Vancomycin : Continuous Infusion

• Vancomycin exhibits time dependent killing, which implies that maintaining trough serum concentrations above the MIC is the most important determinant of therapeutic outcome.
• Vancomycin given as a continuous infusion avoids high peak concentrations and allows the maintenance of a steady state concentration above the MIC
• Additional benefits of a vancomycin continuous infusion include:
• Less nursing time required for administration
• Random vancomycin levels can be obtained for therapeutic drug monitoring
• Less cost of acquisition and wastage

 Dosing

 Dilution and Preparation

 Therapeutic Range

 

References:

1. Vancomycin Dosing - CHW. 23 February 2016
2. https://www.ncbi.nlm.nih.gov/pubmed/23172265
3. Vancomycin Dosing for Pediatrics University Health System

Anaphylaxis in Children

Antihistamines

• The UK Resuscitation Council recommends the use of intravenous
  antihistamines as second line treatment in the initial management of anaphylaxis, and
  suggests considering a 3 day course of oral antihistamines on discharge to reduce the chance of a recurrence.
• Although H1-antihistamines have been shown to be effective in the symptomatic treatment of some localised and less severe allergic reactions (e.g. allergic rhinitis, allergic conjunctivitis and urticaria), there is no published evidence to suggest that they reduce the risk of a further reaction in patients with anaphylaxis

Corticosteroids

• The UK Resuscitation Council recommends the use of intravenous corticosteroids as an adjunct to adrenaline and antihistamine therapy after initial resuscitation, to prevent or shorten protracted
  anaphylactic reactions
• recommends considering a 3 day course of oral corticosteroids on discharge to treat urticaria and reduce the chance of a recurrence.

References:

1. Guideline for the Management of Acute Allergic Reaction. The College of Emergency Medicine, 2009
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3043023/
3. http://www.cps.ca/documents/position/emergency-treatment-anaphylaxis

Treatment of Hypophosphatemia

Phosphate Sandoz tablet is not available in Hospital Keningau, it can be replace with liquid sodium dihydrogen phosphate.

• 1 tablet of Phosphate Sandoz® effervescent tablets contains 16.1mmol of phosphate 
• 10ml of Liquid Sodium dihydrogen phosphate contains 10mmol of phosphate

Liquid Sodium Dihydrogen Phosphate (10mmol/10ml) can be use through oral administration

• Dilution : No need to be diluted 
• Stability : 7 days in fridge 
• Administration : Usually 6 hourly 
• Side effect : Diarrhoea and nausea 
• Compatibility (for dilution): Sodium chloride 0.45%, 0.9%, Dextrose 5%, 10%
• Dose : 1-2mmol/kg per day in divided doses with feeds.Consider this route if the baby is on half oral feeds. Maximum dose daily not to exceed 2mmol/kg

References

• Guideline for the treatment of hypophosphataemia in adults. March 2016
• https://www.cdhb.health.nz/Hospitals-Services/Health-Professionals/Neonatal-Clinical-Resources/Neonatal-Drug-Information-Sheets/Documents/Sodium%20dihydrogen%20phosphate.pdf

Hydrocortisone used in Acute Adrenal Insufficiencies

Recommendation:
Suggest to follow Sarawak Handbook in view of the ease of administration.


References:

• Sarawak Handbook of Medical Emergencies, 3^rd Edition
• Medscape, v4.1.3, updated on 3^rd of April 2017
• Lexicomp, Version 3.0.1, updated on 4^th of April 2017
• http://handbook.ggcmedicines.org.uk/guidelines/endocrine-system/management-of-adrenal-insufficiency/

Salbutamol vs Fenoterol

Duolin Inhaler contains two bronchodilators: levosalbutamol and ipratropium, which work together to relax the muscles of the airways, reducing bronchospasm (contraction of the airways) and increasing air flow into the lungs.

The synergistic action (interacting to enhance the action of each other) of levosalbutamol and ipratropium in Duolin Inhaler reduces bronchospasm to a greater extent than would be provided by each drug alone, helping to prevent and relieve symptoms of asthma and COPD.

There were studies shown that

• Salbutamol and fenoterol are both effective bronchodilators with no significant difference between them puff per puff as regards potency.
• Fenoterol has a greater peak effect and duration of action than salbutamol, effective duration of action of salbutamol was 3 hours and that of fenoterol 4 hours.
• Fenoterol, however, delivers 200mcg per puff as opposed to 100mcg of salbutamol and fenoterol produced a greater stimulatory effect on heart rate with, in some cases, considerable tachycardia at high doses. An unpleasant taste and tremor were more common following fenoterol.

In conclusion, fenoterol is superior to salbutamol in peak effect and duration of action. However, Salbutamol seems more selective than fenoterol if higher doses of inhaled bronchodilator are required.

References:

• Fenoterol versus salbutamol nebulisation in asthma, Postgraduate Medical Journal (August 1983) 59, 504-505
• A cumulative dose comparison between salbutamol and fenoterol metered dose aerosols in asthmatic patients, Postgraduate Medical Journal (1987) 63, 459-461
• https://www.inhousepharmacy.vu/p-706-duolin-inhaler.aspx