Christian Lancaster

[Christian Lancaster]

A study – published in the American Journal of Reproductive Immunology states that Natural killer cells have been found to be higher in many women with recurrent pregnancy loss.

In such cases, Predisolone Steroids have been found to be anti-inflammatory and effective in calming the immune system. 

In some cases the administration of Immunoglobulins can be effective. 

Intralipids is a nutritional supplement made up of fat emulsion which is known to accumulate in macrophages and NK cells. A number of studies have shown that intravenous intralipids suppress NK and pro-inflammatory cytokines cytotoxicity as efficiently as Immunoglobulins 

In our practice we are adding 100 ml of 20% intralipid in 250 or 500 ml of normal saline and infuse over 2-4 hours.

The only disadvantages of intralipid therapy is that there are limited patient studies available on the efficacy and safety of the product in infertility patients. It also has not been studied in patients with other immune conditions such as low Treg cells or elevated Th1:Th2 cytokines. 

below is the link of this study.

http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1600-0897

Regards

[Christian Lancaster]

I echo to Heather in her opinion. We use the same practice for the same reason. Kindly find the below link.

https://www.fda.gov/Safety/MedWatch/SafetyInformation/ucm219000.htm

Best Regards,

[Christian Lancaster]

Using organic phosphate  if calcium is  included in PN, it  is based on the volume of amino acids and dextrose .

As you said Organic phosphate 120 mmol /l of Amino  Acids and 48 mmol per liter amino acids  for Calcium (Gluconate or chloride) the study was based on  calcium chloride ( more elemental calcium) which it gives more advantage for calcium gluconate ( less elemental) and you can add roughly up to  5 to 10% to the numbers mentioned above if you use high dextrose in PN.

This is an example for  calcium and phosphate doses acceptable in PN if you use Organic phosphate

Amino Acids 60 gm and dextrose 200 gm in PN:

If you use Amino Acids formula of concentration 15%. This means it gives you 400 ml of  60 gm Amino acids. So, the acceptable can be added to PN for :

  Organic phosphate is          120 mmol organic phosphate _______  1000 ml of amino acids

                                                       x                                     _______  400 ml of amino acids                 X= 48 mmol  Organic Phosphate

  Calcium Gluconate                48 mmol  Calcium                ———      1000 ml of amino acids

                                                          Y                                 ———      400 ml of amino acids                 Y=  19.2 mmol of Calcium

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[Christian Lancaster]

It’s important to mention that:
Nitrate and PDE5 inhibiter interaction in patients with EFrHF on the basis of Ischemia and use Nitrate could cause a severe, potentially fatal drop in blood pressure.

[Christian Lancaster]

I’ve always also been through using Alteplase for the purpose of catheter occlusion in HD patients. However, it was an excellent opportunity to revise the use of streptokinase for such purpose.

Kindly find the below:-

1- Stability was found to be (8) hours in room temperature due to risk of contamination.

2- Stability was found to be (24) hours in refrigerator

 

(Attached are detailed and highlighted references from Trissel IV Manual)

 

3- I’d like to go with Naveed regarding the preferable use of Alteplase over Streptokinase because:-

 

1. A) Stability of reconstituted Alteplase at concentration of (1mg/ml) in SWFI then frozen at (-20 C) is (6 months in polypropylene syringes) and (32 days in glass vials).

(Reference:- HandBook on injectable drugs 18^th Edition)

1. B) Lower risk of complications than streptokinase

Thanks for such refreshing inquiry.

[Christian Lancaster]

It varies really, depending on the information you are after as well as patient population (paediatric, ICU, medical, oncology etc)!

From a paediatric stand point, besides the usual ASPEN materials (eg paediatric curriculum etc) and their journal articles, JPEN and NCP.
ESPHAGAN is really huge for paediatrics (eagerly awaiting the release of their new guidelines). If you are looking for EBM type material, it is best to consult the literature. This is my humble opinion.

Also, learnt knowledge does not replace what you learn in practice 🙂

[Christian Lancaster]

We started our program ” Bed side discharge” 9 months ago and to answer your questions :

· We are now a team of two discharge pharmacist and 3 unit based pharmacists looking for around 250 beds with a barrage of 20 discharges per day for now.

· Our turn around time targeted to be less than one hour

· We started with selected poly pharmacy patients and now we are covering all discharges around the hospital weekdays from 8 am to 5 pm.

· We have a team of pharmacotherapy specialists who took care of any discharge consultation if required.

· The discharge pharmacist assess all discharge cases clinically before preparing the medications while now we are looking into introducing a “Transition of care team” to do the medication reconciliation on admission and discharge.

[Christian Lancaster]

I would like to clarify an early reply that are easing the screen with a germicidal detergent and water, sterile IPA needs to be used. Sorry for any confusion.

[Christian Lancaster]

I don’t agree. I have been cleaning HEPA protective screens for years without issue and it is important to do so daily with a germicidal detergent and water followed by water daily because of drug overspray and other contamination. The key is not to get the filter behind the screen wet.

Best regards,

[Christian Lancaster]

Attached is a PDF of the Varitect CP product monograph from Biotest Pharma Germany with the requested information highlighted.

 

What is the amount of dilution?

It comes as ready for use solution for IV infusion (Human Varicella zoster immunoglobulin + excipients glycine and water for injection).

 

What is the diluent?

Ready to use solution so, no dilution.

 

What is the infusion time?

Dose is 1ml (25 IU) per kg body weight for prevention of chicken pox.

1ml-2ml (25 IU – 50 IU) per kg body weight for treatment of Zoster infection.

Example: 60ml (1500 IU) dose for 60kg weight.

 

Administration initial rate of 0.1ml/kg body weight/ hour for 10 minutes. If tolerates can go up to a maximum of 1ml/kg body weight/ hour for the remainder of infusion.

 

Example weight 60kg:

Administer initially at 0.1ml X 60kg per hour for 10 minutes = 6ml (150 IU) over 10 minutes.

If patient tolerates, gradually increase to maximum infusion rate of 1ml X 60kg per hour = 54ml (1350 IU) over 60 minutes.

 

I hope this would answer the query.

Please find the attached reference for more information.

https://mega.nz/file/n8YFGaLB#oNlVtJa4PCW_SnbcvEbhtEiwUDl3CWy85pyGoH9wZfc

[Christian Lancaster]

I’d like to thank Rani for the detailed and comprehensive reply which I’ll make sure to benefit from in my practice.

I’d like to clarify that the concern with UpToDate calculator is also valid for younger patients as it considers the patient weight rather than ideal or adjusted body weight when necessary in contrast to Micromedix calculator which adjusts weight as necessary.

Regarding the inquiry about how to assess renal function in AKI patients, the following are my thoughts:-

1- AKI is usually precipitated by causes that affect other factors related to production and excretion of creatinine which makes it difficult to use the commonly used equations that necessitate a stable creatinine level.

2- As per our practice, I recommend to combine two main parameters to judge the kidney function in patients with AKI:-

a) Urine output:- As a measure of the functionality of the kidney. Patient with anuria should be assumed to have a CrCl of less than 10 ml/min regardless of the equation result
b) Original MDRD equation:- As it contains parameters like (Albumin) and (BUN) which are usually altered by the conditions that can lead to AKI.

3- Consider the degree of AKI and treatment required, i.e Spontaneously resolving VS CRRT-managed; in adjusting the dose as per specific drug monograph.

To conclude, combining equations and clinical status of the patient is essential for drug adjustment in patients with AKI taking into consideration the management of precipitating factors for developing AKI.

[Christian Lancaster]

I don’t have the reference clearly stated the dose in previous reply. The practice is either omitting or adjusting the dose and frequency providing of trace elements are variables among health care providers.
This is one option or you may provide 1/4th of the target dose and adjust the frequency if conjugated bilirubin become more worse..
There are many reports published pointed that bone disease and anemia have been reported in infant receiving a copper-free PN formulation in long term.

[Christian Lancaster]

There are many ways suggested for minimizing or preventing PNAC like:
– Avoid NPO if possible: encourage hypocaloric EF
– Prevent infection of the CVC used for PN
– Cyclic PN
– Specialized Amino acid formula (Parenetral Pediatric amino acid solution containing Taurine)
-Oral Antibiotics: metronidazole , gentamicin
-Oral glutamine
-Phenobarbital
-Ursodeoxycholic acid
– New lipids generation (SMOF)
– Removal or adjusting manganese and copper
– Minimal phytosterol content in IV lipids
-Finally liver + SB transplant
I highly recommend to initiate ursodeoxycholic acid in this case. Also, as you tried lipids emulsions supported with fish oil, you may it effects after 7 to 8 weeks.
Also, you have to pay attention that the dose of lipids has to adjusted (0.5- 1gm/kg/day) even TG level is normal.

Manganese then copper are the most toxic trace elements. Regarding using the trace elements mixture in this case, you may provide full dose of trace elements twice a week. No trace element supplementations, NPO patients in particular, on long PN term, patient may develop anemia on lung run due to the lack of copper supplementation.

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