cellulitis with Acute Kidney Injury

Monday 10 April 2023 1

Case presentation on Lower limb Cellulitis with NSAID’s induced

Acute Kidney Injury

By: Abhimanyu Parashar Pharm D


IP no. 258257

UNIT Surgery 1

AGE 70 yrs

SEX Male

WEIGHT 72 Kgs


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


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 +


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


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 +


• 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.


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 +


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


LAB REPORTS :

ELECTROLYTES

Sodium 134 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


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 + +


DAY 3

BP: 130/90 mmHg PULSE : 90BPMO/E: Pain in footCVS/RS: NADSurgery conducted


LAB REPORTS :

ELECTROLYTES

Sodium 138 mmol/l


Chloride 88 mmol/l

BIOCHEMISTRY

Urea 53 mg/dl

S. Cr 3.0 mg/dlGFR: 23.5 ml/min


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 + + +


DAY 4

BP:130/90 mmHg PULSE: 90 BPMO/E: No fresh complainsOphthalmologist opinion: RE: Leucomatous opacity, No viewLE: NormalIMP: No DR, Hypertensive retinopathy


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 + + + +


DAY 5

BP : 130/90 mmHg PULSE :80 BPM Nephrologists opinion: No edemaCVS/ RS: NADRFT: improvingADV: Rpt U/C after 5 days


LAB REPORTS :

ELECTROLYTES

Sodium 140 mmol/l


Chloride 100 mmol/l

BIOCHEMISTRY

Urea 34 mg/dl

S. Cr 2.0 mg/dlGFR: 35 ml/min


TREATMENT CHART

DRUG DOSE R F 1 2 3 4 5


Inj. Metronidazole 500 mg IV 1-1-1 + + + + +

Inj. pantoprazole 40 mg IV 1-0-0 + + + + +

Inj. Tramadol 50 mg IV 1-1-1 + + +


K check powder PO 6hrly + + + + +

Inj Cefoperazone + Sulbactum 1.5 g IV 1-0-1 +


DAY 6

BP: 130/90 mm Hg PULSE: 90 BPM• O/E : No fresh complains • Ortho opinion: Physiotherapy


TREATMENT CHART

DRUG DOSE R F 1 2 3 4 5 6


Inj. Metronidazole 500 mg IV 1-1-1 + + + + + +

Inj. pantoprazole 40 mg IV 1-0-0 + + + + + +

Inj. Tramadol 50 mg IV 1-1-1 + + + +


Calcium Gluconate PO 6hrly + + + + + +

Inj Cefoperazone + Sulbactum 1.5 g IV 1-0-1 + +


DAY 7

BP: 130/80 mm Hg PULSE: 84 BPMO/E : No fresh complains CVS/ RS: NADAfebrileADV: CST


TREATMENT CHART

DRUG DOSE R F 1 2 3 4 5 6 7


Inj. Metronidazole 500 mg IV 1-1-1 + + + + + +

Inj. pantoprazole 40 mg IV 1-0-0 + + + + + +

Inj. Tramadol 50 mg IV 1-1-1 + + + + +


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 +


PHARMACEUTICAL CARE PLAN (SOAP)


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


FINAL DIAGNOSIS

Based on subjective and objective evidence the patient was diagnosed as Lower limb Cellulitis

with NSAID’s induced Acute Kidney Injury


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.


TREATMENT OPTIONSCELLULITIS:• Beta lactam Antibiotics• Macrolides• Clindamycin • Vancomycin

HYPERKALEMIA:• Insulin• Salbutamol• Calcium gluconate• Calcium polysterate• Hemodialysis (in rare cases)


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


PROBLEMS IDENTIFIED

• Untreated indication LVH.• Monitoring error: continues use of salbutamol

even after potassium levels came to normal.


MONITORING PARAMETERS

• Serum electrolytes• Renal function test• ECG• Blood pressure• Tissue culture


PATIENT COUNSELLING


About Disease

• What is cellulitis?• What are the symptoms?• How do you get cellulitis?• How can you prevent cellulitis?


About Medications

– Name and purpose

– Dose and frequency

– Medication adherence

– Possible adverse effects

– Missed dose

– Avoid use of OTC drugs (NSAID’s)


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.


Health & Medicine

cellulitis with Acute Kidney Injury