Chief Complaint

Not available.


Martin James is a 73-year-old man who originally presented to the hospital with symptoms of heart failure that culminated in aortic and mitral valve replacement surgery. His surgery was complicated by a 1-hour hypotensive episode, with BP as low as 70/50. Three days post operation, purulent drainage was noted from the surgical site, and he was subsequently diagnosed with mediastinitis. At that time, the patient was also found to have a Serratia bacteremia (blood cultures × 4 positive for Serratia marcescens, sensitive to gentamicin, piperacillin, ceftazidime, and ciprofloxacin; resistance was noted to ampicillin). Therapy was initiated with gentamicin and piperacillin. Thus far, he has completed day 25 of a 6-week course of antibiotics. A gradual increase in his BUN and serum creatinine concentration from baseline and signs of volume overload have been noted over the past 7 days


Type 1 DM





Atrial fibrillation


Aortic and mitral valve replacement surgery 28 days ago


Father had Type 1 DM


Denies smoking or alcohol; retired coal miner (11 years ago)

Current Meds

Gentamicin 180 mg IVPB Q 48 h (See Table 48-1 for previous


Ceftazidime 1 g IVPB Q 12 h × 25 days

Enalapril 5 mg po once daily

Colace 100 mg po BID

Furosemide 80 mg po Q 12 h × 2 days

Digoxin 0.25 mg po once daily

Allopurinol 100 mg po once daily

Ranitidine 150 mg po Q 12 h

Meperidine 25 mg IM Q 4–6 h PRN pain (started 3 days ago)

Ibuprofen 400 mg po Q 4–6 h PRN pain (started today for joint pain)

Sliding scale insulin

* All

Bactrim (experienced rash about 10 years ago; subsided when drug discontinued)


Currently complains of trouble breathing, weakness, general malaise, and pain in joints in hands. No fever or chills.

* Physical Examination


Confused-appearing man in mild distress


BP 152/90, P 80, RR 26, T 37.7°C; Current Wt 87 kg (admission Wt 73 kg), Ht 5’10”


Normal skin turgor


PERRLA, EOMI, poor dentition

Neck/Lymph Nodes

(+) JVD


Basilar crackles, inspiratory wheezes


S1, S2 normal, no S3, irregular rhythm


Soft, nontender, (+) BS, (–) HSM


(–) Masses


2+ Ankle/sacral edema


A & O to person and place, but not to time

� Labs (Current)

* UA

Color, yellow; character, hazy; glucose (–); ketones (–); SG 1.010; pH 5.0; protein 30 mg/dL; coarse granular casts 5–10/lpf; WBC 0–3/hpf; RBC 0–2/hpf; no bacteria; nitrite (–); osmolality 325 mOsm; urinary sodium 45 mEq/L; creatinine 33 mg/dL, FENA = 3.2%.

* Repeat Blood Cultures Today


* Fluid Intake/Output and Daily Weights


Acute kidney injury with extracellular fluid expansion


Problem Identification

1.a. Create a list of the patient’s drug therapy problems.

1.b. What information (signs, symptoms, laboratory values) indicates the presence or severity of the patient’s problem(s)?

1.c. Based on the patient’s estimated creatinine clearance and clinical presentation, do any of his medications require dosage adjustment? If so, what adjustment would you recommend?

1.d. What additional laboratory information would assist in the assessment of this patient?

1.e. When assessing fractional excretion of sodium (FENA), what influence do previous dosages of furosemide have on interpretation of the results?

1.f. Could any of the patient’s problems have been caused by drug therapy?

1.g. What risk factors did the patient have for gentamicin-induced acute kidney injury?

1.h. What therapeutic interventions could have been initiated to decrease the likelihood of developing drug-induced acute kidney injury?

Desired Outcome

2. What are the goals of pharmacotherapy in this case?

Therapeutic Alternatives

3.a. What nondrug therapies might be useful for this patient?

3.b. What feasible pharmacotherapeutic alternatives are available for treating acute kidney injury in this patient?

Optimal Plan

4. What drugs, dosage forms, doses, schedules, and duration of therapy are best for this patient?

Outcome Evaluation

5. What clinical and laboratory parameters are necessary to evaluate therapy for achievement of the desired therapeutic outcomes and to detect or prevent adverse effects?

Patient Education

6. What information should be provided to the patient to enhance compliance, ensure successful therapy, and minimize adverse effects?