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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
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Patient Description
Name : AAG R/N : 8051180Ward :C7-B27Gender : Male Ethnic : Indian Age : 88 yo Weight : 55 kg Admission: 8/10/10
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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.
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History of Present Illness
Urosepsis in July 2010Benign Prostatic HyperplasiaSuspected Pulmonary TB
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Past Medical History
DMHTNUrosepsisESRF
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Family History
Most of his family are smoking and consume alcohol except him.
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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
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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
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Essential vital sign &
Laboratory values
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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
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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
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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
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Input / output
In 2860 cc
Out 2700 cc
Balance 160 cc
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TDM Request Form
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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
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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
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Laboratory Data (14/10/2010)
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Laboratory Data (19/10/2010)
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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
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TDM Request Form
Therapeutic level on 19/10/2010
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Blood Pressure - mmHg
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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
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Pulse Rate (beats per minute)
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Body Temperature
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Respiratory Rate – Breaths/minute
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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
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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
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Current Drug Therapy
• Parenteral1.IV Ranitidine 15 mg TDS – Start on 19/102.IV Vancomycin 1 g Stat BD – Start on 14/10