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EDITORIAL BOARD ADVISOR: PN HJH ROHAYAH BINTI ABD. GHANI
BULETIN
JULY 2019 VOLUME 2/2019
PENAWAR
HOSPITAL SULTANAH AMINAH JOHOR BAHRU KEMENTERIAN KESIHATAN MALAYSIA JALAN PERSIARAN ABU BAKAR SULTAN, 80100 JOHOR BAHRU
TEL: 07-2257000 FAX: 07-2242694 EMAIL: [email protected]
EDITORS: PN SITI ROSNAH BT SURADI PN NG WANG SING CIK ZANARIAH BT ABU BAKAR PN LI SHIN GIE
HOSPITAL SULTANAH AMINAH JOHOR BAHRU
ACUTE ISCHAEMIC STROKE PROTOCOL HSAJB PAGE 2-3
INFLUENZA VACCINES PAGE 4-5
MANAGEMENT OF DIABETES IN PREGNANCY PAGE 6-7
CYANIDE POISONING PAGE 8-9
PROGRAM KENALI UBAT ANDA PAGE 10
ACUTE ISCHAEMIC STROKE PROTOCOL HSAJB Stroke is a global health problem. It has consistently seen as one of the top five leading cause of death since year 2000’s.
Algorithm
Service’s Introduction Started on 12 November 2017 and applied only
during office hours.
Protocol for IV tPA for Acute Stroke
Inclusion criteria
Absolute contraindication
Relative Contraindication
Significant trauma within 3 months
(include CPR with chest compressions
within past 10 days)
Stroke within 3 months
History of intracranial hemorrhage or
symptoms suspicious.
Major surgery within past 14 days
Minor surgery within past 10 days,
including liver and kidney biopsy,
thoracentesis and lumbar puncture.
Arterial puncture at non-compressible site
within past 14 days
Pregnant (up to 10 days postpartum) or
nursing women
Gastrointestinal, urologic or respiratory
hemorrhage within past 21 days
Known bleeding diathesis (include renal
& hepatic insufficiency)
Peritoneal dialysis or hemodialysis
PTT > 40 seconds; PT >15 seconds
(INR>1.7; platelet count< 100,000)
SBP >180mmHg or DBP> 110 mmHg,
Seizure at onset of stroke
Glucose <2.8 or >22 mmol/L
Consideration should be given to the
increased risk of hemorrhage in patients
with severe deficits (NIHSS >20), age >75
or early edema with mass effect on CT
Mild or rapidly improving deficits
JABATAN FARMASI, HOSPITAL SULTANAH AMINAH JOHOR BAHRU PAGE 2
BY NURAINI BINTI ARSHAD
Abbreviation: tPA: tissue plasminogen
activator
rTPA: recombinant tPa
NIHSS: NIH Stroke Scale
ASPECT: Alberta Stroke
Program Early CT
Pre-Treatment Work Up
Alteplase Infusion Pre and Post Treatment Management
• ICU/HDU/General Medical Ward Acute Bed admission for monitoring for at least 24 hour
• Vital signs every 15 mins for 2 hours, then every 30mins for 6 hours, then every hour for 24 hours
• Strict control of BP for 24 hours per protocol (SBP<180mmHg, DBP<110mmHg)
• Neurological check hourly for 24 hours (GCS) • Maintain oxygen saturation 95% • No antiplatelet agents or anticoagulants in the first 24 hours • No Foley catheter, nasogastric tube, arterial catheter or
central venous catheter for 24h (unless absolutely necessary)
Blood Pressure Control after IV tPA SBP(mmHg) DBP(mmHg) Management
180-230 105-120 Give IV Labetalol 10mg over 1-2 minutes. May repeat or double every 10-20 minutes up to a total dose of 150mg. Monitor BP every 15 minutes.
>230 121-140 Same with above management, but if no response, infuse Sodium Nitroprusside (0.5-10µg/kg per minute).
- >140 Infuse Sodium Nitroprusside (0.5-10µg/kg per min). Monitor BP every 15min.
Symptomatic Hemorrhage After IV tPa 1. STAT head CT, if intracelebral hemorrhage is suspected. 2. Refer neurosurgery and ICU. 3. Check FBC, PT, PTT, platelets, fibrinogen and D-dimer. Repeat every 2 hours until bleeding is con-
trolled. 4. Give 2 units Fresh Frozen Plasma every 6 hours for 24 hours. 5. Give 6 units Cryoprecipitate. If fibrinogen level <200mg/dl at 1h, repeat Cryoprecipitate dose. 6. Give 4 units platelets. 7. Give Mannitol 20% 200ml stat and TDS. 8. Institute frequent neurological checks and therapy of acutely elevated in, as needed.
JABATAN FARMASI, HOSPITAL SULTANAH AMINAH JOHOR BAHRU PAGE 3
BY NURAINI BINTI ARSHAD
Influenza Vaccines
Influenza: A contagious respiratory illness caused by influenza viruses that infect nose,
throat and lungs.
• Physical exam
• Look for signs and symptoms of influenza
• Laboratory diagnost ic p r o c e d u r e s i n v o l v e collection of appropriate respiratory samples .
• Rapid influenza diagnostic tests (RIDTs) are commonly used but have lower sensitivity compared to Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) methods that detect influenza-specific RNA by RT-PCR
Clinical Diagnosis
Complications
Uncomplicated Serious
Typically resolves
after 3-7 days
Cough and
malaise may
persist for >2
weeks
Pneumonia is the
most common
complication
Others: otitis media,
tracheobronchitis,
rhabdomyolysis with
renal failure
Distribution of Influenza Viruses Subtype Worldwide
Clinical Presentations
• Abrupt onset of fever
• Severe myalgia and/or arthralgia
• Severe dry cough
• Loss of appetite
• Headache
• Malaise
• Sore throat
Aetiology
Seasonal Influenza Avian Influenza
Types of virus: A, B and C
Types A & B are the main
causes of influenza outbreaks
Also known as ‘bird flu’
Caused by type A
strains such as H5N1
How Does Vaccine Work?
Stimulates your body’s immune
system to make antibodies to attack
the influenza viruses
Reduces flu-related doctor’s
visits or hospitalizations
Important preventive tool for
people with chronic health
conditions
Helps protect women during
and after pregnancy
Can be life-saving in children
Uncomplicated Vaccines
Prevention
-Should be given annually for those ≥6 months old with no contraindi-cation to any of its components
-People who have a history of severe egg allergy should be vaccinated in a medical setting
Treatment
Symptomatic
Therapy
Fever & Myalgia:
non-opioid analge-
sics & antipyretics
Cough & cold
preparations:
expectorants,
mucolytics
Influenza Management
Complicated
Antiviral
Therapy
M2 inhibitors
(Amantadine or
Rimantadine)
Neuraminidase
inhibitor
(Oseltamivir or
Zanamivir)
Benefits of Vaccines
JABATAN FARMASI, HOSPITAL SULTANAH AMINAH JOHOR BAHRU PAGE 4
BY ER PEY LING
WHO Recommended Vaccines’ Compositions
References: 1.World Health Organization. Influenza. Available from: https://www.who.int/influenza/en/ [Accessed 29th Jan 2019]. 2. Centers for Disease Control and Prevention (CDC). Key Facts About Seasonal Flu Vaccine. Available from: https://www.cdc.gov/flu/protect/keyfacts.htm [Accessed 30th Jan 2019]. 3. Treanor JJ. Clinical Practice. Influenza Vaccination. New Eng-land Journal of Medicine.2016; 375:1261-1268. 4. Grohskopf LA, Sokolow LZ, Broder KR, Walter EB, Fry AM, Jernigan DB. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Im-munization Practices-United States, 2018-19 Influenza Season. MMWR Recomm Rep. 2018;67(3):1-20.
Possible Side Effects: Very common: Injection site reactions such as
pain, swelling & redness, headache, myalgia Common: Nausea, vomiting and
diarrhoea Uncommon: Rash, thrombocy-
topenia, convulsions, cellulitis
Southern Hemisphere Northern Hemisphere
Trivalent: A/Michigan/45/2015
(H1N1) pdm09-like virus, A/
Switzerland/8060/2017 (H3N2)-
like virus & B/Colorado/06/2017
-like virus
Quadrivalent: the above-
mentioned antigens plus B/
Phuket/3073/2013-like virus
Trivalent: A/Michigan/45/2015
(H1N1) pdm09-like virus, A/
Singapore/INFIMH-
160019/2016(H3N2)-like virus
& B/Colorado/06/2017-like vi-
rus
Quadrivalent: the above-
mentioned antigens plus B/
Phuket/3073/2013-like virus
Trivalent or Quadrivalent Vaccines
Trivalent
B H3N2 H1N1
Quadrivalent
Methods of Production Vaccine Categories Vaccine Delivery
Egg-based
Cell-based
Recombinant
Live Attenuated (LAIV)
Inactivated (IIV)
Recombinant (RIV)
Nasal spray (2-49 age
Injectable Flu Vaccine
Comparisons between IIV, LAIV and RIV
Vaccine Type IIV LAIV RIV
No. of virus strains 3 or 4 4 4
Approved age ≥6 months 2-49 years ≥18 years
Route of administration Intramuscular or
intradermal
Intranasal spray Intramuscular
Dosage 1 or 2 doses depending
on vaccination history
1 or 2 doses depending
on vaccination history
Single dose
(annually)
Contraindicated in chronic medical
conditions/immunocompromised/
pregnant woman
No
Yes No
Brand names Afluria®, Fluarix®,
Fluzone®
FluMist® FluBlok®
Children: 6 months to 5 years old
Immuno-compromised
Eg. HIV/AIDS, cancer
Elderly > 65 years old
Chronic medical conditions
Eg. asthma,
diabetes, cardiac diseases
Pregnant women at any stage of
pregnancy
Healthcare workers
BY ER PEY LING
JABATAN FARMASI, HOSPITAL SULTANAH AMINAH JOHOR BAHRU PAGE 5
B H3N2 H1N1 B
MANAGEMENT OF DIABETES IN PREGNANCY
INTRODUCTION
Diabetes during pregnancy can be separated in two groups:
(a) Pregestational diabetes
diagnosed before pregnancy with either insulin dependent or insulin independent
(b) Gestational diabetes mellitus (GDM)
carbohydrate intolerance first detected during pregnancy.
SCREENING AND DIAGNOSIS RISK FACTOR
• Previous history of GDM
• Body mass index (BMI) >27 kg/m²
• First-degree relative with diabetes mellitus
• History of macrosomia (birth weight >4 kg)
• Bad obstetric history (unexplained intrauterine
death, congenital anomalies, shoulder dystocia)
• Glycosuria ≥2+ on two occasions
• Current obstetric problems (essential
hypertension, pregnancy induced hypertension,
polyhydramnios and current use of
corticosteroids)
COMPLICATION
• Neural tube defects
• Incidence of stillbirth is greatest after 36 weeks’ gestation in women with poor
glycaemic control
• Macrosomia, defined as birthweight >4 kg
• Shoulder dystocia
• Infants of diabetic mothers also are at increased risk for prolonged
hypoglycaemia after delivery, respiratory distress syndrome,
hypocalcaemia, polycythaemia and hyperbilirubinaemia during the neonatal
period
GOAL OF TREATMENT
To reduce the maternal and fetal morbidity and mortality associated with diabetes
JABATAN FARMASI, HOSPITAL SULTANAH AMINAH JOHOR BAHRU PAGE 6
BY LOW YI WEN
TREATMENT OF GDM
1. ORAL ANTIDIABETIC AGENT 2. INSULIN
Metformin (Biguanide)
MOA: Decreases hepatic glucose production and intestinal
absorption and improves insulin sensitivity by increasing
peripheral glucose uptake and utilization.
Pregnancy category: B (Animal study has failed to demonstrate a
risk to the fetus and there are no adequate and well-controlled
studies in pregnant women).
Compared with insulin, metformin is associated with less
maternal weight gain but higher incidence of premature birth
(<37 weeks gestation).
Prandial insulin: short or rapid onset of action for controlling the
post-prandial glucose excursion.
Basal insulin: intermediate or long-acting pharmacokinetic profile to
cover the basal insulin requirements in between meals and
overnight.
Premixed insulin: biphasic insulin that incorporates the combination
of short or rapid-acting insulin with its intermediate-acting.
Supplement of 5 mg folic acid per day should be given to women
with diabetes who plan to become pregnant at least three months
prior to conception and continue until 12 weeks of gestation.
BLOOD GLUCOSE TARGET IN
PREGNANCY
POSTPARTUM LIFESTYLE
MODIFICATION
Moderate physical activity (brisk walking, swimming or modified
yoga), 20-30 minutes, four days per week.
OGTT should be performed at six weeks after delivery.
If the result is negative, annual screening should be performed.
References 1. CPG of Management of diabetes in pregnancy. (2017). Malaysia Health Technology Assessment Section (MaHTAS) Medical Development Division, Ministry of Health
Malaysia Level 4, Block E1, Precinct 1 Federal Government Administrative Centre 62590, Putrajaya, Malaysia.
2. Alldredge, B., Koda-Kimble, M. and Young, L. (n.d.). Koda-Kimble Applied therapeutics. 9th ed.
POSTPARTUM MONITORING
FOLIC ACID SUPPLEMENT
SELF MONITORING BLOOD
GLUCOSE (SMBG) MONITORING
BY LOW YI WEN
JABATAN FARMASI, HOSPITAL SULTANAH AMINAH JOHOR BAHRU PAGE 7
Timing of Blood Glucose Target Value (mmol/L)
Fasting or preprandial 5.1
1-hour after the start of a meal 7.8
2-hours after the start of a meal 6.7
CYANIDE POISONING
• Remove Casualty from further exposure to cyanides.
• Support ABC (Airway, Breathing, Circulation)
• Decontaminated
• Transfer patient to medical facility
What is Cyanide?
• Fast acting and highly toxic chemical.
• Presented in Cyanide salts (Potassium/Sodium) & Hydrogen
cyanide gas.
• Commonly used in chemical industry, mining and
electroplating industries.
• Odour of bitter almonds.
Controlling Risk
Personal Protective Equipment:
• Gloves
• Protective apron
• Rubber boots
• Face Shield/goggles
• Appropriate respiratory equipment
First Aid
Patient should always be taken
to the nearest hospital for
assessment and monitoring.
Poisoning by Ingestion • Vomiting should not be induced
unless told by a registered medical practitioner
• Rinse the mouth with water
• Go to nearest hospital ASAP
Exposure of cyanide by eye contamination • Wash the eye with
copious water or saline for at least 10 minutes
• Monitor signs and symptoms of poisoning
Routes of Exposure
Mouth-to-mouth
resuscitation should
be avoided
• Inhalation (Most Common)
• Eye Contact
• Skin Contact
• Ingestion (Less common)
JABATAN FARMASI, HOSPITAL SULTANAH AMINAH JOHOR BAHRU PAGE 8
By Yong Guo Shen
Pathophysiology
Binds with ferric ion in mitochondrial
cytochrome oxidase
Prevent electron transport chain
(Inhibit oxidative phosphorylation & ATP
production)
Prevent utilisation of oxygen in cellular
metabolism
Increased demands on anaerobic glycolysis
Excessive lactic acid production
Severe acid-base imbalance
*CNS, myocardium are particularly
sensitive to the toxic effects of cyanide*
Medical Facility Care
Signs of Cyanide Poisoning
Arterial and venous blood gases
• Arteriovenous oxygen differences (<10%)
• Metabolic acidosis
Blood Lactate Level
• Smoke Inhalation - > 10 mmol/L
• Pure Poisoning - > 6 mmol/L
Altered Mental Status
• e.g. confusion, disorientation
Prioritise first aids, oxygen therapy & other life supporting measures (e.g. metabolic acidosis correction) Cyanide antidotes only be given when:
Patient’s condition deteriorates
Severe symptoms of cyanide poisoning *Panic symptoms (tachypnoea, vomiting) may mimic early cyanide poisoning symptoms. Hence, true cyanide poisoning is needed to confirm before antidote administration.
Monitoring of Patient: • At least 48-72 hours after initial emergency
treatment (especially after antidote administration)
• Continuation of 100% oxygen administration should be determined based on the response to antidote
• Watch for development of pulmonary oedema, aspiration pneumonia and seizures in comatose patient
• Correct any further metabolic acidosis
Symptoms of Cyanide Poisoning
• Fast onset
• Depends on: Cyanide form, route of exposure, amount of
cyanide exposed to.
Acute (Severe)
• Seizures
• Gasping for breath
• Cardiac arrest
• Rapid Loss of
consciousness
*Death may occur within few minutes of expo-sure to moderate or high amounts of cyanide.
Headache Anxiety
Shortness
of Breath
Dizziness
General
Weakness Nausea,
Vomiting
Acute (Mild)
References
1. Safe Work Australia. Guide for preventing and responding to cyanide poisoning in the workplace. Australia: SWA; 2013. 20 p.
2. Cyanokit (single 5-g vial) [package insert]. Columbia, MD: Meridian Medical Technologies, Inc.; 2011.
3. National Institute for Occupational Safety and Health (NIOSH), 2016. Respirator Trusted-Source Information – Section 3: Ancillary
Respirator Information.
4. Atsdr.cdc.gov. (2019). ATSDR - Medical Management Guidelines (MMGs): Cyanide. [online] Available at: https://
www.atsdr.cdc.gov/mmg/mmg.asp?id=1073&tid=19 [Accessed 4 May 2019].
JABATAN FARMASI, HOSPITAL SULTANAH AMINAH JOHOR BAHRU PAGE 9
By Yong Guo Shen
Antidotes (IV)
Types of
Antidotes
Mechanism of
Action
Dosage & Administration Redosing Adverse Ef-
fects
Monitoring
Hydroxo-
cobalamin
(Cyanokit)
Binds to
cyanide ions to
form cyanoco-
balamin then
excreted in the
urine
Adult: IV 5g over 15 mins; may
repeat if necessary
(Max cumulative dose: 10g)
Second dose of 5g
may be
administered if
signs of cyanide
poisoning
reappear
Transient
chromaturia,
increased
blood pres-
sure, nausea,
headache
• Renal functions for 7 days after treatment
• Blood pressure • Allergic reaction: ana-
phylaxis, rash, chest tightness
Sodium
Thiosulphate
12.5g/50mL
Acts as
sulphur
donor for
rhodanese and to
enhance
endogenous
cyanide
detoxification
capacity of the
body
Adult: IV 12.5g over 10 mins,
repeat if necessary with half of
first dose.
Children: IV 412.5mg/kg at rate
0.625 to 1.25g/min. Max dose:
12.5g
If signs of
cyanide poisoning
reappear after 30
minutes to 2 hours
after administra-
tion, may repeat
with half of first
dose
Hypotension,
headache,
disorientation
• Signs & symptoms of
thiocyanate poisoning
(Serum thiocyanate >
10mg/100mL)
Sodium
Nitrite*
300mg/10mL
* Indicated for
sequential use
with
sodium
thiosulfate
Reacts
Haemoglobin
↓
Methaemoglobin
Cyanide
preferably binds
to methaemoglo-
bin than
ferric ion of
mitochondrial
oxidase. Hence
restoring
cytochrome
oxidase
activity
Adult:
• Sodium Nitrite - IV 10mL at
rate 2.5 to 5 mL/min
• Sodium Thiosulfate - IV 50mL
immediately following
administration of Sodium
Nitrite.
Children:
• Sodium Nitrite - IV 0.2mL/kg
at rate 2.5 to 5 mL/min
• Sodium Thiosulfate - IV 1mL/
kg but not exceed 50 mL total
dose immediately following
administration of Sodium
If signs of
cyanide
poisoning
reappear, repeat
treatment using
half of
original dose of
both Sodium
Nitrite and
Sodium
Thiosulphate
Syncope,
hypotension,
methemoglo-
binaemia,
tachycardia,
palpitation
• Blood pressure moni-
toring is a MUST.
• Pulse oximetry
(oxyhaemoglobin, car-
boxyhaemoglobin, met-
haemoglobin level) in
patient with anaemia/
smoke inhalation injury
*Monitor at least 1-2 days
after antidotes administra-
tion
*Renal impairment patient
has higher risk of toxic
reactions to this drug
Guide for Preventing and Responding to
Cyanide Poisoning in the Workplace
Empty containers cannot be reused
Thoroughly rinsed with large amounts of
water
Container should be crushed and disposed
Disposal
Storage • Small quantities of cyanides should be stored
separately
• Storage areas should be fire-resistant with a con-
crete floor
• Keep cyanides in original containers and keep
them securely closed and the oldest material is
used first.
• Do not eat, drink or smoke in a cyanide store
• Minimise the likelihood of unintended reactions
with incompatible materials (acids, oxidising
agents)
JABATAN FARMASI, HOSPITAL SULTANAH AMINAH JOHOR BAHRU PAGE 10
PROGRAM KENALI UBAT ANDA
Jabatan Farmasi Hospital Sultanah Aminah telah menganjurkan Program Kenali Ubat
Anda pada 16 Mei 2019 di Dewan Sekolah Menengah Foon Yew, Johor Bahru. Program ini
telah melibatkan pelajar Tingkatan 5 dan 6.
Program ini dijalankan untuk memastikan pelajar mengenali ubat-ubatan dan
mengambilnya secara rasional. Selain itu, sesi ceramah, kuiz and aktiviti ini memberi
peluang kepada pelajar untuk menimba pengetahuan baru. Secara tidak langsung, Jabatan
Farmasi dapat memastikan maklumat yang betul telah disampaikan kepada pelajar. Secara
keseluruhannya, pameran ini telah berjalan dengan lancar dan meriah.
Program ini bermula pada jam 9.30 pagi hingga 11.30 pagi. Program ini terdiri
daripada pelbagai pameran, kuiz, ceramah dan aktiviti. Terdapat dua ceramah yang
disampaikan kepada pelajar:
1) Kenali Ubat Anda
2) Pemilihan komestik yang selamat dan bahaya penggunaan kosmetik yang tidak
bernotifikasi