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									December 2002
Volume 8 No. 2

              The Pharmacy Department wishes you and your family a
              very Merry Christmas and a Happy and Safe New Year

    Review of Schedule 8 (S8) and                                The new medication chart
        Schedule 4 (S4) drugs                                   (MR52) is now in circulation
                                                            Some features of the new medication chart include:
   In view of recent media attention and some problems      ( reduced number of pages for the main chart;
   we have been experiencing internally, the Pharmacy       ( the Body Surface Area calculation for determining
   Department will be undertaking a review of the           certain drug doses (e.g. Aciclovir); and
   processes by which S8 and some S4 drugs are handled      ( an abbreviated RCH prescribing policy that ALL
   within our hospital.                                     prescribers need to adhere to before drugs can be
    In the meantime, we remind all nursing staff of the     dispensed by pharmacists or administered by nursing
   following:                                               staff.
   / The Drug of Addiction safe used to store Schedule 8    If you have not been able to attend an education session
   drugs should solely be used for this purpose,            or have any questions, please contact Melissa Steele on
   i. e. no money or other valuables;                       pager 4884 or via email:
   / The balance of drugs in the Drug of Addiction
   administration books must be checked at all shift
   changes by two registered nurses; and                         Vancomycin Infusion Rate
   / A patient’s full name and UR number must be
   included when entering medication out of the Drug of     There has been a recent increase in the incidence of
   Addiction administration book for a patient. The entry   vancomycin induced “red man” syndrome.
   should be signed by two registered nurses.
                                                            Staff are reminded to follow the guidelines below to
                                                            reduce this risk.
                                                            ( For most patients, vancomycin should be given as a
                                                                 5 mg/mL infusion over at least 60 minutes.
                    Staff news....
                                                            ( For neonates, infuse over 120 minutes.
                      Congratulations                       ( For fluid restricted patients, vancomycin can be
             to our newly qualified pharmacists                  given as a 10 mg/mL infusion over 60 minutes via a
             Renee Howlett, Christine Ng and                     central line ONLY.
                      Trysha Salanguit.
                                                            Patients who develop “red man” syndrome at the
                                                            recommended infusion rate may benefit from a longer
                                                            infusion time or pre-treatment with an antihistamine.

       See Purple Think Pharmacy!
       A reminder to all staff that purple pens are used by pharmacists when writing on
       medication charts. This practice was initiated over two years ago to ensure that a
       distinction is made between prescribers’ information, and any other extra information that
       pharmacists may add to the medication chart.
       The Pharmacy Department would therefore appreciate it if doctors and nurses avoid using
       purple pens on medication charts.
  Complementary & Alternative                                                                        New antifungal drug:
    Medicines (CAM) at RCH                                                                            VORICONAZOLE
The use of complementary and alternative medicines                                    Voriconazole, Vfend® is a triazole antifungal agent
(CAM) by patients of the Royal Children's Hospital is                                 derived from fluconazole. Like fluconazole it is active
increasing and most parents/carers do not disclose this                               against Candida and Aspergillus spp. In addition,
use to their doctor. This increasing use has been                                     voriconazole is also active against other less commonly
recognised with the recent approval of the hospital                                   encountered fungi such as Cryptococcus neoformans and
policy for "Use of Complementary and Alternative                                      Fusarium spp.
Medicine (CAM) by Inpatients of RCH". Full details of the
                                                                                      Currently, voriconazole is licenced in Australia for the
policy and accompanying flowcharts, consent forms,
                                                                                      treatment of:
record chart and parent brochure can be found at:
                                                                                      # invasive aspergillosis;
                                                                                      # serious Candida infections;
The guidelines apply to CAM initiated by families if                                  # serious fungal infections caused by Scedosporium
they wish to continue using the medicine while the                                         spp and Fusarium spp; and
child is in hospital. It does not apply to medication                                 # other serious fungal infections in patients intolerant
initiated and prescribed by RCH medical staff (where                                       of, or refractory to, other therapy.
usual prescribing policy applies).
                                                                                       Therapy with voriconazole must be initiated with a
The quality of CAM products and the level of evidence                                 loading dose for the first 24 hours. The recommended
for the use of these products varies greatly. In addition,                            dose of voriconazole for paediatric patients is:
these therapies may have adverse effects and possible                                  Loading dose IV/Oral: 6 mg/kg q12h; and
interactions with prescribed medications.                                             Maintenance dose IV/Oral: 4 mg/kg q12h.
                                                                                      Start maintenance dose 24 hours after loading dose has
     The RCH Drug Information Centre (ext 5208)                                       commenced.
   is able to assist hospital staff and families
         with assessing these products.                                               The severity of adverse events reported during
                                                                                      voriconazole therapy was generally mild to moderate.
In addition to the large range of resources in the centre,                            The most frequently reported adverse events were visual
we are able to suggest reputable websites where families                              disturbances, liver enzyme elevations and skin reactions.
and hospital staff can obtain further information.
                                                                                      Extensive drug interactions have been reported with
                                                                                      voriconazole. Examples include rifampicin, phenytoin,
                                                                                      carbamazepine, tacrolimus and omeprazole.
The opening hours of the Pharmacy
                                                                                      Before voriconazole can be supplied by the Pharmacy
Department over the coming holidays are:                                              Department, approval by two Drug Usage Committee
                                                                                      members (one of whom should be Dr Nigel Curtis) must
  25 th Dec. Closed                                                                   be obtained.
             On-call service via Nursing Admin.
  26 th Dec. 9 a.m. - 1 p.m.
  1 st Jan.   10 a.m. - 12 noon                                                                                      Feedback?
                                                                                          Feel free to contact the pharmacy department on
 All other days have regular opening hours.                                                ext. 5492 or email

Xylocaine Viscous: Topical lignocaine toxicity
Systematic review of medication orders in August has highlighted a need for caution with the prescribing of topical
lignocaine. Ward-based pharmacists intervened on three occasions where excessive doses of lignocaine 2% gel
(Xylocaine Viscous) for local anaesthesia of the mouth were ordered. A comprehensive review of the clinical
pharmacology of lignocaine highlights the potential for toxicity when applied to mucous membranes in infants.1
Serious adverse systemic reactions to lignocaine have been reported after ingestion of the topical forms.
Please ensure that prescriptions comply with the following current dosage recommendations of topical lignocaine:2
Up to 3 mg/kg/dose (max 300 mg). This is equivalent to 0.15 mL/kg/dose of Xylocaine Viscous (2%) . Do not repeat
within two hours. Can dab gel onto severe mouth ulcers before fluid and foods.
As a safety initiative, the Pharmacy Department has placed a bright, pink dosage sticker on bottles of Xylocaine Viscous.
1. Mofenson HC, Caraccio TR, Miller H, et al. Lidocaine Toxicity from Topical Mucosal Application. Clinical Pediatrics 1982; 22(3): 190-2.
2. Kemp CA, McDowell JM, editors. Paediatric Pharmacopoeia. 13th ed. Melbourne, Pharmacy Dept, Royal Children's Hospital; 2002

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