Acute left ventricular failure secondary to Ischemic heart disease and Acute kidney injury
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ACUTE Left Ventricular failure SECONDARY TO IHD AND AKD Bashar Talal Saad Mohammed 1 st year M.Pharm Pharmacy practice Jss university pharmacy college
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Transcript of Acute left ventricular failure secondary to Ischemic heart disease and Acute kidney injury
ACUTE Left Ventricular failure SECONDARY TO IHD AND AKD
Bashar Talal Saad Mohammed1st year M.PharmPharmacy practice
Jss university pharmacy college
Heart Failure
• Age: 56 years• Sex: male• Weight: 58 Kg• Unit: CCU• IP No: 87215
• Reasons for admission: C/O chest discomfort since 3 day ,
breathlessness since 4 day patient was apparently normal till past 4 days
sever breathlessness , chest pain central not radiating ,not associated with sweating and burning type .
• PMHx: No k/c/o HTN/DM No h/o IHD /fever / CO
chronic alcoholic , not smoker
• Allergies: NKA
• SHx: NS
General examination
• O/E no PICCLE• c/o breathlesness • BP: 120/70 mmHg Pulse: 90 BPM• CVS: S1S2 + • RS: B/L NVBS + B/L diffuse crepitation's +• CNS: NFND• JVP.
PROVISIONAL DIAGNOSIS
Acute Left Ventricular Failure and secondary to IHD and AKI
CARDIOMYOPATHYSigns of Heart Failure
• Pul. Edema• S3 gallops• Cool extremities• Pleural effusion• Cheynes stoke respiration• Tachycardia• Cardiomegaly• Increased JVP• Peripheral edema
DAY1
• c/o breathlessness SpO2 100% on NIV support• BP: 120/70 mmHg Pulse: 90 BPM• CVS: S1S2 + • RS: B/L NVBS + B/L diffuse crepitation's +• CNS: NFND• Creatinine : 5.5 mg/dl • GFR : 12.4 ml/min• I/O : 730.8 /1975 ml
DAY 1 cont…
• ADV: I/O chart , Urea, Serum Creatinine, Serum electrolytes, Urine routine, ECG, 2D-ECHO, CXR, ABG, nephrologist opinion.
• ADV continue fluid + dopamine + noradrenaline .
LAB REPORTSHematology
Hb:WBC:DLC:•N•E•B•L•MPlt:ESR:
13.4g%7890 cells/ cumm
73.6 %1.1 %0.4 %17.7 %7.2 %1.33 lakhs cells/ cumm90 mm/hr
RBSUREAS.Cr
155 mg/dl180 mg/dl5.5 mg/dl
Electrolytes
SodiumPotassiumChlorides Uric acid
132 mmol/ L4.4 mmol/ L105 mmol /L10.3 mg/dl
TREATMENT CHARTDrug Dose R Freq. D
1 D2
T.Aspirin 150mg PO 0-1-0 + +
T. Clopidogrel 75 mg PO 1-0-0 + +
T. Atorvastatin 20 mg PO 0-0-1 + +
T. Trimetazidin MR 35 mg PO 1-0-1 + +
Inj. Lasix 20 mg inj 1-1-0 + +
Inj. Heparin 5000 IU INJ 48 Hrs + +
Dopamine + noradrenaline inj 1-0-0 + +
DAY 2
• BP: 120/70 mmHg Pulse: 88 BPM• RS: B/L NVBS + B/L diffuse crepitation's +• FCBG: 250 mg/dl• SpO2: 86% on NIV support.• CVS: S1S2 +, no Murmurs• Neurologist opinion: acute kidney injury caused by Cardiogenic shock
advice for Antibiotics and continue Lasix 20 mg
DAY 2 cont….• Chest X-ray showing pulmonary edema.• Creatinine : 4.7 mg/dl.• GFR : 13.4 ml/min.• I/O : 1070/ 1300 ml • Added antibiotics and continue as chart.
Drug Dose R Freq. D1
D2
T.Aspirin 150mg PO 0-1-0 + +
T. Clopidogrel 75 mg PO 1-0-0 + +
T. Atorvastatin 20 mg PO 0-0-1 + +
T. Trimetazidin MR 35 mg PO 1-0-1 + +
Inj. Lasix 20 mg inj 1-1-0 +
Inj. ceftazidine + sulbactam 1.5 mg inj 1-0-1 +
Inj. Heparin 5000 IU INJ 48 Hrs + +
Dopamine + noradrenaline inj 1-0-0 + +
TREATMENT CHART
DAY 3
• BP: 100/60 mmHg Pulse: 83 BPM• RS: B/L NVBS + B/L decrease crepitation's +• FCBG: 170 mg/dl• SpO2: 86% on NIV support.• CVS: S1S2 + no Murmurs• Creatinine : 3.1 mg/dl• GFR: 21.6 ml/min• I/O : 1335/1240 ml
DAY 3 cont….
• Advice :1-Repeat RFT , Chest x-ray and take nephrologist opinion.2- CBG every eight hours .
TREATMENT CHARTDrug Dose R Freq. D
1 D2
T.Aspirin 150mg PO 0-1-0 + +
T. Clopidogrel 75 mg PO 1-0-0 + +
T. Atorvastatin 20 mg PO 0-0-1 + +
T. Trimetazidin MR 35 mg PO 1-0-1 + +
Inj. Lasix 20 mg inj 1-1-0 + +
Inj. ceftazidine + sulbactam 1.5 mg inj 1-0-1 +
Inj. Heparin 5000 IU INJ 48 Hrs + +
Dopamine + noradrenaline inj 1-0-0 + +
DAY 4
• BP: 100/70mmHg Pulse: 76 BPM• CVS: S1S2 +, no Murmurs• RS: B/L NVBS + B/L decrease crepitation's +• ADV: Treatment as per chart• FCBG :170 mg/dl• Creatinine : 2.2 mg/dl• GFR: 32.1 ml/min• I/O : 1850/1710 ml
DAY 4 cont….
• Nephrologist : ptz is stable , renal function are gradually return to normal.
• Ptz still need to repeat echo and chest x- ray for minotring .
• Advice to stop dopamin and adrenaline .
TREATMENT CHARTDrug Dose R Freq. D
1 D2
T.Aspirin 150mg PO 0-1-0 + +
T. Clopidogrel 75 mg PO 1-0-0 + +
T. Atorvastatin 20 mg PO 0-0-1 + +
T. Trimetazidin MR 35 mg PO 1-0-1 + +
Inj. Lasix 20 mg inj 1-1-0 + +
Inj. ceftazidine + sulbactam 1.5 mg inj 1-0-1 +
Inj. Heparin 5000 IU INJ 48 Hrs + +
DAY 5
• BP: 100/74mmHg Pulse: 72 BPM• CVS: S1S2 +, no Murmurs• RS: B/L NVBS +, crepts +• CBG: normal • Improvement of renal function .• ADV: Repeat urea, Creatinine, S/E• ADV: continue in physiotheraby.
TREATMENT CHARTDrug Dose R Freq. D
1 D2
T.Aspirin 150mg PO 0-1-0 + +
T. Clopidogrel 75 mg PO 1-0-0 + +
T. Atorvastatin 20 mg PO 0-0-1 + +
T. Trimetazidin MR 35 mg PO 1-0-1 + +
Inj. Lasix 20 mg inj 1-1-0 + +
Inj. ceftazidine + sulbactam 1.5 mg inj 1-0-1 +
Inj. Heparin 5000 IU INJ 48 Hrs + +
Discharge medicationsDrug Dose R Freq.
T.Aspirin 150mg PO 0-1-0
T. Clopidogrel 75 mg PO 0-1-0
T. Atorvastatin 20 mg PO 0-0-1
T. Trimetazidin MR 35 mg PO 1-0-1
Pharmaceutical Care Plan
Subjective Evidence Objective Evidence
• Breathlessness • edema • crepitation's •JVP
•ECG•ECHO•Blood Pressure•Crepitation sound. •S.Cr levels•Urea levels
Final Diagnosis
Based on subjective and objective evidence the patient was diagnosed with
ACUTE LEFT VENTRICAL FAILURE SECONDARY TO ISCHEMIC HEART DISEASE
AND ACUTE KIDNEY INJURY
Goals of Treatment For Heart Failure:
• Relieve symptoms of central and peripheral circulatory congestion
• Improve quality of life • Reduce neurohormonal
activation • Minimize or prevent acute
CHF exacerbations • Slow progression of CHF • Increase survival • Maintain appropriate blood
pressure and lipid values. • Reduce mortality
For Renal injury:• Gradually relieve of
renal function • Prevent symptoms of
renal failure • Prevent progresses of
renal failure.• Prevent long-term
complication . • Maintain a flexible
and normal lifestyle.
Treatment Options
For Heart Failure• ACE inhibitors / ARB’s• Diuretics• Beta blockers• Spironolactone • Digoxin / Dopamine
Goals achieved • Patient was symptomatically better by day 3• Renal function was brought to near normal by
day 4.
Problems identified• Cardiac enzymes were not done (CKMB).• CBG was abnormal and no treated or advice
Glycosylated Hb.• Platelet and RBC were be Decreased and no
treated.
Monitoring Parameters
Disease Related• ECG• ECHO• Chest X-ray• Blood pressure• Fluid intake• Electrolytes • Vital signs • Renal function test• Blood Glucose levels
Drugs Related• Blood Pressure• Blood Glucose levels• Electrolytes• Renal function test
Patient Counseling
THANK YOU
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