Sept. 2002 Volume 8 No. 2
Trading places
Our congratulations go to the following people: H Thirza Titchen on her secondment for a twelve month period to the Drug And Therapeutics Information Service (DATIS). As an academic detailer, Thirza will be focusing on two projects, aiming to support GPs on the topics of HbA1c and H. Pylori testing. H Antun Bogovic has been appointed Deputy Director of Pharmacy during Thirza's absence. H Soula Zambetis is the Senior Clinical Pharmacist during this time.
The Paediatric Pharmacopoeia at your fingertips
The new edition of the Paediatric Pharmacopoeia is now available and just a computer screen away. Fully updated, it is available in 3 user-friendly formats: Paediatric Pharmacopoeia 13th edition paperback Å includes approximately 100 new drug entries Å includes a range of hospital based protocols including Guidelines for Empiric Antibiotic Use, Anticoagulation and Good Prescribing Practice Å contains current Australian Immunisation Schedule with state pathways and vaccine availabilities Paediatric Pharmacopoeia e-book Å is an electronic version of the 13th edition Pharmacopoeia Fully revised and available now Å contains linked entries to facilitate easy dosage and comparison of drugs to protocols Å is readily accessible online from the wards, consulting rooms or anywhere in the hospital off the front page of the hospital Intranet or directly at http://www.rch.unimelb.edu.au/pharmacy/intranet/pharmacopoeia/ Paediatric Pharmacopoeia, Pocket Prescriber, an abridged version of the parent text containing doses only. It is an ideal companion to the 13th edition and readily portable in your pocket. The Pharmacy Department wishes to acknowledge the enormous contribution of the many reviewers both in the hospital and around Australia.
Need drugs in the middle of the night or after hours?
To assist with obtaining stock when the pharmacy is closed, a list of all drugs kept on the wards is now available online. Go to the front page of the hospital Intranet under ‘Paediatric Resources’. It is always worth checking the list before calling the on-call pharmacist.
Coming soon…
The new Medication Chart (MR52) and the new Fluid Balance/IV Order Chart will be arriving in November. Please keep an eye out for the upcoming education sessions as everyone needs to know this chart and be able to use it well. There will be notices on the Bulletin Board and around the hospital outlining dates and times. Education sessions will be held in Vernon Collins Theatre for the new Medication Chart (MR52), as well as ward/unit based education. The new Fluid Balance/IV Order Chart will be introduced after the MR52. For further information, please contact Melissa Steele on pager #4884 or via email: steelem@cryptic.rch.unimelb.edu.au
Medication Safety Committee Findings:
In the last two months, 15 paracetamol incidents have been reported to the Medication Safety Committee. The majority of these incidents relate to incorrect dosing which can result in serious adverse reactions. Other errors are related to orders written in mL and not mg. Paracetamol is contained in a number of products such as Panadol, Dymadon, Panamax and Tylenol. Each of these products are available in a number of strengths which can add to the risk of incorrect dosing. Prescribers need to make sure that orders for paracetamol are written correctly and clearly. Nurses need to be aware of these common errors and carefully read the order and product label before administration.
Ibuprofen vs Paracetamol
Ibuprofen has been widely promoted for use in children. It is increasingly being used instead of paracetamol for the treatment of pain and fever. Common side effects of ibuprofen include nausea, dyspepsia, diarrhoea, headache, dizziness and salt and fluid retention. Less common reactions include gastrointestinal ulceration or bleeding, heart failure, hyperkalaemia, renal impairment, confusion, bronchospasm and rash. The incidence of side effects from therapeutic use of ibuprofen is greater than the incidence caused by paracetamol. Two significant ibuprofen related adverse reactions were recently reported in RCH patients. In the literature there are numerous case reports of children developing renal impairment associated with ibuprofen therapy. Children at risk of ibuprofen-induced nephrotoxicity are: l those with renal insufficiency, congestive heart failure or hepatic dysfunction l those receiving other nephrotoxic drugs or drugs that alter or are affected by changes in serum potassium concentrations l those receiving prolonged ibuprofen therapy whilst dehydrated. Caregivers should be advised: l to use paracetamol instead of ibuprofen, when appropriate l not to use ibuprofen for more than 3 days without medical supervision l to check ingredients of medications to avoid giving more than one ibuprofen containing product at a time l to avoid giving ibuprofen during illnesses that are accompanied by vomiting, decreased fluid intake or diarrhoea.
Tramadol (Tramal ®)
is a new opioid-like agonist recently added to the RCH formulary. It requires Drug Usage Committee approval before supply, except if prescribed by a Consultant Anaesthetist. Tramadol has a two-fold mechanism of action. It is a weak opioid receptor agonist, as well as being a serotonin (5-HT) and noradrenaline reuptake inhibitor. It is mainly used for the treatment of mild to moderate pain e.g. postoperatively when paracetamol or non steroidal anti-inflammatory drugs (NSAIDs) are contraindicated, as in the case of severe hepatic or renal impairment. The recommended dose in children is: IV/IM/Oral: 1-2 mg/kg/dose (adults 50-100mg/dose) QID or 6 hourly (max 400 mg/day), or 2 mg/kg/dose BD (using the oral slow release preparation only). Common side effects include nausea, constipation (less compared with morphine), sweating, sleep disturbances, and respiratory/CNS depression (especially with high doses). The advantages of this drug compared with opioid analgesics include: ! better side effect profile ! less respiratory/CNS depression, constipation and abuse potential. The disadvantages include: ! naloxone only partially reverses the effect of tramadol ! increased risk of seizures, and ! more expensive than other analgesics. Tramadol has several clinically significant drug interactions. When given with monoamine oxidase inhibitors (MAOIs) and selective serotonin reuptake inhibitors (SSRIs), the risk of Serotonin Syndrome is increased. Care should be taken when tramadol is used with other respiratory/CNS depressants because of an additive effect. Use with ondansetron (a 5-HT3 antagonist) may decrease the analgesic effect of tramadol. When given with another opioid agonist (e.g. morphine) tramadol can decrease the analgesic effect of morphine.
Itchy Opioids
Approximately 5 cases of opioid induced pruritus are reported to the Adverse Drug Reaction (ADR) committee each month. This reaction can be severely debilitating and decreases patient comfort whilst in hospital. It was discovered, through a medical records review, that the current treatment practices within RCH were unfortunately far from adequate. Patients' itch was not satisfactorily treated, which often meant the opioids were ceased, leading to inadequate pain control. It is a misconception that antihistamines are an effective treatment option for opioid induced pruritus. The systemic itch caused by opioids is not histamine related, but due to a centrally mediated opioid receptor action. Based on this information, the ADR committee has formulated guidelines for the treatment of opioid induced pruritus. These recommendations include switching to an opioid with a lower incidence of pruritus and the use of naloxone or ondansetron as needed. A full report of the literature search and references can be found at: http://www.rch.unimelb.edu.au/pharmacy/intranet/pages/pruritu s.html