A Case of Patient with CHF with Acute Chronic Renal Failure and Hyperkalaemia

MOHEMMAD REDZUAN BIN MOHEMMAD RIZAL

Name R/N Age Gender Race Date of admission

: SM : 799231 : 69 : Female : Malay : 20th June 2013

CHIEF COMPLAINT

Referred from Hospital Muadzam Shah due to Acute on CRF 2 to UTI with Uremic Symptoms Admitted to HMS on 17/6/2013.

HISTORY OF PRESENTING ILLNESSES

Bilateral pedal edema x 2/52 Poor oral intake Nausea and vomiting

Past Medical History

Diabetes Mellitus and Hypertension for past 10 years Congestive Heart Failure for past 5 years Under follow-up at Hospital Muadzam Shah.

Social and Family History

Mother of 2 children Housewife

Past Medication History

T. Glicazide 160mg BD T. Metformin 1g BD

T. Digoxin 0.125mg OD T. Potassium Chloride 1.2g OD

T. Perindopril 8mg OD

T. Frusemide 40mg OD T. Lovastatin 20mg OD

Vital Sign During Admission

Blood Pressure Pulse Rate Respiration Rate Temperature SpO2 : 104/54 mmHg : 92 pulse/minute : 20 breaths/minute : 37C : 92% RA

Diagnosis in Ward

CHF with Acute Chronic Renal Failure Urinary Tract Infection

Hyperkalaemia U/L Diabetes Mellitus and Hypertension

Blood Pressure
21/6 22/6

Temperature
21/6
39 38.5 38 37.5 37 36.5 36 20/6/2013 9am 1pm 9pm 12mn 9am 12nn 2pm
Tepid Sponging

22/6

Temperature
IV Cefuroxime 750mg TDS

LABORATORY RESULTS

BUSE/RENAL PROFILE
Parameter Urea Na K Cl Ca Mg PO4 SCr ClCr Normal Range 1.7-8.3 mmol/L 135-145 mmol/L 3.5-5.0 mmol/L 96-106mmol/L 2.1-2.6 mmol/L 0.7-1.3 mmol/L 0.8-1.45 mmol/L 64-122 mol/L 105-150 ml/min 20/6 31.9 143 5.7 106 2.42 0.90 2.37 289 14.82 21/6 35.4 140 5.8 107 2.38 0.87 2.73 330 12.97 22/6 36.1 142 6.6 108 2.24 0.90 2.90 380 10.84

FULL BLOOD COUNT

Parameter Normal Range 20/6 21/6 22/6

TWBC Hb Platelet

4 11 x 109 /L 11.5 16.5 g/dL 150 400 x 109 /L

8.91 16.9 247

11.32 16.4 200

11.02 16.0 189

LIVER PROFILE
Normal range
Albumin T. Bilirubin T. Protein ALP ALT 35-50 g/L < 20 mol/L 66-87 g/L 53-141 /L < 32 /L 21/6 31.3 49 69 217 32 22/6 27.8 49.1 63 172 30

INPUT/OUTPUT CHART
20/6 21/6

Input Output

84 150

582 350

Balance

-66

+232

DEXTROSE CHART
20/6 1am 3am 5am 7am 9am 12noon 2pm 4pm 6pm 11.7 13.2 21/6 9.2 6.0 8.7 17.1 11.4 22/6 . 12.3 13.4 11.9 7.9 -

1030pm
11pm

11.8

Metabolic Acidosis

ABG
20/6 7.311 45.4 251 21/6 7.179 68.8 104.5

Normal Range pH pCO2 pO2 7.35-7.45 35-45 80-100

CnS Result
Date Sample 20/6 Date Result Pending Source Sample Urine C+S Microorganism Sensitivity Resistance -

MEDICATION IN WARD

Drug

Indication

Date start

Date stop

Antibiotics

IV Cefuroxime 750mg TDS

Drug

Urinary Tract Infection

Indication

20/6

Ongoing

Date start

Date stop

IV Lytic Cocktail Stat T. Perindopril 8mg OD

Hyperkalaemia CHF

22/6/13 20/6/13 20/6/13 20/6/13 20/6/13 20/6/13

22/6/13 21/6/13 21/6/13 Ongoing Ongoing 21/6/13 21/6/13 Ongoing Ongoing

Others

IV Frusemide 40mg BD T. Lovastatin 20mg ON IV Omeprazole 40mg OD T. Glicazide 160mg BD T. Metformin 1g BD Oral kalimate 10g TDS S/C Actrapid 6u

Fluid Overload
Prevention CVD

Prophylaxis of Peptic Ulcer Type 2 DM Hyperkalaemia

20/6/13 20/6/13 22/6/13

Type 2 DM

PHARMACEUTICAL CARE ISSUE

1.
2.

Congestive Heart Failure Hyperkalaemia

1) Management of Congestive Heart Failure

Description
Pathophysiology1 Decreased cardiac contractility, it appears in a variety of conditions such as acute myocardial infarction, chronic uncontrolled hypertension and valvular disease. Decreased cardiac output and ejection fraction. Autonomic compensatory mechanism: increased sympathetic discharge results from inadequate tissue perfusion and hypotension and causes tachycardia, increased renin released and increased peripheral arteriolar and venous constriction this effects increase the cardiac work load and eventually lead for further decompesation.

Management
Recommended management2: (Refer to Algorithm treatment for Heart Failure) Management in the ward T. Perindopril 8mg OD IV Frusemide 40mg BD Comment:

Plan
The was an inappropriate management of Congestive Heart failure for this patient. Monitor Blood Pressure, ECG, RP

1) Micheal S, Jay I Peter, Congestive Heart Failure: Diagnosis, Pathophysiology, Therapy, and Implications for Respiratory Care Unit, April 2004, vol 51 no 4. 2) Management of Heart Failure, Ministry of Health Malaysia.

Flowchart: Optimizing Drug Therapy in CHF, Management of Heart Failure

2) Management of Hyperkalaemia
Description
Pathophysiology3

Management
Recommended management4:

Plan
Comment:

Goals: An abnormally high 1) To protect the heart from effects of K concentration of by antagonizing its effect on cardiac potassium in the conduction . blood. Potassium is an 2) To shift K from ECF to ICF important electrolyte 3) To reduce total body K in the body and high levels can cause the (Refer to Sarawak Handbook of heart and muscles to Medical Emergencies) function improperly and result in death. Management in the ward Common causes are IV Lytic Coctail Oral Kalimate 10mg TDS kidney failure and medications.

The was Inappropriate management of hyperkalaemia. Monitor Renal Profile, ECG

Sign and Symptoms Weakness, slow heart rate, fainting, breathing problem

3) Hyperkalemia, Medscape, Available at: http://emedicine.medscape.com/article/240903medication#5 4) Sarawak Handbook of Medical Emergencies 3rd Edition Section 7.12

Recommendation:
1.

Mild to moderate Hyperkalaemia (K; 5.5-6.5 mmol/L) with no ECG changes Low potassium diet Stop drugs which may cause hyperkalemia Cation exchange- resin Correction of acidosis in patient with metabolic acidosis +/- Glucose and insulin infusion\ Above treatments. Immediate calcium administration Glucose and insulin Infusion Sodium bicarbonate Infusion Beta-agonist therapy Dialysis (Refer to Sarawak Handbook of Medical Emergencies)

2. Severe Hyperkalaemia (K>6.5 mmol/L) or with ECG changes:

Drug Related Problem

1. 2. 3. 4.

TDM for Digoxin Inappropriate Use of Drug Causing Hyperkalemia Late Administration of Lytic Cocktail Inappropriate use of Metformin and Glicazide on Acute CRF

1) TDM Digoxin
Description of problem
Patient on 1. T. Digoxin 0.125mg OD upon admission to HTAA from HMS.
On 21/6/2013, TDM sample for Digoxin was sent.
Drug Analysis T. Digoxin 0.125mg OD Result Normal Therapeutic Level 0.5-2 mcg/L

Justifications4

Digoxin MOA: Direct inhibition of membranebound Na+/K+ -ATPase1. Sign and symptoms of digoxin toxity2; confusion, irregular pulse, loss of appetite, nausea, vomiting, diarrhea, palpitations, Hyperkalemia. Additional symptoms2; decreased consciousness, decreased urine output, difficulty breathing when lying down and overall swelling.

3.25 mcg/L

Recommendation/ Outcome
Recommendation Suggest to withold T. Digoxin 0.125mg OD Suggest to reassay sample on 22/6/13 Suggest to monitor potassium level 4-5mmol/l
Outcome T. Digoxin 0.125mg OD is withold No sample was sent to TDM Potassium level: 6.6 mmol/l

Potassium Level: 5.8 mmol/L

1 ) Lexicomp. Drug Information Handbook. 20th Ed. Lexi-Comp.Inc. 2011..Pg 482 2) Digoxin Toxity; Sign and symptoms . Available at: http://www.nlm.nih.gov/medlineplus/ency/article/000165.htm

2) Inappropriate Use of Drug Causing Hyperkalaemia

Description of problem On 20/6, patient was given: 1. T. Perindopril 8mg OD 2. IV. Frusemide 40mg OD On 20/6, Potassium level = 5.7 mmol/l was noted.

Justifications4
Patient with hyperkalaemia, especially that associated with renal impaired or congestive heart failure, ACE inhibitor may further raise serum potassium level3. Loop diuretic will help to increases renal excretion of potassium4.. However, for this patient IV Frusemide is off on 21/6

Recommendation/ Outcome
Recommendation Suggest to withhold T. Perindopril 8mg OD Continue IV.Frusemide 40mg OD Outcome T. Perindopril 8mg OD is off IV. Frusemide 40mg OD is off
3) Hyperkalemia, Available at: http://www.aafp.org/afp/2006/0115/p283.html#afp20060115p283-t5 4) Lexicomp, Drug Information Handbook 19th Edition , Page 736

3) Late Administration of Lytic cocktail

Description of problem
On 21/6 Potassium level =5.8

Justifications5,6
Lytic cocktail: 1. Calcium administration (10ml of 10% IV Calcium Gluconate or 3-10ml of 10% calcium chloride over 2-5 minutes. 2. Glucose and insulin infusion; Rapid acting insulin 10 U + 50ml of 50% dextrose infused 30-60min Oral Kalimate remove potassium via the digestive tract Recommendation/ Outcome
Recommendation Suggest to start IV Lytic cocktail stat on 22/6 Continue Oral kalimate 10g TDS
Outcome IV Lytic cocktail stat x 1 was given to the patient. Continue Oral Kalimate 10g TDS

mmol/l, Lytic cocktail stat was prescribed by doctor. However, there are no administration of lytic coctail to the patient. On 22/6 Potassium level = 6.1 mmol/l, However, there are no lytic cocktail was given to the patient.

5) Sarawak Handbook of Medical Emergencies 3rd Edition, Section 7.12 6) Hyperkalemia. Available at: http://www.aafp.org/afp/2006/0115/p283.html#afp20060115p283-t5

4) Inappropriate Use of Metformin and Glicazide on Acute CRF

Description of problem
Patient on: 1. T. Metformin 1g BD 2. T. Glicazide 160mg BD The use of T..Metformin and T.Glicazide was inappropriate Noted Clcr:

Justifications4
Glicazide Severe renal impairment: Avoid if possible; if no alternative reduce dose and monitor closely7. Contraindicated in severe impairment8 Clcr <50 ml/min: Avoid.9 Metformin Should not be given to the patient with renal impairment even if it is mild, as it may predispose patients to lactic acidosis7. Clcr < 50 ml/min: Avoid; increased risk of lactic acidosis10. Recommendation/ Outcome

7)

Nolin TD, Frye RF, Matzke GR. Hepatic Drug Metabolism and transport in patient with kidney disease. Am J Kidney Dis 2003; 42(5): 906-925 8) Kappel J, Calissi P. Safe drug prescribing for patients with renal insufficiency. CMAJ 2002; 164(4): 473-477 9) Long CL, Raebel MA, Price DW, Magid DJ. Compliance with dosing guidelines in patients with chronic kidney disease, Pharmacother 2004; 38: 853-858 10) Swan SK, Bennett WM. Drug dosing guidelines in patients with renal failure. West J Med 1992; 156; 633-638.

Recommendation Suggest to withold T. Metformin 1g BD Suggest to withold T. Glicazide 160mg BD

Outcome T. Metformin 1g BD is withold T. Glicazide 160mg BD is withold

EMPHASIS ON PHARMACISTS ROLE

1.
2. 3.

Ensure safe usage of medication in ward Pharmacist involve in Therapeutic Drug Monitoring Counsel patient on taking proper diet of potassium and herbal medication.

CONCLUSION
Patient is passed away on 22/6/2013 at 8.30pm Cause of death: Urosepsis

Reference
1. 2. 3.

4.
5. 6.

7.

8.

9.

10.

Micheal S, Jay I Peter, Congestive Heart Failure: Diagnosis, Pathophysiology, Therapy, and Implications for Respiratory Care Unit, April 2004, vol 51 no 4. Management of Heart Failure, Ministry of Health Malaysia. Hyperkalemia, Medscape, Available at: http://emedicine.medscape.com/article/240903-medication#5 Sarawak Handbook of Medical Emergencies 3rd Edition Section 7.12 Lexicomp. Drug Information Handbook. 20th Ed. Lexi-Comp.Inc. 2011..Pg 482 Digoxin Toxity; Sign and symptoms . Available at: http://www.nlm.nih.gov/medlineplus/ency/article/000165.htm Nolin TD, Frye RF, Matzke GR. Hepatic Drug Metabolism and transport in patient with kidney disease. Am J Kidney Dis 2003; 42(5): 906-925 Kappel J, Calissi P. Safe drug prescribing for patients with renal insufficiency. CMAJ 2002; 164(4): 473-477 Long CL, Raebel MA, Price DW, Magid DJ. Compliance with dosing guidelines in patients with chronic kidney disease, Pharmacother 2004; 38: 853-858 Swan SK, Bennett WM. Drug dosing guidelines in patients with renal failure. West J Med 1992; 156; 633-638.

2) Management of Urinary Tract Infection

Description
Pathophysiology3
The bacteria causing UTI usually originate from bowel flora of the host. In females, the short length of the urethra and proximity to the perirectal area make colonization of the urethra likely. Bacteria are then enter the bladder from urethra. Once in the bladder, the organisms multiply quickly and can ascend the ureters to the kidney. Patient who are unable to void urine completely are at greater risk of developing UTI and frequently have recurrent infection.

Management
Recommended management4:

Plan
Comment:

The was appropriate (Refer to National Antibiotic Guideline management of 2008 for Antibiotic Regime UTI) urinary tract infection.
Management in the ward IV Cefuroxime 750mg TDS

Monitor CnS, TWBC, Temperature.

3) Barbara G. Wells, Joseph T. Dipiro, Terry L. Schwinghammer, Cecily V.Dipiro, Pharmacotherapy Handbook 7th Edition. 4) National Antibiotic Guidelines 2008, MOH

What and which level of Hemoglobin require for blood transfusion in anemia??

(Refer from Recommendation for the transfusion of RBC, Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2652237/)