PHARMACY PEARLS CHANIN WRIGHT, PHARMD

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1 PHARMACY PEARLS CHANIN WRIGHT, PHARMD

2 OBJECTIVES From the pearls heard, discuss with someone near you What is something you can apply to your setting

4 Traumatic brain injury in children Goals Correct and prevent early hypotension and hypoxia Establish an airway What drug should you use Ketamine = decrease ICP and increase CPP CPP = MAP - ICP Document GCS prior to medications J Neurosurg Pediatr 2009;4:40-6

5 TBI Mannitol Although mannitol is commonly used in the management of raised ICP in pediatric TBI, no studies meeting inclusion criteria were identified for use as evidence for this topic

6 TBI Hypertonic saline Should be considered for the treatment of severe TBI associated with intracranial hypertension There is insufficient evidence to support or refute the use of hypertonic saline >3% Dose: ml/kg or CI: ml/kg Minimum dose needed to maintain ICP <20 should be used Serum osmolarity should be maintained <360

7 TBI Pentobarbital Should be considered for refractory ICP Barbiturate coma LD: -2 mg/kg CI: 1- mg/kg/hr Serum levels : mg/l (send out) Myocardial suppression Dopamine, epinephrine Long term effects on neurological outcomes are unknown

8 TBI 2012 guidelines The use of corticosteroids are not recommended to improve the outcome or reduce ICP for children with TBI No studies showing efficacy GI bleeding Glucose intolerance Electrolyte abnormalities infection

9 Post Traumatic Seizures Occurs early within days of injury Pediatrics at greater risk than adults <2 years old 3 fold increased risk than children between 2 and 12 Greatest risk < days post injury GCS <10 Cortical contusion Depressed skull fracture Subdural, epidural, intracerebral hematoma Penetrating head wound Seizures in the 1 st 24 hours post injury

10 Post Traumatic Seizures Phenytoin vs. placebo 3.6% vs. 14.2% Phenytoin for the 1 st days post injury in patients who had no seizure on presentation Subsequent trials have shown similar results Levetiracetam 2 studies concluded equal efficacy compared to phenytoin At this time can t be recommended over phenytoin

11 TBI DVT prophylaxis Consider if 30 kg > or any sign of puberty SQ heparin or SQ enoxaparin May be started within 48 hours of TBI

12 Emergency Medicine PEARLS Intranasal midazolam 0.2 mg/kg Imaging, positioning 0. mg/kg Laceration repair Ortho procedures IV line placement Maximum of 10 mg /dose or repeat administration

13 IN Midazolam May burn with administration Few patients complain or have memory of burning Shows no significant respiratory depression Give a max of 1 ml per nare Rec mg/ml conc Allows for a rapid, non-invasive method for mild to moderate sedation

14 Adenosine IO Dosing : 0.1 mg/kg 0.3 mg/kg Max of 6 mg initially, and 12mg on repeat Extremely short half-life (<10 sec) Reduce initial dose if post-cardiac transplant patients On dipyridamole or carbamazepine Given through a central line Increase dose if on theophylline or caffeine

15 Adenosine IO Case report of administration through IO 11 day old with SVT Converted with IV adenosine 0.1 mg/kg IO adenosine converted to NSR Converted to SVT Additional 0.1 mg/kg IO needed

16 Adenosine IO Case report 2 month old with SVT Converted with IV adenosine 0.0 mg/kg, 0.1 mg/kg, 0.2 mg/kg IO no conversion 0.1 mg/kg given IV peripherally converted to NSR

17 Adenosine IO Case report 4 month old Converted with IV adenosine 0.1 mg/kg, 0.2 mg/kg no conversion 0.1 mg/kg, 0.2 mg/kg femorally caused transient asystole, conversion to NSR, then return to SVT

18 Methylene Blue for Joint Injuries Suspected open joint injuries extravasation would be highly indicative of open joint injury Use 1% lidocaine first (0.6ml/kg max) 1 ml methylene blue in 00 ml NS instilled into the joint space Adverse effects Injection of methylene blue may cause effusion Contraindications Known hypersensitivity to the drug Severe renal impairment G6PD deficiency Methemoglobinemia Topical skin discoloration can be treated with a weak bleach solution

19 SCIWORA Spinal cord injury w/o radiographic abnormality Over 6% cases occur in children <8 years old High dose methylprednisolone NOT routinely recommended Fluid resuscitation and pressor therapy alpha agonists i.e.. Norepinephrine or phenylephrine

20 Tissue entrapment by zipper

Tissue entrapment by zipper Before reaching for the wire cutters which freak out a grown man let alone a year old Try a liberal amount of mineral oil to the

21 Tissue entrapment by zipper Before reaching for the wire cutters which freak out a grown man let alone a year old Try a liberal amount of mineral oil to the area and waiting -10 minutes. Often the tissue will slide out easily! If not, a dose of IN midazolam may be in order before the wire cutters are brought out!

22 SVC syndrome Superior vena cava syndrome Encircled by lymph nodes responsible for draining thoracic cavity Most often seen in kids with Hodgkin's or non- Hodgkin's Lymphoma Massive adenopathy obstructs SVC, resulting in dilated chest and neck veins, facial edema, drowsiness, stupor All intravenous therapy must be via the lower extremities SVC obstruction results in poor circulation in the upper extremities and torso Drug distribution is restricted and there is an increased risk of thrombus formation

23 Topical Analgesia Many available products Aerosols Creams Gels Ointments Injections Compounds

24 Topicals Product selection depends on procedure Is the skin broken or intact What is the surface area involved What is your timeframe Three common products Lidocaine 2.% with prilocaine 2.% oil in water eutectic mixture Lidocaine 4% liposomal cream LET gel

25 Topicals Intact skin Open skin Occlusive dressing OOA 20 OOA 30 OOA 60 DOA 60 EMLA X X X X 4% X +/- X X LET X X DOA 120

26 TOPICALS Road rash Can make lido-lube Lidocaine 3-4 mg/kg (as1 or 2% solution for injection) Large tube of sterile surgical lubricant Use small emesis basin Mix in lubricant until the consistency is a thin gel Slather over area, wait 20 min, then scrub

28 Hazardous Drugs National Institute for Occupational Safety and Health (NIOSH) Goal: to prevent the occupational exposure to antineoplastic/hazardous drug in health care setting Recommend standard or universal precautions Chemotherapy, antivirals, hormones, bioengineered, miscellaneous

29 Hazardous Drugs Drug Source AHFS Acitretin Aldesleukin Ambrisentan Alefacept 6 Pharmacologic-therapeutic classification 88:04 Vitamin A 4, 24:12.92 Vasodilating agents, miscellaneous 84:92 Skin and mucous membrane agents, miscellaneous Alitretinoin 3,4, 84:92 Skin and mucous membrane agents, miscellaneous Altretamine Amsacrine 3, Not in AHFS (antineoplastic agent) Anastrozole 1, Arsenic trioxide Asparaginase Azacitidine 3, Azathioprine 2,3, 92:44 Immunosuppressant agents Bacillus Calmette-Guerin (BCG) 1,2,4 80:12 Vaccines Bendamustine HCl Bexarotene 2,3,4,

30 Bicalutamide Bleomycin Bortezomib Bosentan Busulfan Cabergoline agonists Capecitabine Carbamazepine Carboplatin Carmustine Cetrorelix acetate 1, 6 6 Chlorambucil Chloramphenicol 1, Choriogonadotropin alfa Cidofovir 3, Cisplatin Cladribine Clofarabine 6 Clonazepam Colchicine Cyclophosphamide 24:12.92 Vasodilating agents, miscellaneous 10:00 Antineoplastic agents 28: Ergot-derivative dopamine receptor 28:12.92 Anticonvulsants, miscellaneous 92:40 Gonadotropin-releasing hormone antagonists 8:12.08 Chloramphenicols 68:18 Gonadotropins 8:18.32 Nucleosides and nucleotides 28:12.08 Benzodiazepines 92:16 Antigout agents

31 Cyclosporin 1 Cytarabine Dacarbazine Dactinomycin Dasatinib 6 Daunorubicin HCl Decitibine 6 Degarelix Denileukin 3,4, Diethylstilbestrol Dinoprostone Docetaxel Doxorubicin Dronedarone HCl Dutasteride Entecavir 6 Entecavir 6 Epirubicin Ergonovine/methylergonovine Estradiol 1, Estramustine phosphate Estrogen-progestin combination 92:44 Immunosuppressive agents Not in AHFS (nonsteroidal synthetic estrogen) 6:00 Oxytocics 24:04.04 Antiarrythmics 92:08 -alpha reductase inhibitors 8:18.32 Nucleosides and nucleotides 8:18.32 Nucleosides and nucleotides 6:00 Oxytocics 68:16.04 Estrogens 68:12 Contraceptives

32 Estrogens, conjugated Estrogens, esterified Estrone Estropipate Etoposide Everolimus Exemestane Finasteride Floxuridine Fludarabine Fluorouracil Fluoxymesterone Flutamide Fulvestrant Ganciclovir Ganirelix acetate antagonists Gemcitabine Gemtuzumab ozogamicin Gonadotropin, chorionic Goserelin Hydroxyurea Idarubicin Ifosfamide 1, 1,3, 1,2, 68:16.04 Estrogens 68:16.04 Estrogens 68:16.04 Estrogens 68:16.04 Estrogens 10:00 Antineoplastic agents 10:00 Antineoplastic agents 92:08 -alpha reductase inhibitors 68:08 Androgens 8:18.32 Nucleosides and nucleotides 92:40 Gonadotropin-releasing hormone 1,3,4, 1,2, 68:18 Gonadotropins

33 Imatinib mesylate 1,3,4, Irinotecan HCl Ixabepilone Leflunomide 3, Lenalidomide 6 Letrozole 1, Leuprolide acetate 1,2, Lomustine Mechlorethamine Medroxyprogesterone acetat 6 Megestrol 1, Melphalan Menotropins Mercaptopurine Methotrexate Methyltestosterone Mifepristone Mitomycin Mitotane 1,4, Mitoxantrone HCl Mycophenolate mofetil 1,3, Mycophenolic acid Nafarelin 92:36 Disease-modifying antirheumatic agents 92:20 Biologic response modifiers 68:32 Progestins 68:18 Gonadotropins 68:08 Androgens 6:00 Oxytocics 92:44 Immunosuppressive agents 92:44 Immunosuppressive agents 68:18 Gonadotropins

34 Nelarabine 6 Nilotinib Nilutamide 1, Oxaliplatin 1,3,4, Oxcarbazepine Oxytocin Paclitaxel Palifermin 6 Paroxetine** 6, Pazopanib HCl Pegaspargase Pemetrexed 6 Pentamidine isethionate 1,2,3, Pentetate calcium trisodium Pentostatin Phenoxybenzamine HCl blocking agents Pipobroman 3, Plerixafor Podofilox agents (mitotic inhibitor) Podophyllum resin miscellaneous 28:12.92 Anticonvulsants, miscellaneous 6:00 Oxytocics 84:16 Cell stimulants and proliferants 28: Selective serotonin uptake inhibitors 8:30.92 Antiprotozoals, miscellaneous 6 Not in AHFS 12: Non-selective alpha-adrenergic Not in AHFS (antineoplastic agent) 20:16 Hematopoietic agents 84:92 Miscellaneous skin and mucous membrane 84:92 Skin and mucous membrane agents,

35 Pralatrexate Procarbazine Progesterone Progestins Raloxifene Rasagiline mesylate Ribavirin Risperidone Romidepsin Sirolimus Sorafenib Streptozocin Sunitinib malate Tacrolimus Tamoxifen Televancin Temozolomide Temsirolimus Teniposide Testolactone Testosterone Tetracycline HCl 6 1,2, , 1,2, 3,4, 68:32 Progestins 68:12 Contraceptives 68:16.12 Estrogen agonists-antagonists 28:36 Antiparkinsonian agents 8:18.32 Nucleosides and nucleotides 28: Atypical antipsychotics 92:44 Immunosuppressive agents 92:44 Immunosuppressive agents 8: Glycopeptides 68:08 Androgens 8:12.24 Tetracyclines

36 Thalidomide Thioguanine Thiotepa Topotecan Toremifene citrate Tretinoin Trifluridine Triptorelin Uracil mustard Valganciclovir Valproic acid/ divalproex Na Valrubicin Vidarabine Vigabatrin Vinblastine sulfate Vincristine sulfate Vinorelbine tartrate Vorinostat Zidovudine Ziprasidone HCl Zoledronic acid Zonisamide 1,3, 1, 1,2,3, 1,2, 3, 1,3, 1,2,3, 1,2, 6 1,2, 6 92:20 Biologic response modifiers 84:16 Cell stimulants and proliferants 2:04.20 Antivirals Not in AHFS (antineoplastic agent) 8:18.32 Nucleosides and nucleotides 28:12.92 Anticonvulsants, miscellaneous Not in AHFS 28:12.92 Anticonvulsants, miscellaneous 8:18:08 Antiretroviral agents 28: Atypical antipsychotics 92:24 Bone resorption inhibitors 28:12.92 Anticonvulsants, miscellaneous

37 HD Residue 2010 study drugs studied 3 hospitals % of pharmacy wipes contaminated 43% of nursing wipes contaminated Connor, TH. JOEM 10/2010

40 HD PEARLS OSHA has no standards but has generated 3 guidelines in 1986, 199, 1999 Employers have a general duty to provide a workplace free from recognized, serious hazards Requires training programs and worker protection

41 HD PEARLS Handle materials safely Use spill kits Label appropriately Line surfaces Bag for transport

42 HD PEARLS Wipe, don t spray spraying the vial may move the HD to other items or areas Put gloves on and take off carefully! Sanitize with wipes Gowns get contaminated- don t save! Saving may result in drug transfer

43 So, what do you know? Who needs to know it? Share what you know!

Objective: To provide a standard procedure for the recycling of unused medication and the disposal of medicines across all BCPFT Hospital sites.

WARDS/DEPARTMENTS By: 0 01/09/019 1 of 3 Objective: To provide a standard procedure for the recycling of unused medication and the disposal of medicines across all BCPFT Hospital sites. Scope: All Black