 16 15.9 15.3
Hgb(mg/dl) 10.8 11.9 12.4
Hct(%) 34.6 38.2 39.8
Platlet (1x103) 27 26 51
Na+ 144
K+ 39
Urea 38.1
Creatinine 587
Uric Acid/Mg 1.08

• Elevation of WBC above 12000 indicate the

sepsis
• Lowering of platelet count
Data
Date 30/8 31/8 1/9
Ca2+ 1.90
LDH(U/L) 346
CPK/MB(U/L) 137
INR(s) 1.6
PT/aPTT(s) 18/128.6
Bili 35
ALT/AST(U/L) 88/33
Alk Phos(U/L) 154
Concurrent
Medication
• IV dopamine
• IV Fluconazole 200mg OD
• IV Cefepime 1gm OD
• IV hydrocortisone 50mg b.d
• IV Esomeprazole 40mg b.d
• Neurobion Oral OD
• B co / Vit C Oral b.d
Diagnosis
• ESRF with severe sepsis in shoke
• Septic arthritis
• Complete Heart block
Vancomycin
Drug Dose Date Last dose taken Sampling
name, & started Date Time Date Time
route, Frequ
dose & ency
frequency

Vancomycin 1g OD 19/8/10 28/8/10 Not 1/9/10 11.40am

given
• Serum Drug Concentration

Date 1/9/2010 28/8/2010 26/8/2010

Therapeutic 15-20mg/L
Range
Measured 25.64mg/L 14.96mg/L 28.23mg/L
level

Pharmacist’s comment :
• Since the measured level is still high,
• Another stat dose of vancomycin can only be given
tomorrow (2/9/2010)
Problem ?
• The pre – concentration of Vancomycin on
1/9/2010 was 25.64 mg/L.
• This concentration was considered as high
and in toxic level.
• Since our target pre – concentration is <
20 mg/L, how long do we have to with hold
the Vancomycin dose regimen before
giving a new stat dose?
Calculation
• ClCr = ( 140 – age ) x Body Weight
SCr x 72
= (140 – 49 ) x 60 kg
587/88.4 x 72
= 11.42 ml/min
• Ke = 0.00083 Cr CL + 0.0044
= 0.00083 (11.42) + 0.0044
= 0.01388 hr-1

• T ½ = ln 2
Ke
= ln2
0.01388
= 50 hr

• Since this patient is an ESRF patient, he has low renal

function .
• Therefore, half life of vancomycin in this patient is very
long compared to normal adult ( 7 hours ).
• Cl = 0.65 ×CrCl
= 0.65 × 11.42
= 7.423 ml/min
= 7.423 ml/min × 60 min /hr
1000 ml/L
= 0.445 L/ hr

• Vd = Cl
Ke
= 0.445L/hr
0.01388 hr-1
= 32.06 L
Dose
Recommendation
There are 3 alternatives
1. Set a target therapeutic concentration
2. Withhold for 24 hours
3. Dose modification
• Alternative 1
C = Co e –Ke Γ
17mg/L = 25.64mg/mL e – (0.01388 hr-1)(Γ)
17mg/L = e – (0.01388 hr-1)(Γ)
25.64mg/L
0.663 = e – (0.01388 hr-1)(Γ)
ln 0.663 = – (0.01388 hr-1)(Γ)
Γ = ln 0.663
– (0.01388 hr-1)
= 29.6 hr ≈ 30 hr
Therefore, based on the calculation a stat dose of
Vancomycin being given at 5.40pm on 2/9/2010.
However, in practical ,the dose must be administered
before 5.00pm
Alternative 2
C = Co e –Ke Γ
= 25.64mg/mL e – (0.01388 hr-1)(24)
= 18.38 mg/L

After withhold the dose for 24 hr, the

predicted measured level will drop to
18.38mg/L. Then, only we give a new stat
dose.
 Alternative 3
Dose modification: 1g 750mg
• Calculate the possible peak level
Cpost = Dose / Vd (1 – e-ket)
Cpost = 750 mg / 32.06 L (1 – e-0.01388 hr-1(24 hr))
= 12.28 mg/L

• Calculate the predicted trough

Cpre = Cpost(e-ket)
Cpre = (12.28 mg/L)(e-0.05hr-1(24 hr))
= 8.8 mg/L
Conclusion
• In fact, alternative 1 and 2 are more
preferred.
• Besides, the alternative 3 tend to increase
the wastage .
• Basically the vancomycin are come in a 1
ml per vial. Due to the stability the solution
must be administered immediately once
the vial is broken.
THANK YOU