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Monday 10 April 2023 1
Case presentation on Lower limb Cellulitis with NSAID’s induced
Acute Kidney Injury
By: Abhimanyu Parashar Pharm D
Monday 10 April 2023 2
IP no. 258257
UNIT Surgery 1
AGE 70 yrs
SEX Male
WEIGHT 72 Kgs
Monday 10 April 2023 3
Reasons for admission :
c/o: Ulcer on Right foot since 10 daysc/o: Pain in both limbs since 2 years10 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, TBSHx: NS
Monday 10 April 2023 4
General Examination• Elderly male patient• Conscious oriented• BP: 170/100 mmHg• Pulse: 85 BPM• Pallor +• Cataract +
• Swelling of Rt Lower limb from knee to toes
• Small ulcer +• Discharge +• Left leg normal• CVS: S1S2 +• RS: B/L NVBS +
Monday 10 April 2023 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
Monday 10 April 2023 6
LAB REPORTS :HEMATOLOGY
Hb 9.4 g%
WBC 7000 Cells/ cumm
DLC N: 87 % , L: 11 %, M: 02 %E: 00 %, B: 02 %
PLT 4.82 L/ cumm
BT 3 min
CT 6 min
ELECTROLYTES
Sodium 144 mmol/l
Potassium 6.5 mmol/l
Chloride 115 mmol/l
BIOCHEMISTRY
RBS 117 mg/dl
Urea 57 mg/dl
S. Cr 2.5 mg/dl
MICROBIOLOGYAFB: -veHIV: -veHBS Ag: -ve
GFR: 28 ml/minUrine Culture
Pus cells +
Gram –ve bacilli +
Monday 10 April 2023 7
• Physician opinion:Not a k/c/o DM, HTNCVS: S1S2 +, TachycardiaECG: Tachycardia, mild LVHC- X-ray Pul. EdemaIMP: 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 parametersIf surgery is necessary then it should be done after the
consent of the patient.
Monday 10 April 2023 8
TREATMENT CHART
DRUG DOSE R F 1
Inj. Ceftriaxone 1 g 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 +
Calcium Gluconate PO 6hrly +
Monday 10 April 2023 9
DAY 2
BP :130/90mm Hg PULSE :90 BPMNephrologists' opinion: H/O NSAID’s Abuse since 6
monthsCVS/ RS: NADIMP: Cellulitis with Hypertension with ? NSAID Induced
CKDADV: 2 pints of NS at 75 ml/hrAvoid NSAIDS, Rpt U/C, USG abdomen + KUB,Low potassium diet, salbutamol, Calcium gluconate, H.
actrapid 8 units with 25% dextrose
Monday 10 April 2023 10
LAB REPORTS :
ELECTROLYTES
Sodium 134 mmol/l
Potassium 5.6 mmol/l
Chloride 106 mmol/l
BIOCHEMISTRY
RBS 96 mg/dl
HbA1C 5.2 g%
Urea 55 mg/dl
S. Cr 3.0 mg/dl
GFR: 23.5 ml/min
Monday 10 April 2023 11
TREATMENT CHART
DRUG DOSE R F 1 2
Inj. Ceftriaxone 1 g 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 8 U SC +
K check powder PO 6hrly + +
Monday 10 April 2023 12
DAY 3
BP: 130/90 mmHg PULSE : 90BPMO/E: Pain in footCVS/RS: NADSurgery conducted
Monday 10 April 2023 13
LAB REPORTS :
ELECTROLYTES
Sodium 138 mmol/l
Potassium 3.3 mmol/l
Chloride 88 mmol/l
BIOCHEMISTRY
Urea 53 mg/dl
S. Cr 3.0 mg/dlGFR: 23.5 ml/min
Monday 10 April 2023 14
TREATMENT CHART
DRUG DOSE R F 1 2 3
Inj. Ceftriaxone 1 g 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 + + +
K check powder PO 6hrly + + +
Monday 10 April 2023 15
DAY 4
BP:130/90 mmHg PULSE: 90 BPMO/E: No fresh complainsOphthalmologist opinion: RE: Leucomatous opacity, No viewLE: NormalIMP: No DR, Hypertensive retinopathy
Monday 10 April 2023 16
TREATMENT CHART
DRUG DOSE R F 1 2 3 4
Inj. Ceftriaxone 1 g 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 + + + +
K check powder PO 6hrly + + + +
Monday 10 April 2023 17
DAY 5
BP : 130/90 mmHg PULSE :80 BPM Nephrologists opinion: No edemaCVS/ RS: NADRFT: improvingADV: Rpt U/C after 5 days
Monday 10 April 2023 18
LAB REPORTS :
ELECTROLYTES
Sodium 140 mmol/l
Potassium 4.8 mmol/l
Chloride 100 mmol/l
BIOCHEMISTRY
Urea 34 mg/dl
S. Cr 2.0 mg/dlGFR: 35 ml/min
Monday 10 April 2023 19
TREATMENT CHART
DRUG DOSE R F 1 2 3 4 5
Inj. Ceftriaxone 1 g 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 + + + +
K check powder PO 6hrly + + + + +
Inj Cefoperazone + Sulbactum 1.5 g IV 1-0-1 +
Monday 10 April 2023 20
DAY 6
BP: 130/90 mm Hg PULSE: 90 BPM• O/E : No fresh complains • Ortho opinion: Physiotherapy
Monday 10 April 2023 21
TREATMENT CHART
DRUG DOSE R F 1 2 3 4 5 6
Inj. Ceftriaxone 1 g 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 + + + +
Calcium Gluconate PO 6hrly + + + + + +
Inj Cefoperazone + Sulbactum 1.5 g IV 1-0-1 + +
Monday 10 April 2023 22
DAY 7
BP: 130/80 mm Hg PULSE: 84 BPMO/E : No fresh complains CVS/ RS: NADAfebrileADV: CST
Monday 10 April 2023 23
TREATMENT CHART
DRUG DOSE R F 1 2 3 4 5 6 7
Inj. Ceftriaxone 1 g 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 + + + +
Calcium Gluconate PO 6hrly + + + + + +
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 +
Monday 10 April 2023 24
PHARMACEUTICAL CARE PLAN (SOAP)
Monday 10 April 2023 25
SUBJECTIVE EVIDENCE
• Ulcer on Right foot since 10 days• Pain in both limbs since 2 years• H/O NSAID’s abuse
OBJECTIVE EVIDENCE
• Elevated Serum creatinine• Elevated Blood Urea levels• Elevated Potassium Levels• ECG: Tachycardia, Mild LVH
Monday 10 April 2023 26
FINAL DIAGNOSIS
Based on subjective and objective evidence the patient was diagnosed as Lower limb Cellulitis
with NSAID’s induced Acute Kidney Injury
Monday 10 April 2023 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.
Monday 10 April 2023 28
TREATMENT OPTIONSCELLULITIS:• Beta lactam Antibiotics• Macrolides• Clindamycin • Vancomycin
HYPERKALEMIA:• Insulin• Salbutamol• Calcium gluconate• Calcium polysterate• Hemodialysis (in rare cases)
Monday 10 April 2023 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
Monday 10 April 2023 30
PROBLEMS IDENTIFIED
• Untreated indication LVH.• Monitoring error: continues use of salbutamol
even after potassium levels came to normal.
Monday 10 April 2023 31
MONITORING PARAMETERS
• Serum electrolytes• Renal function test• ECG• Blood pressure• Tissue culture
Monday 10 April 2023 32
PATIENT COUNSELLING
Monday 10 April 2023 33
About Disease
• What is cellulitis?• What are the symptoms?• How do you get cellulitis?• How can you prevent cellulitis?
Monday 10 April 2023 34
About Medications
– Name and purpose
– Dose and frequency
– Medication adherence
– Possible adverse effects
– Missed dose
– Avoid use of OTC drugs (NSAID’s)
Monday 10 April 2023 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.
Monday 10 April 2023 36
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