Drug store Induction for Junior Doctors

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Review. Foundation to safe recommending in pediatrics and

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Drug store Induction for Junior Doctors RHSC Edinburgh

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Overview Background to safe recommending in pediatrics and 'Brilliant Rules' Common pitfalls Hospital and trust arrangements Lothian joint model Pharmacy administrations Scenarios Safe endorsing test Tomorrow Pain administration Quiz criticism

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Background Safe recommending is a fundamental non specific ability Particular issues for pediatrics Most meds endorsed by weight Most youngsters don't care for tablets so fluid plans utilized Differing pharmacokinetics in various age bunches Dose blunders more inclined to be noteworthy

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Pharmacokinetic contrasts Absorption : Gastrointestinal tract pH higher → diminishes ingestion of phenobarbitone, phenytoin Gastric purging slower: Skin, thin striatum, all around hydrated Muscle, less bulk, adjusted blood stream: PR, slower and inadequate Distribution of body liquid Premature neonate 92% body water :Newborn 75% Child half, Gentamicin Low fat, 3% in untimely, 12% newborn, 1 year old 30% Adults 18% Protein Binding Low fondness and capacity,Phenytoin Metabolism : Enzyme frameworks are youthful :Huge contrasts from untimely to 2 weeks old. Phenytoin 72 hours to 8 hours. :Phenobarbitone from 200 hours to 20. From age 1 – 9 leeway can surpass grown-up qualities/m 2 Elimination Glomerular Filtration Rate – increments with age until around 1 year. Tubular discharge youthful, solute loads including Sodium, Potassium.

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Golden Rules for Safe Prescribing NHS Lothian form on intranet Adapted for use in RHSC (enlistment pack) Standardized NHS Lothian tranquilize kardex from September 2009

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Golden Rules Write plainly in square capitals in dark ballpoint pen Complete all required patient subtle elements on the front of the kardex, and name/DOB on each page being used Use endorsed (non specific) names for solutions Exceptions – oral morphine, mix items, particular items

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Golden Rules Write the medication measurement unmistakably Accepted shortenings g, mg, ml Round to sensible dosages eg 82mg →80mg Avoid decimel focuses if conceivable eg 100 MICROGRAMS not 0.1mg Use acknowledged courses of organization IV, IM, SC, SL, PR, PV, NG, ID, TOP, INHAL Write different courses in full eg ORAL, INTRATHECAL

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Golden Rules 6. Enter begin date If medicine not required on some days, utilize a X in the container when the pharmaceutical is not required For once just treatment, utilize front of graph Sign and PRINT your name on the remedy Enter points of interest of whatever other outlines being used

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Golden Rules Times of organization – utilize the 24 hour clock BD 06 18 TDS 08 16 24 QDS 06 12 18 24 11. Never modify remedies – drop and rework Discontinue solutions accurately 13. Rewriting a kardex – score through each page, utilize unique begin dates

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Hospital Policies Incident Reporting DATIX shapes (intranet), bolsters back to PNDT Anonymous Identifies degree and nature of blunders Improved attention to high hazard circumstances Changes executed to limit future dangers

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Trust Policies INTRATHECALS Trained staff on enroll just Registrar level or more Prepared in drug store IV and Intrathecal pharmaceuticals not diagrammed in the meantime on various graphs Errors can prompt to fatalities

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Lothian Joint Formulary Internet www.ljf.scot.nhs.uk Aims Promote protected, powerful and monetary recommending in essential and auxiliary care Produce more noteworthy recognition with a restricted scope of prescriptions Develop understanding over the interface amongst essential and optional care Promote a consistent way to deal with endorsing

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Hospitals 15% 85% General Practices Lothian Drug Budget £100,000,000 40% of medications utilized as a part of essential care are impacted by auxiliary care. Review Comission: A medicine for development. London HMSO 1994

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Committees Scottish Medicines Consortium Evaluates new prescriptions Formulary Committee Lothian wide, month to month gatherings Considers SMC counsel and NICE, SIGN rules Reviews new applications -FAF1 Drugs endorsed by SMC -FAF2 Drugs originating before the SMC -FAF3 Unlicensed/off name drugs Implementation working gathering Increase mindfulness and utilization of the LJF in Lothian, utilizing promotional material

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Ensures all meds achieve principles for wellbeing, quality and adequacy License permits medication to be promoted for -particular conditions -in concurred dosage extend -by specific course -utilizing tried definition Based on clinical trials information Drug Company Licensing specialist License Drug Company Market Drug Licensing

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Problems with Licensing in Pediatrics Lack of clinical trials eg 1994-98: 80% of new medications had no data in kids Ethics Long term impacts Micro-systematic strategies Low return for speculation <40% of solutions endorsed by healing center pediatricians are outside the permit or have no permit

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Directive 89/341/EEC All specialists can endorse there is no statutory necessity to unveil to a patient when a pharmaceutical is unlicensed prescriber ought to know about unlicensed recommending choice to endorse unlicensed meds ought to be to best advantage of patient All drug specialists can apportion

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Off License Examples IV infusion given orally-Midazolam IV infusion given intranasal-Diamorphine Not suggested in kids Pentasa tablets Outwith the age go Paracetamol neonates Different sign Domperidone for GOR

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Pharmacy Services Location Opposite ward 4 Hours Monday-Friday 0830 – 1700 Weekend 1100-1200 Ward drug specialists Dispensing and one-stop Aseptic – Chemo, TPN, IV anti-infection agents, intrathecals Distribution/ward best up Medicines data – enquiries, tranquilize communications, named tolerant medications Clinical drug store – sedate levels, general meds guidance Out of hours – crisis cabinet/accessible as needs be pharmacist*

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Scenarios A 6 year old kid is conceded with pneumonia and is to be dealt with IV augmentin and support IV liquids. He is requiring 2l of oxygen to keep up his immersions. He has a background marked by cerebral paralysis, epilepsy and asthma. Current solutions are phenytoin 16ml BD, clenil modulite 2 puffs BD and salbutamol PRN. He is not presently wheezy. What additional data is expected to finish his medication kardex and IV liquid outline, and where might you discover it? What else may you need to recommend for him?

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What additional data is expected to finish his medication kardex and IV liquid outline? - Name, DOB, CHI, advisor -any sensitivities -Weight-genuine or appraise: weight = (age +4) x 2 = (6+4) x 2 = 20kg -Dose of IV augmentin-monograph -Strength of phenytoin suspension - BNFC -Strength of clenil modulite inhaler – patient's own, current letter, GP -U&E comes about What else may you need to recommend for him? - Oral paracetamol +/ - ibuprofen as antipyretics -Rescue drug for seizures if proper

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Name Joe Bloggs, DOB 01/02/04, CHI 0102049900 Consultant Dr Jeckyll Actual weight 24kg No known sensitivities

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IV augmentin – IV monograph 30mg/kg TDS = 30 x 24 = 720mg TDS Clenil Modulite – BNFC 50, 100 , 200 quality Salbutamol – BNFC 100 or 200 quality Phenytoin – BNFC 30mg/5ml 16ml = 30/5 x 16 = 96mg

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Na 136, K 3.2 Weight 24kg Fluid Prescription – IV liquid rules 1 st 10kg 100 x 10 =1000ml 2 nd 10kg 50 x 10 =500ml Next 4kg 20 x 4 =80ml TOTAL 1000+500+80 =1580ml Hourly rate = 1580/24 = 65ml/hr Use 0.45% NaCl/5% Glucose with 10mmol KCl per 500ml

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2. A 10 month old baby called John Smith (weight 8.1kg, DOB 01/10/09, CHI 0110090000) has come back to the surgical ward taking after washout of a septic joint. No absense of pain has been endorsed. He has spewed twice since theater and is by all accounts in agony. Could you recommend proper absense of pain?

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Paracetamol – Vomiting, so utilize PR or IV course PR – BNFC or intense and postoperative torment rules Loading dose 30mg/kg stack = 40 x 8.1 = 324mg Suppositries 60, 125, 250, 500mg quality Use 1 x 250mg + 1 x 60mg = 310mg Maintenance dose 20mg/kg 6 hourly = 20 x 8.1 = 162mg Use 1 x 125mg = 125mg (max 90mg/kg/day)

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Paracetamol IV – Use RHSC IV monograph 10mg/ml Loading dose 20mg/kg = 20 x 8.1=162mg (round to 160mg) Maintenance measurements 10mg/kg 4 hourly = 10 x 8.1 = 81mg (round to 80mg)

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Ibuprofen – utilize BNFC or intense and postoperative agony rules Check no contraindications Dose 10mg/kg 6 hourly = 5 x 8.1 = 40.5mg, round to 40mg Volume 100mg/5ml suspension Dose = 5/100 x 40 = 2ml

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John has quit heaving and has had rectal paracetamol and oral ibuprofen, however remains tachycardic and unsettled. What do you do? Evaluate to guarantee no entanglements of surgery bringing about tachycardia/torment eg drain, hypovolaemia, disease. Utilize pain relieving stepping stool and intense and postoperative torment rules, recommend codeine. Codeine orally 1mg/kg 4 hourly = 1 x 8.1=8.1mg, round to 8mg 25mg/5ml suspension measurements 5/25 x 8 = 1.6ml

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Summary Safe recommending a fundamental non specific aptitude Pitfalls regular Use accessible assets Ask for help – seniors/drug specialists Safe endorsing test