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Understanding Ketogenic Nutrition Support For Cancer Patients

Ketogenic nutrition support terminology  either parenteral nutrition or enteral feedings concept  is applied to  patients with intractable seizure and some cases in inborn error of metabolism like carbohydrate disorder metabolism and characterized by high fat, low carbohydrate, and maintenance protein contents.

The goal of nutrition support in cancer patients is to minimize wasting but not for ideally nutrition repletion and gaining weight.

Furthermore, the goal of nutrition support in a patient with cancer (adult) maintenance support which is between 23- 25 Kcal/kg/day, not anabolic support as theoretically high calories providing may feed cancer cells as stated in some studies.

The idea behind ketogenic diets is relatively simple. If glucose is the primary fuel for cancer, then lower carbohydrate intake and replace carbohydrates with other sources of fuel, such as fats, in order to push the body’s metabolism into ketosis.

Preclinical and case report studies indicated that the restricted ketogenic diet can be an effective “metabolic therapy” for managing malignant cancer in children and adults.

Addition of Carnitine should be considered along with a high-fat or ketogenic PN solution. Carnitine is a nonessential amino acid that facilitates the transport of fatty acids from long-chain fats into the mitochondria. It is also essential in certain conditions, such as liver disease, trauma, sepsis, and organ failure, and is advised when the major source of calories are derived from fat.

Selenium is an essential trace mineral that is generally included in PN solutions when used longer than four weeks.

I hope this helps.

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Should A Pharmacist Holds PN During Blood Transfusion

The practice of holding Parenteral Nutrition during blood transfusion is to avoid fluid load in short time that may affect cardiopulmonary system.

The average of blood transfusion is between 1 to 4 hrs depending on the number of units. Except platelets that may take just less than one hour. In case of blood transfusion, you have to taper PN rate by half for at least one hour depends on the dextrose concentration in PN. ( no need if patient receiving peripheral PN)

Furthermore, you may recommend fingerstick at the mid of blood transfusion. Regarding, IV lipids you may advise the nurse to commence I.V. lipids after blood transfusion is completed.

So to make it simpler:

  1. Make sure not to infuse Lipid and PN through the same line as Blood; Using the same line of PN and Blood is an absolute contraindication and might cause Blood Dyscrasias.
  2. There is no absolute contraindication of infusing blood with the same time with PN and Lipids using different lumen unless if the patient is fluid overloaded.
  3. Most patients can tolerate the low infusion rate of lipid same time with Blood transfusion; however, most clinicians don’t favor discontinuation and manipulation of lipid.
  4. If the patient is at risk of fluid overload, then hold PN; hold lipid and resume after blood transfusion.
  5. If you know the time of blood transfusion in advance, try to start lipid after completion of blood transfusion. So you avoid holding and restarting.

Hope this helps.

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Protocol Of Treatment Of Confirmed COVID19 Infection

This is just trials done by the CDC MICC team, thought you might want it shared:

Treatment of COVID19 upper respiratory tract infection (fever, runny nose, cough without lung infiltrate + positive PCR)

MED

ROUTE

DOSE

Chloroquine Phosphate

Oral

500MG BID for 5 Days

Oseltamivir

Oral

150MG BID for 5 Days

Treatment of COVID19 Pneumonia

MED

ROUTE

DOSE

Chloroquine Phosphate

Oral

500MG BID for 5 days

Darunavir / cobicistat

Oral

Darunavir 800MG + Cobicistat 150MG daily for 2 weeks

Or

Atazanavir

Oral

400MG once daily for 2 weeks

Oseltamivir

Oral

150MG BID for 5 Days

Corticosteroids 

Intravenous

Methylprednisolone 40MG bid for 5 days


SUPPORTIVE CARE AND ANTIVIRAL TREATMENT OF SUSPECTED OR CONFIRMED COVID-19 INFECTION

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Disclaimer: This is a living guidance that is subject to change as more data emerge. It will be updated regularly whenever needed. The guidance should be used to assist healthcare practitioners select the best available antiviral therapy for COVID-19 infection according to the optimum and current evidence and is not intended to replace clinical judgment but rather complement it.

COVID-19 TESTING

CATEGORY

SUPPORTIVE CARE

ANTIVIRAL THERAPY

PRECAUTIONS

Suspicious cases 


Mild to moderate:
Symptoms with no shortness of breath

  • Treat symptoms
  • If no hospital admission required, need to follow instructions and recommendations posted by CDC

NOT REQUIRED

  • Use acetaminophen
  • Avoid ibuprofen
  • Labs and work-up: CBC, Urea/Electrolytes, Creatinine, CRP, LFTs, Chest X-Ray, COVID-19 PCR tests.

Mild to moderate:
Symptoms with shortness of breath in high risk patients

  • Treat symptoms
  • If no hospital admission required, need to follow instructions and recommendations posted by CDC
  • Consult infectious disease specialist

Case needs to be discussed with infectious disease specialist, to initiate an empirical antiviral therapy, based on the potential delay to obtain results.

  • Admission to negative pressure room
  • Labs and work-up: CBC, Urea/Electrolytes, Creatinine, CRP, LFTs, Chest X-Ray, COVID-19 PCR tests.

Mild to moderate:
Symptoms with no shortness of breath in high risk patients

Confirmed cases

Asymptomatic

Follow instructions and recommendations posted by CDC

NOT REQUIRED

  • Use acetaminophen
  • Avoid ibuprofen
  • Labs and work-up: CBC, Urea/Electrolytes, Creatinine, CRP, LFTs, Chest X-Ray, COVID-19 PCR tests.

Mild to moderate:
Symptoms (no O2 requirement and no evidence of pneumonia)

  • Treat symptoms
  • Consult infectious disease specialist

- consider starting Hydroxychloroquine 400mg BID for 1 day, followed by 200mg BID up to 5 days

- If Hydroxychloroquine is not available, consider Chloroquine 600mg (10mg/kg) at diagnosis and 300mg(5mg/kg) 12 hours later, followed by 300mg (5mg/kg) BID up to day 5, or Chloroquinephosphate 1000mg at diagnosis and 500mg 12 hours later, followed by 300mg BIDup to day 5

Hydroxychloroquine and Chloroquine:

- Labs and work-upL Same as above with additional G6PD screening if chloroquine will be used

- Perform ECG daily if initial QTc 450 -  500msec, and biochemistry according to underlying disease

Sever:

Symptoms as 1 of the following:

- Respiratory rate 30/min(adults); 40/min (children)

- Blood oxygen saturation 93%

- PaO2/FiO2 ration <300

- Lung infiltrates >50% if the lung field within 24 to 48 hours

  • Treat symptoms
  • ICU admission, decision by ICU treating team
  • Consult infectious disease specialist
  • consider antibiotics or antifungals according to local antibiogram and institutional pneumonia management guidelines.

- consider starting Hydroxychloroquine 400mg BID for 1 day, followed by 200mg BID up to 5 days

- If Hydroxychloroquine is not available, consider Chloroquine 600mg (10mg/kg) at diagnosis and 300mg(5mg/kg) 12 hours later, followed by 300mg (5mg/kg) BID up to day 5, or Chloroquine phosphate 1000mg at diagnosis and 500mg 12 hours later, followed by 300mg BIDup to day 5

- consider combination therapy (Lopinavir/Ritonavir) 400/100mg (2 tabs of 200/50mg) BID and (Hydroxy)chloroquine up to 10 days

Lopinavir/Ritonavir:

- Labs and work-upL Same as above with additional G6PD screening if chloroquine will be used

- Perform ECG daily if initial QTc 450 -  500msec, and biochemistry according to underlying disease

- Avoid coadministration with drugs that are highly dependent on CYP3A fod clearance or with potent CYO3A inducers

- precautions with patient with renal or liver impairments 

Critical:

Symptoms as 1 of the following:

- Acute respiratory distress syndrome

- Sepsis

- Altered consciousness

- Multi-Organ failure

  • Treat symptoms
  • ICU admission, decision by ICU treating team
  • Mechanical ventilation
  • Consult infectious disease specialist
  • Specific prevention and treatment of ARDS
  • Secondary bacterial and opportunistic (Aspergillus) infection according to local antibiogram and institutional pneumonia management guidelines
  • - Prevention of subsequent lung fibrosis

- consider combination therapy (Lopinavir/Ritonavir) 400/100mg (2 tabs of 200/50mg) BID and (Hydroxy)chloroquine up to 10 days, crushed in NGT and the same dosage and monitoring as above

- Remdesivir (compassionate use, once available) 200mg loading dose (IV, within 30 min), followed by 100mg once daily for 2 to 10 days

- however, since the clinical efficacy of (Hydroxy)chloroquine isn't demonstrated, caution is required in case of kidney / liver / cardiac failure and abstention in such situations is preferred

Remdesivir:

- Inclusion criteria for the use of Remdesivir: ICU + confirmation of SARS-cov-2 by PCR + mechanical ventilation

- Exclusion criteria for the use of Remdesivir:

Evidence of multi-organ failure, need of inotropic, creatinine clearance < 30ml/min, dialysis/hemofiltration, transaminases > 5 x  ULN of concomitant use of Lopinavir/Ritonavir

- This means that most(if not all) patient in ICU will not be eligible


update 26-03-2020:  Role of Pharmaceutical companies against COVID-19



Update 31-03-2020:

Concluding Remarks ...

  • COVID 19 has caused the worst pandemic since the Spanish influenza
  • The virus spreads rapidly and efficiently
  • Droplet and contact precautions are recommended by WHO except for aerosol generating procedures where airborne isolation is necessary
  • In countries where rigorous measures were taken such as Hong Kong and Singapore containment was achieved (banned gathering, work from home, social distancing. HCWS practices)
  • Vaccine trials are underway
  • Treatment options include chloroquine/hydroxychloroquine +/- azithromycin; need to be verified in randomized controlled trials 
  • Lopinavir/Ritonavir to be considered early in the treatment course but needs to be studied further
  • Antiviral medications (remdesivir, favipiravir) are not currently available in the Middle East but for compassionate use 
  • IL-6 antagonists to be considered for severe cases with cytokine storm
Few COVID-19Facts

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First Ebola Virus Vaccine

On December 19, 2019, the US FDA approved Ervebo(R) (ebola zaire vaccine, live) intramuscular suspension indicated for the prevention of disease caused by Zaire ebolavirus in individuals 18 years of age and older. Approval is based off of a study conducted during the 2014-2016 outbreak in Guinea where Ervebo was determined to be 100% effective in preventing Ebola cases with symptom onset greater than 10 days after vaccination. Additionally, no cases of ebola virus disease with symptom onset greater than 10 days after vaccination were observed in the group immediately given the vaccine as opposed to 10 cases of ebola virus disease in the group who received a delayed vaccination.

Prescribing information can be found https://www.merck.com/product/usa/pi_circulars/e/ervebo/ervebo_pi.pdf.

Full Article

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How tech is transforming healthcare

How tech is transforming healthcare

1

Wearables

Data captured from health devices could provide precious information to provide accurate care to the patients.
As we noticed wearable gadgets are increasing in numbers as well as accuracy.

2

Augmented Reality

Allowing the healthcare providers to jump instantly between patients, or view organs, or even project radiology images over the body during operations to reduce mistakes.
Combining live video-streaming with Augmented Reality surgeons carrying out operations are able to consult the other side of the world. Who says that you can’t be in two places at once?

3

Online Consultation

The patient, who can afford it, can always consult with their preferred healthcare providers online and even afford a sort of on-call medical service, other than emergency services.

Last Updated on

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.

Last Updated on

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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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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