innohep – tinzaparin sodium

Bringing the freedom to focus

innohep®

tinzaparin sodium


Get ready to meet your new friend


“A baby is something you carry inside you for nine months, in your arms for three years, and in your heart until the day you die.”

- Mary Mason -

Antenatal assessment and management (to be assessed at booking and repeated if admitted)

Any previous VTE except a Single event related to major surgery

HIGH RISK

Requires antenatal prophylaxis with LMWH
refer to trust-nominated thrombosis in pregnancy expert/team

Hospital admission

Single previous VTE related to major surgery

High-risk thrombophilia + no VTE

Medical comorbidities e.g. cancer, heart failure, active SLE, IBD or inflammatory polyarthropathy, nephrotic syndrome, type 1 DM with nephropathy, sickle cell disease, current IVDU

Any surgical procedure e.g. appendicectomy

OHSS(first trimester only)

INTERMEDIATE RISK

Consider antenatal prophylaxis with LMWH

Obesity (BMI > 30KG/M2)

Age

Parity ≥ 3

Smoker

Gross varicose veins

Current pre-eclampsia

Immobility, e.g. paraplegia, PGP

Family history of unprovoked or estrogen-provoked VTE in first-degree relative

Low-risk thrombophilia

Multiple pregnancy

IVF/ART

Transient risk factors:

Dehydration/hyperemesis; current systemic infection; long-distance travel

Fewer than three risk factors

Four or more risk factors:
Prophylaxis from first trimester

Three risk factors:
Prophylaxis from 28 weeks

LOWER RISK

Mobilisation and avoidance of dehydration

For more information

Regarding the timing of first antenatal and/or postnatal thromboprophylactic dose; please refer to RCOG Green-Top Guideline No. 37a (thrombosis and Embolism during Pregnancy and the Puerperium, Reducing the risk - Published 13/04/2015)

Postnatal assessment and management (to be assessed on delivery suite)

Any previous VTE
anyone requiring antenatal LMWH
High-risk thrombophilia
Low-risk thrombophilia + FHx

HIGH RISK

At least 6 weeks, postnatal prophylactic LMWH

caesarean section in labour

BMI ≥ KG/M2

Readmission or prolonged admission (≥3 days) in the puerperium

Any surgical procedure int the puerperium except immediate repair of the perineum

Medical comorbidities e.g. cancer, heart failure, active SLE, IBD or inflammatory polyarthropathy, nephrotic syndrome, type 1 DM with nephropathy, sickle cell disease, current IVDU

INTERMEDIATE RISK

At least 10 days postnatal prophylaxis with LMWH

NB if presisting > 3 risk factors; consider extending thromboprophylaxis with LMWH

Age > 35 years
Obesity (BMI > 30KG/M2)
Parity ≥ 3
Smoker
Elective caesarean section
Family history of VTE
Low-risk thrombophilia
Gross varicose veins
Current systemic infection
Current pre-eclampsia
Immobility, e.g. paraplegia, PGP, long-distance travel
Multiple pregnancy
Preterm delivery in this pregnancy (<37+0 weeks)
Stillbirth in this pregnancy
Mid-cavity rotational or operative delivery
Prolonged labour (< 24 hours)
PPH > 1 litre or blood transfusion
Family history of unprovoked or estrogen-provoked VTE in first-degree relative
Low-risk thrombophilia
Multiple pregnancy
IVF/ART
Two or more risk factors
Fewer than two risk factors

LOWER RISK

Mobilisation and avoidance of dehydration

Antenatal and post natal prophylactic dose of LMWH

Weight < 50KG = 20MG enoxaparin / 2500UNITS dalteparin / 3500UNITS tinzaparin daily.
Weight 50-90KG = 40MG enoxaparin / 5000UNITS dalteparin / 4500UNITS tinzaparin daily.
Weight 91-130KG = 60MG enoxaparin / 7500UNITS dalteparin / 7000UNITS tinzaparin daily.
Weight 131-170KG = 80MG enoxaparin / 10000UNITS dalteparin / 9000UNITS tinzaparin daily.
Weight > 170KG = 0.6MG/KG enoxaparin / 75UNITS/KG dalteparin / 75UNITS/KG tinzaparin daily.

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octaplex – Prothrombin Complex Concentrate

Accurate prevention and fast control of life-threatening bleeding.
octaplex® provides a rapid and complete reversal of vitamin K antagonists (VKA) induced coagulopathy due to:
  • Easy storage at room temperature and quick availability.
  • Small infusion volume with no risk of fluid overload.
  • Short infusion time.
  • No need for blood type matching.
  • Balanced content of vitamin K coagulation factors and inhibitory proteins.
octaplex is ready to be used in life-threatening bleeding, unlike FFP:

octaplex®

FFP

20-40ML

2100ML (30ML/KG)

10 minutes

14-50 hours

Blood matching not required

Blood matching is required

Used immediately in room temperature

-25°C
thawing time: 30 minutes

References:
  1. Dowlatshahi, D., Butcher, K. S., Asdaghi, N., Nahirniak, S., Bernbaum, M. L., Giulivi, A., … Coutts, S. B. (2012). Poor Prognosis in Warfarin-Associated Intracranial Hemorrhage Despite Anticoagulation Reversal. Stroke43(7), 1812-1817. doi:10.1161/strokeaha.112.652065
  2. Lubetsky, A., Hoffman, R., Zimlichman, R., Eldor, A., Zvi, J., Kostenko, V., & Brenner, B. (2004). Efficacy and safety of a prothrombin complex concentrate (Octaplex®) for rapid reversal of oral anticoagulation. Thrombosis Research113(6), 371-378. doi:10.1016/j.thromres.2004.04.004
  3. Management of severe perioperative bleeding. (2014). European Journal of Anaesthesiology31(4), 247. doi:10.1097/eja.0000000000000066
  4. Varga, C., Al-Touri, S., Papadoukakis, S., Caplan, S., Kahn, S., & Blostein, M. (2012). The effectiveness and safety of fixed low-dose prothrombin complex concentrates in patients requiring urgent reversal of warfarin (CME). Transfusion53(7), 1451-1458. doi:10.1111/j.1537-2995.2012.03924.x

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Improving Patient’s Safety By Controlling The Doctor Orders For Ranged Dose Or Ranged Frequency.

Improving Patient’s Safety By Controlling The Doctor Orders For Ranged Dose Or Ranged Frequency.

Are you familiar with range orders for medications like MORPHINE 2-9MG IV Q6hr PRN at your facility? Does your hospital policy contains any restrictions on these orders?! And in case of a ranged order; how does the nurse determine the exact dose to be given and at which frequency?!

Where I work, we do allow them, and the nurse is giving all the needed training for pain assessment. We’re also using an electronic system, where prescriber must enter the required indication for each scenario. And not leaving the medication order prune to error and assumptions of the other healthcare staff.

Other hospitals might only allow one range... perhaps dose or maybe frequency! Yet, in both cases, the physicians must clearly enter the required dose range [i.e. for pain score 1-3 give 2MG, for pain scale 4-9 give 4MG …. etc.]

In some cases if the physician does not specify – the lowest dose and shortest frequency are used. A nurse must start at the lowest dose unless the patient has recently received a higher dose of the medication (or equivalent)

During the doctor's entry for the ranged order, they were using a free text field, and that doesn’t really help our clinical support system. That's why in most cases we had to verify the ranged doses manually and double checking them while dispensing and administration.

For orders with insulin doses from our insulin pumps and doses from our PCAs; ranged orders are required.

For non-pain medications, we instruct the nurse to start low and assess for effect, then proceed as necessary to address the condition.   Also have a Pain Management policy that guides the nurse to choose the pain order and dose that matches the pain score obtained from the assessment of the patient pain medication asks the prescriber to choose a Pain severity (mild, moderate or severe), all of which have scores assigned to them in the policy. For example, if the dose range is 1-2MG when mild pain, and the patient expressed the higher end of that range, then the nurse would choose 2MG.  If there are multiple products ordered, the nurse first picks the one attached to the pain score and then determines the dose which gives the nurse a guideline, but allows some flexibility in adjusting to the patient response.

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Stat

A common medical abbreviation for urgent or rush. From the Latin word statum, meaning 'immediately.'

Often used in medical contexts.

The patient's heart just stopped working.
We need a defibrillator in here stat!

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TUMOR FDG-PET/CT IMAGING

EXAMINATION: TUMOR FDG-PET/CT IMAGING

SCANNER: Biograph mCT flow PET/CT

RADIOPHARMACEUTICAL: 9.9 mCi F-18 Fluorodeoxyglucose (FDG) I.V.

HISTORY: 43 – year – old male with intra-abdominal leiomyosarcoma. S/P laparotomy exploration and removal of tumor on 10/7/2018, followed by 2 cycles of chemotherapy.

Restaging CT dated 17/9/2018 showed peripherally enhancing rounded necrotic residual lesion in the left upper quadrant has decreased from 6.3 x 5.4 cm to 4.8 x 3.6 cm, and stable multiple (at least 5) hypodense hepatic lesions in both liver lobes measuring up to 2.5 x 2.3 cm. The study is requested for restaging , and monitoring response to therapy.

TECHNIQUE: The patient fasted for more than 6 hours. His fasting blood glucose level, measured by glucometer before injection of FDG, was 79 mg/dL. While he lay quietly in a room Plain water (1.2 L) was given as a negative contrast after the FDG injection. A low dose – noncontrast CT scan was acquired for attenuation correction and for fusion with emission PET images to allow for anatomical localization of PET findings, and not for diagnostic purposes. Emission PET images were then obtained. The area imaged spanned the region from the skull vertex to the proximal thighs with the arms positioned above the head. The time from injection of FDG to start of imaging was 40 minutes. Transverse image reconstruction using an iterative algorithm was performed with reoriented tomograms displayed in the transaxial, coronal and sagittal planes.

FINDINGS:

ABDOMEN AND PELVIS:

  • 1
    walled hypodense left hydrochondrial mesenteric cystic lesion noted abutting the wall of splenic flexure of colon. It measures about 4.4 x 3.4 cm and showed only mild peripheral FDG-avidity at its thick wall (SUV max of about 2) with cold non-FDG-avid center.
  • 2
    Preexisting multiple hypodense hepatic lesions noted at both liver lobes, currently has no corresponding pathological FDG-avidity, probably benign i.e. hemangioma.
  • 3
    Mildly FDG-avid midline upper anterior abdominal wall healing surgical scar noted.
  • 4
    The Spleen, pancreas, and adrenal glands are unremarkable regarding any pathological FDG avid lesions.
  • 5
    Both kidneys showing physiological FDG excretion that drains into urinary bladder.
  • 6
    The stomach and bowel show physiological FDG-activity.
  • 7
    There is no sizable FDG-avid lymphadenopathy seen in the abdomen and pelvis

HEAD AND NECK:

  • 1
    On the PET study, physiological FDG activity in the surveyed parts of brain gray matter is noted
  • 2
    Bilateral FDG uptake in the medial and lateral rectus extraoccular muscles, and mylohyoid muscles which is physiological in nature.
  • 3
    Foci of brown fat uptake noted at the neck
  • 4
    Diffuse physiological FDG uptake is noted in the soft palate, tonsils, parotid, submandibular salivary glands, and vocal cords.
  • 5
    No significant FDG-avid sizable cervical or supraclavicular lymph nodes, apart from few small, mildly FDG avid likely reactive nodes.
  • 6
    FDG-avid hypodense right thyroid lobe nodule measures about 1 x 0.7 cm cm and has SUV max of 5.97 noted.

CHEST:

  • 1
    The chest wall is devoid of any metabolic activity or sizable FDG avid pathological lesions
  • 2
    Both lung fields show unremarkable FDG metabolic activity, with no FDG-avid sizable lung nodules.
  • 3
    No FDG-avid sizable lymphadenopathy in the mediastinal, hilar or axillary regions.
  • 4
    Physiological uptake is seen in the myocardium.

CHEST:

  • 1
    There are no FDG-avi​​​​d osseous lesions at the surveyed parts of the skeleton.
  • 2
    Non-FDG-avid few small sclerotic densities noted both iliac wings and neck of left femur, probably benign bone islands for follow up.

CONCLUSION:
The current PET/CT study demonstrates:

  • Thick walled hypodense left hydrochondrial mesenteric cystic lesion noted abutting the wall of splenic flexure of colon, with mild peripheral FDG-avidity at its thick wall, probably residual/recurrent/metastatic lesion vs post-operative sequel for follow up.
  • Preexisting multiple hypodense hepatic lesions noted at both liver lobes, currently has no corresponding pathological FDG-avidity, probably benign i.e. hemangioma for follow up.
  • Non-FDG-avid few small sclerotic densities noted both iliac wings and neck of left femur, probably benign bone islands for follow up.
  • Incidental finding of hypermetabolic right thyroid lobe nodule for further evaluation with high resolution neck U/S, TFT, and serum TG.

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Abiraterone Acetate

About Abiraterone Acetate:

It's an antiandrogen medication that is used to treat prostate cancer.

Abiraterone Acetate is used for:

Prostate cancer, metastatic:

  • Treatment of metastatic, castration-resistant prostate cancer 
  • Treatment of metastatic, high-risk castration-sensitive prostate cancer

Abiraterone Acetate Mechanism of Action:

Abiraterone selectively and irreversibly inhibits CYP17 , an enzyme required for androgen biosynthesis which is expressed in testicular, adrenal, and prostatic tumor tissues. Inhibits the formation of the testosterone precursors dehydroepiandrosterone (DHEA) and androstenedione.

Dosing of Abiraterone Acetate:

Adults:
Zytiga: 1,000 mg once daily (in combination with prednisone 5 mg twice daily)

Yonsa (micronized formulation): 500 mg once daily (in combination with methylprednisolone 4 mg twice daily)

Doesn't require dose adjustment for renal patients.


Patients with currently hepatic impairment; it depends on the severity of the liver status:
Mild: No dosage adjustment necessary.
Moderate : 250 mg once daily (Zytiga) or 125 mg once daily (Yonsa). Permanently discontinue if ALT and/or AST >5 times the ULN or total bilirubin >3 times ULN occur during treatment in patients with baseline moderate hepatic impairment.
Severe: Do not use.

Ref.
BNF
Lexicomp - Drug information handbook


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Chemotherapy Compatibility Chart

Next update will be adding a new page under projects; that will be including a compatibility chart for chemotherapy preparations versus different intravenous fluids.

It should look like the image below...

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IV ADMIXTURE HIS Module

Iv admixture is a major deal in any healthcare facility; therefore, the pharmacy is currently brainstorming with the IT department to develop an interface to manage all IV admixtures from physicians, nurses as well as from pharmacy side.

I chose to start with imagining the label for the final product, and added to most of the needed info.

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Himss Certification

Got a call from our IT department informing me about getting selected for a task force to get the himss certification for our current HIS. I'm really looking forward to start this project; as we've already been working on a way to improve the Inpatient pharmacy dashboard and all other related modules.

Will be posting updates here once things started to roll on.


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New Clinical Support System

Image via logomakr.com

I just received a note that the hospital I’m working in will start a new adaptation of a fully functional clinical support system, and the management decided to include me in the team populating the data tables for the IT department to start the project… YAY!!!

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