Effectiveness of hyperosmolar oral liquid medications guideline to prevent necrotizing. Songklanagarind Hospital, Songkhla, Thailand.

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1 Effectiveness of hyperosmolar oral liquid medications guideline to prevent necrotizing enterocolitis in preterm neonates Daranee Yodyoi, Pharm D Daranee Yodyoi, Pharm D Songklanagarind Hospital, Songkhla, Thailand. 1

2 BACKGROUND 2

3 Necrotizing Enterocolitis (NEC) N ENGL J MED.2011:364;3 3

4 Risk factors of NEC Including hyperosmolar medications 4

5 Oral liquid drugs and NEC NEC in Preterm neonate 3.6% in oral Ibuprofen Arch Dis Child Fetal Neonatal.2012;97(4) AAP:enteral feeding in neonates should not 16% in oral lvitamin i E Pediatrics.1984;73(3) have osmolality above 400 mosm/kg H 2 O Oral Ca. lactate + 20% sucrose NEC 6/13 (46%) Oral Ca. lactate + water NEC 5/35 (14%) Pediatrics.1977;60(4) 5

6 Incidence of NEC in Songklanagarind Hospital 1 st Sep st Aug 2012 (1 year) Oral liquid drugs 2 14 Developed definite NEC Ibuprofen HCTZ Erythromycin Spironolactone FeSO 4 MTV Joulie s solution Vit E 93 cases 2 severe NEC with bowel perforate was sent to surgery Preterm neonate 6

7 NEC cases associated with hyperosmolar drugs No. Demographic data Hyperosmolar drugs Stage of NEC 1 GA 27 week BW 870 g HCTZ,spironolactone 2A 2 GA 28 week BW 1025 g Ibuprofen 2A 3 GA 28 week BW 905 g Ibuprofen 2A 4 GA 29 week BW 925 g Erythromycin,HCTZ,MTV 2A 5 GA 33 week BW 1860 g FSO4 FeSO4,MTV vitamin i E 2A 6 GA 25 week BW 730 g ibuprofen 2A 7 GA 29 week BW 900 g Joulie s solution 2A 8 GA 29 week BW 1580 g HCTZ,spironolactone 2A 9 GA 28 week BW 640 g Ibuprofen 3B 10 GA 29 week BW 1155 g Joulie solution,mtv,vitamine lti MTVit ie 2A Surgical treatment 11 GA 28 week BW 885 g Erythromycin 2A 12 GA 31 week BW 1440 g Erythromycin,MTV,vitamin y, E 2A 13 GA 33 week BW 1468 g Erythromycin 2A 14 GA 26 week BW 980 g ibuprofen 3B 7

8 Medications in preterm neonate Amoxicillin syrup Cisapride susp. Erythromycin susp. FeSO 4 solution Furosemide susp. Ibuprofen susp. MTV solution Spironolactone susp. Sildenafil susp. Vitamin E emulsion HCTZ susp. Contain additive (syrup, sorbitol) that raise the osmolality of products 8

9 OBJECTIVE 9

10 OBJECTIVE Establish the guideline for management of high osmolality medications Evaluate the guideline effectiveness Healthcare professionals compliance Incidence of necrotizing enterocolitis (NEC) 10

11 METHOD 11

12 METHOD Oral liquid drugs selection Osmolality y measurement Hyperosmolar oral liquid drugs identification Osmolality > 350 mosm mosm/kg /Kg H2O Guideline development Farm Hosp.2007;31: H lth Healthcare professional f i l education d ti 12

13 Healthcare professional education 13

14 Healthcare professional education 14

15 Healthcare professional education Physicians 15

16 Healthcare professional education Nurses 16

17 RESULTS 17

18 GUIDELINE 18

19 Drugs Osmolality ( mosm/kg H 2 O) Dilution Final Osmolality MTV solution (Drop) : FeSO 4 solution : Chloral hydrate syr : Ursolin susp : Digoxin elixir : Ibuprofen susp : Enalapril susp :9 342 Furosemide syr : Sildenafil susp :8 341 Paracetamol syr. (Drop) :8 338 Paracetamol GPO syr :

20 Drugs Osmolality ( mosm/kg H 2 O) Dilution Final Osmolality KCl solution :7 338 Joulie s solution :6 351 Spironolactone susp : HCTZ susp : Sholh s solution :5 336 Propranolol susp : Vit E emulsion : MTV susp :3 326 Amoxycillin susp :3 326 Erythromycin susp : Cisapride susp : Caffeine solution

21 After guideline was launched Drugs Osmolality No. of patients Medication Doctor Administration order sheet Record Follow up hyperosmolar drug guideline using in 95 preterm neonates MTV Ferrous sulfate Chloral hydrate Guideline applied Ibuprofen Water uptoin % ml Furosemide Water upto 2.5 ml Drugs Osmolality Dilution Final Osmolality preterm neonates ( mosm/kg H 2 O) Sildenafil Joulie s solution Ibuprofen : Spironolactone HCTZ Erythromycin y Cisapride

22 NEC cases associated with hyperosmolar drugs No. Demographic data Hyperosmolar drugs Stage of NEC No reported of severe NEC with surgical treatment 1 GA 27 week BW 1000 g Vitamin E, MTV, FeSO 4 2A 2 GA 34 week BW 2126 g Ibuprofen 2A 3 GA 26 week BW 690 g Chloral hydrate, Joulie, MTV, Sildenafil, Spironolactone 4 GA 30 week BW 1585 g FeSO 4,Vitamin E 2A 5 GA 31 week BW 1135 g Ibuprofen 2A 6 GA 30 week BW 1375 g FeSO 4,MTV,vitamin E 2A 2A 22

23 CONCLUSION 23

24 Limitation of drug dilution in water Drugs Osmolality Dilution ( mosm/kg H 2 O) MTV solution (Drop) large 8512 dilution 1:25 FeSO 4 solution volumes :11 24

25 CONCLUSION Guideline for dilution of hyperosmolar oral liquid medications could be an alternative for severe necrotizing enterocolitis prevention in preterm neonates. 25

26 Any suggestion or question please contact me at: Daranee Yodyoi Yodyoi, Pharm D Pharmacy department, Faculty of Medicine, Songklanagarind Hospital 15 Kanchanavanich Road, Hatyai, Songkhla, Thailand. Tel Tel , cx-square@hotmail.com cx square1986@gmail com cx.square1986@gmail.com Thank you 26

What effect do oral drugs have on the osmolality of feeds given to preterm infants?

What effect do oral drugs have on the osmolality of feeds given to preterm infants? Zoe Lansdowne, Research Pharmacist, Southampton Pharmacy Research Centre and NIHR Southampton Biomedical Research Centre