1. CASE 1 TDM Case Presentation By : Group B
End-Stage Renal Failure on IV Vancomycin
(Line related sepsis with MRSA)
CASE 1
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)

2. Patient Description Name : AAG R/N : 8051180 Ward :C7-B27
Gender : Male
Ethnic : Indian
Age : 88 yo
Weight : 55 kg
Admission: 8/10/10

3. 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.

4. History of Present Illness
Urosepsis in July 2010
Benign Prostatic Hyperplasia
Suspected Pulmonary TB

5. Past Medical History DM
HTN
Urosepsis
ESRF

6. Family History
Most of his family are smoking and consume alcohol except him.

7. 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
ʘ = tenuis bilabial click

8. On 14/10/10 [3.40 pm] Result from Pathology Dept. Noted MRSA positive
Sensitive to Vancomycin
Medication Plan:
IV Vancomycin 1g BD
Stop IV Cefepime
Cefepime is 4th gen of cyclosporin.

9. Essential vital sign & Laboratory values

10. White Blood Cell test 14/10/10 19.9x103 16/10/10 13.3x103 Dates
Volume (µL)
Comments
14/10/10
19.9x103
Normal value
4, ,800
cells/µL.
High than
normal value
16/10/10
13.3x103

11. Renal test Blood urea nitrogen concentration
Dates
Concentration (mg/dL)
comments
14/10/10
19.5
Normal value 8-18 mg/dL.
Slightly high
19/10/10
17.5
normal
Serum creatinine concentration
Dates
Concentration (µmol/L)
comments
14/10/10
374
Normal value µmol/L
High
16/10/10
385
same

12. Liver function test date 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 g/L

13. Input / output In
2860 cc
Out
2700 cc
Balance
160 cc

14. TDM Request Form Name AAG Diagnosis Acute on CFR, 2° Urosepsis (MRSA)
Ward/Unit
C7-27
R/N
Age
88 years old
Sex
Male
Race
Indian
Weight (kg)
55 kg
Pregnant No
Smoking
Alcohol

15. Last dose taken/ administered
On 16/10/2010
Drug
Dose & Frequency
Date & Time
Started
Last dose taken/ administered
Sampling
Date
Time
IV Vancomycin
1g BD
14/10/ PM
16/10
8 am
7.30 am
12.00pm

16. Last dose taken/ administered
On 19/10/2010
Drug
Dose & Frequency
Date & Time
Started
Last dose taken/ administered
Sampling
Date
Time
IV Vancomycin
750 mg BD
14/10/ PM
18/10
8 am
19/10
7.30 am
10.30pm

17. Laboratory Data (14/10/2010) Lab Data Value K+ 3.0 Na+ 134 BUN 19.5
Serum Creatinine
374
SGPT/SGOT
Alk Phos

18. Laboratory Data (19/10/2010) Lab Data Value K+ 2.6 Na+ 140 BUN 17.5
Serum Creatinine
385
SGPT/SGOT
Alk Phos 82

19. TDM Request Form Therapeutic level on 16/10/2010 Drug Vancomycin
Therapeutic Range
Trough: μg/mL
Peak: μg/mL
Measured level
Pre : μg/mL
Post: μg/mL
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

20. TDM Request Form Therapeutic level on 19/10/2010 Drug Vancomycin
Therapeutic Range
Trough: μg/mL
Peak: μg/mL
Measured level
Pre : μg/mL
Post: μg/mL

21. Blood Pressure - mmHg

22. 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

23. Pulse Rate (beats per minute)

24. Body Temperature

25. Respiratory Rate – Breaths/minute

26. 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

27. Current Drug Therapy Oral Vitamin B complex I/I OD – Starts on 15/10
Fe Fumarate II/II OD – Starts on 18/10
Mist KCl 2g TDS – Starts on 18/10
NaHCO3 2g BD – Starts on 19/10

28. Current Drug Therapy Parenteral
IV Ranitidine 15 mg TDS – Start on 19/10
IV Vancomycin 1 g Stat BD – Start on 14/10