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Case Report??? ??? ??? ??? Group 15: Susan Ahn, Christina Andros, Lauren Brzozowski, Nicole Dutton, Alison NavarroProblem ListHyperkalemia Diabetic foot infection HyperglycemiaSuspected osteomyelitis secondary to DFIDVT prophylaxis (secondary to osteomyelitis confirmation)Diabetes managementObesity GR presents with signs of severe hyperkalemia as can be noted by his most recent potassium level of 7 mEq/mL and abnormal, peaked T wave on the ECG. Goals for the management of GR’s hyperkalemia include restoration of a normal sinus rhythm and reduction of serum potassium level to below 5 mEq/L in order to prevent life-threatening cardiac arrhythmias. Hyperkalemia is defined as a serum potassium level above 5 mEq/mL.1 One common cause of this electrolyte imbalance is diabetes, as it is present in this patient.1 According to the 2006 article on acute hyperkalemia management from the American Academy of Family Physicians, when a patient presents with potassium levels above 6 mEq/L, a stepwise approach should be taken to emergently treat the patient.1 When ECG changes are present, the patient requires emergent potassium reduction.1 To protect the myocardium, first, 15 mLs of IV calcium gluconate 10% can be given.2 Ten units of insulin can then be given with or without albuterol via nebulizer.2 The AAFP journal article also state that insulin should be given with 50 mLs of a 50% glucose solution, but that glucose is not necessary in patients with blood glucose levels greater than 250 mg/dL.2 Since GR’s glucose is currently 300 mg/dL, D50%W is not necessary. Insulin and albuterol work to enhance the cellular uptake of potassium into the cells.2 In order to reduce total body potassium, there are two options for therapy, 20-40 mg of intravenous furosemide can be administered or 50 grams of sodium polystyrene sulfonate can be dissolved in 30 mL of water for oral administration or 50 grams in a rectal retention enema.2 Furosemide will increase the renal excretion of potassium while sodium polystyrene sulfonate acts as an sodium exchange resin in the gut to remove potassium.2 In GR, because of his chosen therapy (vancomycin) for his current diabetic foot infection (see below) this can lead to nephrotoxicity, in order to reduce renal stress, the superior option would be to give one dose of sodium polystyrene sulfonate as this is not renally excreted. Patient GR presents to the ED with a serious diabetic foot infection exhibited by the foul odor emanating from the right foot, lack of sensation in his lower right extremity, and inability to stand two days ago. ?GR’s necrotic third toe has been removed and a 1 cm x 5 cm wound is present where the toe used to be. ?Patient presents with a penetrating wound?with maggots between the great and second toe that tracts to bone on palpation. The fourth and fifth toes have superficial lacerations and the entire foot is warm to the touch. ?GR has multiple deep wounds between the toes and ascending towards the top of the metatarsals with 2+ edema in the right foot. ?The tissue gram stain reveals gram negative rods and gram positive cocci. ?GR has a past medical history of Type 2 Diabetes Mellitus and presents with hyperglycemia thus, increasing GR’s risk of diabetic foot infection. Goals for GR include treatment and resolution of the diabetic foot infection and associated symptoms, prevention of future infections, minimization of future surgery and amputation risk, and control of glycemic levels.According to the IDSA 2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections, GR’s diabetic foot infection would be classified as severe due to the classic findings of infection such as inflammation and purulence as well as the presence of two SIRS criteria: a white blood cell count of 16,000 cells/?L and fever of 100.8°F.3 ?To begin treatment, a culture and sensitivity test to distinguish antibiotic susceptibility is vital upon presentation as well as debridement of necrotic tissue and debris. ?With GR’s wound penetrating all the way to the bone, GR’s risk of osteomyelitis is high and to ensure correct diagnosis, an MRI can confirm if the infection has reached the bone and osteomyelitis is present.3 ?A surgeon upon presentation is necessary for further assessment of surgical intervention for GR’s severe infection.3 As GR’s gram stain indicate the presence of both gram positive cocci and gram negative rods, the IDSA 2012 Guidelines recommend that without identification of a specific pathogen, broad-spectrum empiric antibiotic therapy such as; vancomycin for MRSA coverage given with ceftazidime, cefepime, piperacillin/tazobactam, aztreonam, or a carbapenem for gram-negative coverage should initiated.4 ?For severely ill patients, the vancomycin dose is 30 mg/kg/day IV in two divided doses using the patients actual body weight of 100kg. Ceftazidime is recommended at an IV or IM dose of 0.5 g - 1 g every 8 hours. Cefepime is given in a dose of 2 g IV every 12 hours for 10 days but does not have anaerobic coverage. Piperacillin/tazobactam is given IV 3.375 g every 6-8 hours until patient symptoms improve and patient is afebrile for 48-72 hours which has broad spectrum coverage for gram negative pathogens including pseudomonas. ?Aztreonam is dosed at 1 g IV/IM or 2 g IV every 8 to 12 hours. Treatment duration typically ranges from two to three weeks and does not extend past resolution of the infection to prevent antibiotic resistance.3 ?Of the gram negative covering antibiotics, piperacillin/tazobactam has been most studied and utilized in clinical trials and is the only agent that has specifically been approved by the FDA for diabetic foot infections.4 ?If the culture reveals pseudomonas to be the pathogen correlating with the gram negative rods, this will be effectively covered by piperacillin/tazobactam.4 ?In addition to the antibiotics, GR’s infected wound should ?be dressed to control purulence as well as allow for moist wound healing.3GR presents to the ED with uncontrolled Type 2 Diabetes Mellitus as supported by his past medical history of Type 2 Diabetes Mellitus, symptoms of polyuria, polyphagia, polydipsia, neuropathy, with an elevated A1C of 12.2% and plasma glucose of 300 mg/dL. Goals of therapy for GR include gaining glycemic control, resolving symptoms associated with hyperglycemia, preventing future hyperglycemic events, and preventing diabetic ketoacidosis. According to the 2015 American Diabetes Association Standards of Medical Care in Diabetes Guidelines, it is recommended GR have a pre-meal glucose target of <140 mg/dL and a random blood glucose of <180 mg/dL, but these glycemic targets should be appropriately adjusted according to the patient’s clinical status.5 The 2012 Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Setting: An Endocrine Society Clinical Practice Guidelines recommend the discontinuation of noninsulin antihyperglycemic agents as there is substantial limitations for inpatient use, therefore indicating that GR’s metformin should be discontinued upon hospital admission.6 After the resolution of hyperkalemia, the initiation of subcutaneous insulin therapy is then indicated for this patient following specific formulas for weight-based insulin orders are determined by hospital protocol. A basal insulin (NPH) should be initiated with a dose of 0.1 unit/kg given with both breakfast and supper. In addition to this, the total daily NPH dose should be divided by 6 to determine the dose of nutritional insulin (Regular insulin) to be administered with the basal insulin subcutaneously at breakfast and supper in the same syringe. Depending on the results of blood glucose monitoring during GR’s hospital stay, correctional dosing with Regular insulin may also be appropriate if GR’s blood glucose remains elevated (>151 mg/dL), 24 hours after the initiation of basal and nutritional insulin, following the hospital’s insulin protocol for specific dosing. ?Plan:Administer 1 dose of IV calcium gluconate 10% 15mL over 3 minutes.If no visible changes in ECG, can give another dose of calcium gluconate up to a max of three times total.Administer 10 units of IV insulin regular.If serum glucose is still elevated after 1 hour, may repeat 10 units of insulin again.Administer albuterol nebulizer 15 mg in 3 mL NS over 10 minutes.Monitor glucose levels and potassium levels continuously,ECG Monitor serum K+ every two hours until levels drop below a goal of 5.5 mEq/L.Monitor for signs of tachycardia while using albuterol.Administer 50 g sodium polystyrene sulfonate in 30mL of water.Monitor blood glucose every hour for signs of hypoglycemia.Monitor for signs of dehydration every 2 hours.Clean and debride wound of necrotic tissue via wound drainage upon admission. Obtain specimens for culture/sensitivity and antibiotic susceptibility from deep tissue obtained by a biopsy from the base of debrided ulcerInitiate PTB test to diagnose or exclude diabetic foot osteomyelitisPerform an MRI for diagnostic imaging to assess risk of osteomyelitis Have surgeon assess for any future surgical interventions that may be needed Initiate vancomycin 1.5 g IV every 12 hours at a rate of 1 g/hr for a total of 1.5 hour infusion and piperacillin/tazobactam IV 3.375 g every 6 hours until patient symptoms improve and patient is afebrile for 72 hours Monitor for vancomycin infusion tolerance and Red Man Syndrome.Monitor SCr and initial trough level of vancomycin prior to the 4th dose in hopes to reach a trough level of 15 to reach proper AUC:MIC ratio of 400 and avoid any possible toxicities associated such as neurotoxicity or ototoxicityDiscontinue antibiotic therapy once resolution of the infection to prevent antibiotic resistance within a maximum of 3 weeks totalDuring inpatient wound dressing, change three times daily and monitor foot infection and progress of symptom relief daily.Have patient follow up with podiatrist once discharged where microfilament foot inspections can be doneCounsel patient on potential adverse effects of vancomycin such as nephrotoxicity, ototoxicity, and abdominal pain.Counsel patient in adverse effects of diarrhea, nausea, and headaches with piperacillin/tazobactam.Nonpharmacological Interventions: Advise patient on foot hygiene and to actively change dressing three times daily.Educate patient on redistribution of weight and “off-loading” to avoid the affected foot during the healing processEducate patient on leg elevation and bed rest which will aid in decreasing lower limb edema Educate patient on the importance of changing socks daily, to avoid open toed shoes or sandals, to get proper fitted shoes and to keep feet clean and dryEducate patient on glycemic control and the importance of proper adherence to diabetic medicationsDiscontinue metformin during hospitalization. Monitor blood glucose with bedside capillary point of care testing before meals and at bedtime, matching the patient’s nutritional intake and medication regimen. Initiate 10 units of basal insulin (NPH) subcutaneously with breakfast and supper, for a NPH total daily dose of 20 units.Initiate 3 units of nutritional insulin (Regular insulin) subcutaneously with breakfast and supper, in the same syringe with NPH insulin. Consider the addition of correctional insulin if GR’s blood glucose remains elevated (>151 mg/dL) 24 hours after the initiation of basal and nutritional insulin. Counsel GR on the signs and symptoms of hyperglycemia and hypoglycemia.Counsel GR on diabetes management and about potential short and long term complications of diabetes.Educated GR about regular at home blood glucose monitoring to maintain glycemic control after discharge.References 1 Hollander-Rodriguez JC, et al. Am Fam Physician. 2006; 73(2):283-290. Available from Hollander-Rodriguez JC, et al. Am Fam Physician. 2006; 73(2):283-290. Available from . Figure 2: Algorithm for the management of hyperkalemia. Pg. 288. 3 Lipsky B, Berendt A, Cornia P, et al. 2012 Infectious diseases society of america clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. ?2012; 54(12):132-64. 4 Lipsky B, Berendt A, Cornia P, et al. 2012 Infectious diseases society of america clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. ?2012; 54(12):132-64. Table 8: Suggested Empiric Antibiotic Regimens Based on Clinical Severity for Diabetic Foot infections. Pg. 152.5 American Diabetes Association Standards of Medical Care in Diabetes 2015. Diabetes Care. 2015; 38(supp.1): S1-94. 6 Guillermo W. Umpierrez, Richard Hellman, Mary T. Korytkowski, et al. Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Setting: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012; 97(1): 16-38. ................
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