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Chief Complaint: generalized body weakness HPI: Bong Pacquiao is a 75-year-old man who presents to the ED with complaints of severe weakness that started this morning. He was feeling normal until last night when he felt more tired than usual and went to bed early. Since waking this morning, he has not had the energy to eat or perform his normal ADLs. His wife brought him to the ED because his physician is away on vacation. PMH HTN X 25 years CHF X 8 years PUD (recently diagnosed) FH Father died of an acute MI; mother was diabetic SH Retired and living at home with his wife. Before retirement, the patient was employed as an accountant. No alcohol, no tobacco use. Meds Furosemide 40 mg po once daily Metoprolol succinate 50 mg po once daily Enalapril 20 mg po once daily Famotidine 20 mg po BID All NKA ROS Patient complains of feeling cold but denies chills or fever. No changes in vision. Denies SOB, CP, and cough. Complains of vertigo. Has been having frequent black diarrhea over the last 2 days, but denies abdominal pain. Has noted a decrease in the frequency of urination over the last 24 hours. Denies musculoskel- etal pain or cramping.
Physical Examination Gen Pale, elderly Caucasian man who appears generally weak and lethargic VS BP 96/48 (82/37 on standing), P 105, RR 26, T 37.1°C; Wt 78 kg, Ht 5'9" Skin Pale and cold with poor turgor HEENT PERRLA; EOMI; Fundi normal; conjunctivae pale and dry; TMs intact; tongue and mouth dry Neck/Lymph Nodes No JVD or HJR; no lymphadenopathy or thyromegaly Lungs No crackles or rhonchi CV Tachycardic with regular rhythm; normal S,, Sy; no S3; faint Sq; no MRG Abd Soft, NT/ND; No HSM; hyperactive BS Genit/Rect Stool heme (+); slightly enlarged prostate MS/Ext Weak pulses; no peripheral edema Neuro A&OX 3; CNs intact; DTRs 2+; Babinski (-) Labs Na 139 mEq/L K 5.3 mEq/L Cl 103 mEq/L CO, 21 mEq/L BUN 48 mg/dL SCr 1.8 mg/dL Glu 113 mg/dL Ca 8.6 mg/dL Mg 2.1 mg/dL Phos 4.3 mg/dL WBC 11.3 x 103/mm3 Hgb 9.1 g/dL Hct 27.3% Plt 128 x 103/mm Assessment t/c acute UGI bleed possibly related to PUD • anemia secondary to GIB • AKI secondary to hypovolemia
Problem Identification 1.a. Create a list of the patient's drug therapy problems as they relate to his acute kidney injury (AKI). 1.b. What information (signs, symptoms, laboratory values) indi- cates the presence or severity of hypovolemia and AKI in this patient? Desired Outcome 2. What are the goals of therapy in this case? CLINICAL COURSE Upon admission, the patient was resuscitated aggressively with IV normal saline and multiple transfusions (4 units of PRBCs). His home medications were held, and he underwent an emergent EGD. During endoscopy, a large ulcer in the gastric antrum was found with an oozing vessel at the base. Endoscopic therapy was unsuc- cessful, and the patient was taken to the OR for surgical interven- tion. He was hypotensive in the OR (BP 70 mm Hg systolic on average) and was started on a norepinephrine infusion to maintain a stable BP. Postoperatively his urine output was <100 mL total over the first 12 postoperative hours despite continued aggressive IV hydration and repeated transfusions in the OR. He also remained on norepinephrine for a continued low BP. On the morning of post- operative day 1, his labs were as follows: Na 132 mEq/L K 4.9 mEq/L Cl 98 mEq/L CO, 19 mEq/L BUN 39 mg/dL SCr 2.5 mg/dL Glu 145 mg/dL Ca 8.2 mg/dL Mg 2.2 mg/dL Phos 4.7 mg/dL WBC 14.6 x 103/mm3 Hgb 10.3 g/dL Hct 29.8% Plt 112 x 10/mm3
Urinalysis also showed muddy brown casts, a urine sodium of 72 mEq/L, and specific gravity of 1.004. A diagnosis of ATN was made, and the patient was started on furosemide 80 mg IV Q 8 h. On postoperative day 2, the patient remained on norepinephrine, his urine output had not improved, and his chest radiograph showed diffuse bilateral pulmonary edema with a decrease in O, saturation to 86%. A femoral vein catheter was inserted and continuous venovenous hemodiafiltration (CVVH-DF) was started. On post- operative day 5, his heart failure had resolved, and the catheter was removed. His subsequent hospital course was uneventful, and his kidney function gradually improved. Therapeutic Alternatives 3.a. What nondrug therapies were used to manage this patient's AKI? Discuss the evidence that supports their use. 3.b. What pharmacotherapeutic alternatives have been studied for the treatment of AKI? Optimal Plan 4. Design an optimal therapeutic plan for managing this patient's AKI postoperatively. Outcome Evaluation 5. What clinical and laboratory parameters are necessary to evaluate the therapy for achievement of the desired therapeutic outcome and to detect or prevent adverse effects? Patient Education 6. What information should be provided to the patient to help avoid future episo of AKI?