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cellulitis with Acute Kidney Injury
This case presentation describes a 70-year-old male admitted with right leg cellulitis and acute kidney injury due to long-term NSAID abuse. He had swelling and ulceration of the right leg along with elevated creatinine and potassium. He was treated with antibiotics, insulin, salbutamol and calcium for his cellulitis and hyperkalemia. His kidney function improved over time with treatment but he had residual hypertensive kidney damage. The patient was counseled on preventing future cellulitis episodes and avoiding NSAIDs.
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Introduction of case study on lower limb cellulitis and acute kidney injury due to NSAIDs.
Details of patient (70 years, male, weight 72 kg) admitted for treatment.
Patient admitted due to right foot ulcer and bilateral limb pain with a thorn prick injury.
General condition of patient showing elevated BP, pulse, signs of pallor, ulceration, and limb swelling.
Day 1 vitals recorded, investigations ordered, provisional diagnosis of diabetic foot.
Hemoglobin, electrolytes and biochemistry tests showing possible abnormalities including elevated creatinine.
Summary of physician and anesthetic assessments suggesting necessary precautions for surgery.
Administration of antibiotics and supportive medications outlined in treatment chart.
Vital signs and nephrologist's opinion highlighting NSAID abuse and advice for management.
Update on electrolytes, reporting changes in potassium, sodium, creatinine, and GFR.
Modified treatment regimen including insulin for hyperkalemia and ongoing antibiotic therapy.
Continued monitoring of vitals, confirmation of surgical procedure conducted.
Electrolyte levels post-surgery indicating issues with renal function and potassium.
Ongoing treatment regimen adjustment based on patient response.
Stabilization of BP, review by ophthalmologist revealing hypertensive retinopathy.
Extended treatment chart detailing ongoing medications and adjustments.
Improvement in renal function noted with recommendation for follow-up tests.
Further electrolyte monitoring results demonstrating gradual recovery.
Continued care with a focus on maintaining electrolyte balance and renal health.
Patient condition remains stable with no new complaints; referral for physiotherapy.
Finalized treatment chart as recovery continues with no new complaints noted.
Patient shows improvements; regular assessment of vital signs and overall health.
Consolidated treatment regimen including all medications administered.
SOAP (Subjective, Objective, Assessment, Plan) approach for managing the patient's condition.
Patient's reported symptoms and medical history including NSAID usage.
Documentation of vital signs and lab abnormalities leading to diagnosis.
Objectives set to halt kidney disease progression and manage cellulitis.
Outlines treatment options for cellulitis and hyperkalemia.
Review of patient’s clinical progress and achievements within 6 days.
Problems related to untreated conditions and monitoring errors noted.
Key monitoring metrics to ensure patient recovery and medication effectiveness.
Patient counseling initiatives to educate about disease and treatment.
Information on cellulitis symptoms, causes, and prevention strategies.
Guidelines on medication use including dosing, adherence, and potential side effects.
Advice on maintaining skin health, hydration, and prompt treatment of infections.
Wrap up of the case presentation without additional content.
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cellulitis with Acute Kidney Injury
- 1. Case presentation onLower 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 70yrs 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 malepatient 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 9.4g% 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: Nota 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 :130/90mmHg 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 134mmol/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: 130/90mmHg O/E: Pain in foot CVS/RS: NAD Surgery conducted Wednesday, February 19, 2014 PULSE : 90BPM 12
- 13. LAB REPORTS : ELECTROLYTES Sodium 138mmol/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 140mmol/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: 130/90mm 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: 130/80mm 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 • Ulceron 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 onsubjective 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: • Betalactam Antibiotics • Macrolides • Clindamycin • Vancomycin HYPERKALEMIA: • Insulin • Salbutamol • Calcium gluconate • Calcium polysterate • Hemodialysis (in rare cases) Wednesday, February 19, 2014 28
- 29. GOALS ACHIEVED • Patient’spotassium 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 • Untreatedindication LVH. • Monitoring error: continues use of salbutamol even after potassium levels came to normal. Wednesday, February 19, 2014 30
- 31. MONITORING PARAMETERS • • • • • Serum electrolytes Renalfunction test ECG Blood pressure Tissue culture Wednesday, February 19, 2014 31
- 32. PATIENT COUNSELLING Wednesday, February19, 2014 32
- 33. About Disease • • • • What iscellulitis? What are the symptoms? How do you get cellulitis? How can you prevent cellulitis? Wednesday, February 19, 2014 33
- 34. About Medications – Nameand 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 stylemedications • 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