As-Saydaliah Volume 2 | Issue 1| Jan-June 2019

‫الصيدليه‬

IIUM MEDICAL CENTRE Volume 2 | Issue 1 | Jan-June 2019

AS-SAYDALIAH

A BULLETIN OF PHARMACY DEPARTMENT, IIUM MEDICAL CENTRE

Cold Chain For Beginner : A
Mandatory Lesson For All Staff

Cold chain products are very common in What is
our daily activities, especially in the food
industry. In the pharmaceutical division, Cold
the integrity of the cold chain medicine is
equally important. Chain?

Perceived as an important protocol among Cold chain refers to the management of
pharmacy practices, this subject now gets a temperature-sensitive products as they move
lot of attention – especially after a series of through the supply chain. It is used to
cold chain breach incident in IIUMMC were maintain optimal conditions during the
reported to Pharmacy Department since transport, handling, distributing and storage
January 2019. This leads me to investigate of cold chain products, from the point of the
the reason behind the cases and manufacturer to the point of use, by assuring
acknowledged the vital need for further them to be in cold storage temperature
enlightenment of the subject. between 2°C to 8°C and sub-zero for freezer
item. (continue to page 7)

Cover Story: Cold Humanitarian Medical Outreach Introduction to
Chain For Beginner Mission in Programme at Neonatal PN
Bangladesh
page 1 page 3 Orang Asli Village page 9
page 5

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As-Saydaliah
IDEAS ARE BORN
WITH WRITING TABLE OF CONTENT

EDITORIAL BOARD Editorial Board

Advisor Table of Content
Asst. Prof. Dr. Ilyani Mohamed Nazar
Asst. Prof. Dr. Norny Syafinaz Ab. Rahman MRA Humanitarian Mission to Malaysian
Field Hospital (MFH), Cox’s Bazar,
Editor in Chief
Che Rokiah Ismail Bangladesh Page 3

Editor and Designer Medical Outreach Program in Post Titom and
Fatin Azzyati Pakururazi Post Lenjang Page 5

Columnist Cold Chain For Beginner : A Mandatory
Lesson For All Hospital Staff Page 7
Asst. Prof. Dr. Norny Syafinaz Ab.
Rahman Introduction to Neonatal Parenteral
Fatin Azzyati Pakururazi Nutrition Page 9
Nur Munirah Zainol Abidin
Mery Hu Wei Ying Pharmacy in Action Page 10
Nur ‘Aina Abu Hassan Shaari
Abdul Syahid Bin Dzulkafli QUESTIONS?

Pharmacy Department’s IIUMMC Bulletin Give Us A Call
welcomes articles from all contributors
especially from IIUMMC staff members and INPATIENT PHARMACY: 09-5912591/1622/1623
IIUM Kuantan students. Please submit
contributions to Drug & Poison Information OUTPATIENT PHARMACY: 09-5912577/1352/1353
Service Center (DIS), Inpatient Pharmacy, PRODUCTION PHARMACY: 09-5912567/2544
Level 1, IIUM Medical Centre . EMERGENCY PHARMACY: 09-5911233
Email: <[email protected]> MEDICAL STORE: 09-5912648
DRUG INFORMATION SERVICES: 09-5912558
Disclaimer: As-Saydaliah is a newsletter of
Pharmacy Department, IIUM Medical Centre, SATELLITE PHARMACY: 09-5912652/1067
Kuantan. All efforts have been taken to ensure CLINICAL PHARMACOKINETIC: 09-5912541/1610
the correctness and accuracy of the information
published. Our department is not responsible for
any claims or action as a result of unauthorized
usage of any materials from this newsletter.

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MRA Humanitarian Mission to Malaysian Field
Hospital (MFH) at Cox’s Bazar, Bangladesh

On 16th – 29th December 2018, I The high flux of patients daily sometimes made the
MFH staffs unable to cope with the situation.
was given an opportunity to devote myself as Despite this situation, they tried their best to
one of the volunteers for Malaysian Relief provide the best medical services for the
Agency (MRA) Humanitarian Mission by unfortunate Rohingya people who faced hardship
providing my expertise at Malaysia Field Hospital in their life.
(MFH) in Ukhia district, Cox’s Bazar, Bangladesh.
MFH is one of the busiest field hospitals in which As the volunteers, we play our role to help MFH
receives an average of 7,000 patients per month staffs to reduce their workload in giving medical
from the world’s largest refugee camps. services to the refugees. Throughout my services, I
experienced in preparing and dispensing
Although it is small, it is well equipped with more medication with few limitations. One of it is a
than 20 inpatient beds, 2 OT rooms, ICU, Labour limited amount of device that will ease the
Room, laboratory, radiology room, pharmacy as administration of medication to the patient, such
well as ambulatory clinics in which operated by as a syringe. In Malaysia, we used to give syringe
approximately 50 medical colleagues from for patients that need to take syrup preparation in
Malaysia Armed Force. order to avoid any improper dose during drug

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Malaysian Relief Agency administration. Due to the limited syringe at the
(MRA) is a humanitarian hospital, we only can give a measurement cup or
organisation registered measurement spoon in which was marked to the
under the Trustee Act 1952 closest intended dose taken to the patient.
(PPAB 20/2010), with the primary objective of Although medication error might occur due to the
assisting those affected by natural disasters or inaccuracy of medication administered, we tried
armed conflicts, both local and abroad. In 2014, our best not to overdose the patient by giving the
MRA received special consultative status from safest dose with clear instruction to them.
United Nation – Economic and Social Council (UN –
ECOSOC) which enable MRA to participate in UN Besides, another limitation that we faced was the
deliberations. The set up and running of Malaysia language barrier. The refugees did not understand
Field Hospital (MFH) is one of the manifestations of any other language except their mother tongue.
Malaysia’s assistance to the Rohingya’s refugees. However, with the help of locals that do
understand Rohingya language; we were able to
interact with the patient comfortably. The locals
become our translators and help dispense the
medication as instructed. All counselling
techniques for selected devices were taught to
them by the MFH Pharmacist, Captain Amirah
Rahmatullah Khan to ensure compliance of
medication by the patients.

This volunteerism program had become an eye-
opener to me. Facing the refugee’s day by day,
knowing that the hardship that they faced daily
and how they adapt with their current situation
had given me another perspective in facing the
real-world challenge. Not everything in this world
run as what we planned because God is the best
planner above all. Previously, the refugees live
their life to the fullest. However, due to the crisis
in their country, they tried their best to adapt and
survive with it. They smiled whenever they faced
any problem although during sickness. They are
willing to walk for about 10km from their
settlement to MFH just to get 30 minutes of
medical advice in the hot and dry weather.

Their situation had taught me that I need to
accept (Redha) whatever had written or planned
to me by Allah, and I should not lose any hope in
Allah as well as in myself. Redha in any situation
that we confronted now is not only made our
heart at ease. Also, it will make us becoming
mentally stronger to face any challenge in the
future.

Nur Munirah Zainol Abidin is a
pharmacist in - charge of Clinical
Pharmacokinetic (CPK) Unit.
Volunteerism is her niche as helping
people in need is her goal of life. She can be
contacted via email at [email protected]

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Medical Outreach Programme
in Post Titom and Post Lenjang

A medical outreach

programme to Kampung Titom, Kampung

Cerewes and Kampung Dayok was held from
11th of January 2019 to 14th January 2019. The
medical partners for this visit were Federation of
Private Medical Practitioners’ Associations,
Malaysia (FPMPAM) headed by Dr Steven Chow
with the involvements of few medical students
from Malaysian Medical Students’ Association
Victoria (MAMSA Vic) while Raleigh Kuala
Lumpur provided logistic support.

The aims of this time visit were to follow up with
the same community and continuity in building
trust with the community, to provide firsthand
experience to MAMSA Vic students and
volunteers the insight of medical condition in
rural village and for Raleigh Kuala Lumpur to
continue their development plan in Post Lenjang
and Post Titom for the needed community.

A quick background of the villages that I had received At 8.00am 11th January 2019, all members and
prior to the outreach programme was: volunteers assembled at Hospital Orang Asli,
Gombak for the launching of “Drs for All”.
All 3 villages are located 7 hours away from Kuala Lumpur, the Deputy Minister of Health, YB Dr Lee Boon Chye
nearest town on the way to their village is Pekan Sungai Koyan. launched the “Drs for All’’ then proceeded to flag
A 2.5 hours of muddy trek to reach these 3 villages. They are of off the convoy with Dr Steven Chow and Director
the Semai community, second largest tribe in Peninsular of Hospital Orang Asli, Gombak.
Malaysia in the context of Orang Asli Community.
The journey to the villages took us off the tarred
Kampung Dayok and Kampung Cerewes have 150 villagers road, the path was muddy and slippery; we even
respectively, and Kampung Titom has 200 villagers. All three had to cross a river in order to reach the villages.
villages don’t have proper road access, electricity and filtered We reached Kampung Cerewes at late evening,
water, sanitation and telecommunication. Please expect a basic where we were greeted by the Tok Batin (village
living condition. They have a good mix of Christian, Muslim and chief), briefed on logistic and itinerary by
Non-Religion in the community. members of Raleigh KL and had a quick ice-
breaking session. It required a slight hike up to
reach my accommodation, to my surprise the
hosts were already waiting for us and greeted us
with lit up fireplace, in the house. Tired from the
journey, I just dozed off. It was a chilly night, and
some said that it hit 17O C that night.

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The next morning, all of us Raleigh International Kuala Lumpur
(Raleigh KL) is a sustainable, youth-
gathered at the Tok Batin’s house, had breakfast developmental organisation and
and moved to Kampung Titom. A team from the was founded in 1999 by a group of
Ministry of Health joined us too. I was given the task passionate, young Malaysian individuals who were
to set up the pharmacy, assisted by Dr Tajudin, inspired from the works of Raleigh International, an
Major Nor’ain and a medical student. With limited organization started by HRH Prince Charles in Britain
space and resources, we will have to make do with since 1978. They mainly carries out various adventure,
whatever we have and be creative cum resourceful. community and environmental projects locally.
Using tapes as labels on bottled medications, i.e.
syrups and lotions, using measurements such as Federation of Private Medical
teaspoon and tablespoon instead of millilitres were Practitioners’ Associations, Malaysia
among some improvisation that I had encountered. (FPMPAM) is the national body
representing doctors in private practice
The highlight of the day was Dr Hew Kin Sun (a GP) in Malaysia. Founded in 1989, it consists of seven state-
did a home visit to a patient who claimed had been level associations and has over 5000 members.
having stomachache and loss of appetite (I did not
manage to follow as was preoccupied at the Video for this medical camp can be accessed
pharmacy counter). However, I was the one who via this link:
revisits the home to dispense medications to the https://www.youtube.com/watch?v=59Wvy-
patient. At the end of the day, we packed up and oB11s&feature=player_embedded (Drchow
returned to Kampung Cerewas. On the third day, Steven’s Youtube Channel)
the set up was done at the Tok Batin house itself.
The doctors and pharmacy counter were stationed Mery Hu Wei Ying is the pharmacist
inside the Tok Batin house. The camp proceeded in - charge of Outpatient Pharmacy
smoothly. (OPD). She enjoys binge watching anime
whenever opportunity arises. She
This medical outreach camp was an eye-opener to can be contacted through email:
me. The journey to the villages itself was both fun [email protected].
and exhilarating. The need to cross a river in a 4-
wheel drive was unimaginable until it was done.

Furthermore, I am humbled by the lifestyle of these
villagers. They went through day by day with basic
living condition, i.e. without electricity, no filtered
water, no proper bathroom or sanitization, no
telecommunication. However, they welcomed us
with open arms and provided great hospitality. This
taught me to be grateful with what I have and
always remember that they are people more
underprivileged than me, lend a hand when
feasible. Being stripped of communication had
sharpened my senses to the wonder of nature at
Pos Titom.

I am glad to be a part of this multidisciplinary team
consisted not only of medical doctors but also
members from Raleigh KL who assisted in logistic
and to be able to contribute in any way to this good
cause. It is an extraordinary experience; mentally,
physically, spiritually and occupationally.

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Cold Chain For Beginner : A Mandatory
Lesson For All Hospital Staff

Definitions WHAT TO DO
IF A COLD
Kept Frozen: Medications that should be stored below CHAIN IS
freezing temperature (0°C). BREACHED?
Eg: Germeprost Pessary
In most cases, cold chain breaches must be reported
Store in Refrigerator: Medications that require to the pharmacy department as soon as possible.
maintenance of temperature in the range of +2°C to Although pharmacy will replace the breached
+8°C medication with a new one after an incident report is
submitted, staff involved on the incident should not
Keep at Room Temperature: Medications that require take the leniency for granted.
maintenance of temperature anywhere between +15°C
to +25°C Everyone should be aware that not only the incident
placed a financial burden to the hospital, but it depicts
Cold chain breach: is the exposure of medication to a weak understanding among staff on how to protect
temperatures outside the recommended range of 2°C the cold chain medications and lack of responsibilities
to 8°C, excluding fluctuations up to 12°C lasting less upon medication under their care.
than 15 minutes when restocking, cleaning the fridge or
stock taking.

How To Maintain The Cold Chain When
Transporting From Pharmacy to Ward?

1. Bring ICE BOX/COLD 3. To accurately maintain the desired
CONTAINER as a carrier when temperature, we encourage the use of
collecting/transporting the TEMPERATURE MONITORING DEVICE.
medications

2. Inside the ice box, one must place a COOLANT

to help maintain the temperature while

transporting. Glacier Ice Pack

Cold Water Pack

Freeze Alert™ Q Tag® Quad

4. Store the medication in a refrigerator as soon
as you arrive at your destination

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Three Reasons Why No. Generic Name Brand Name Optimal Temperature
Medications Need To Be
Stored In The Refrigerator 1 Aflibercept Inj Eylea 2 -8
1.4-19.7oC
1. To maintain the medication’s effectiveness. 2 Alprostadil Inj Prostin VR 3.5-20oC
Medications that need to be kept cold will lose their 3.5-20oC
effectiveness when placed outside the recommended 3 Amphotericin B (lyophilized) Inj Amphotret
temperature range after a certain period of time. The 4 Anidulafungin Inj Eraxis 2-8
period of stability is dependent on the type of medication 1.4-19.7oC
and is usually specified in the package insert. 5 Atosiban Inj Tractocile 3.5-20oC

2. To maintain the medication’s sterility. 6 Atracurium Besylate Inj Atracorium-hamelin 2-8
Sterile means medications are free from microorganisms -0.5-20.4oC
such as bacteria. Some medications especially eye drops 7 Beclometahsone Diproprionate Inhaler Foster
or ear drops that are compounded at healthcare facilities 3.5-20oC
aseptically (free from germ) and without preservatives 8 Chorionic Gonadotropin Inj Pregnyl 2-8
should always be kept in cold conditions to slow the 2-8
growth of bacteria. 9 Carboprost Tromethamine Inj Hemabate
1.4-19.7oC
3. To maintain the physical form of medication. 10 Chloral Hydrate Chloral Hydrate Crystal
Some medications in suppository form need to be stored 2-8
in the refrigerator so that they do not melt before use. 11 Chloramphenicol Ear & Eye Drop Dysport 3.5-20oC
12 Clostridium Botulinum Inj 3.5-20oC
How to Pack Medication
in Cold Box 13 Desmopressin/Terlipressin/Vasopressin Minirin/Terpresin 2-8
1.4-19.7oC
1. Arrange the ice packs against the sides of the box. Do 14 Denosumab Inj Xgeva -0.5-20.4oC
not put any ice pack at the bottom of the box or on top 15 Diagnostic Agent Synacten/Tuberculin
of the medication. 16 Dinoprostone Pessary 2-8
17 GLP-1 injection (Dulaglutide/Liraglutide) Prostine -10oC
2. Put the medication in a plastic bag, in the middle of 18 Erythropoietin Injections Trulicity/Victoza 2-8
the cold box to protect them from damage due to 19 Filgrastim Inj 1.4-19.7oC
condensation. 20 Follitropin Alfa Inj Recormon -0.5-20.4oC
21 Germeprost Pessary Neupogen
22 Glucagon Inj 1.4-19.7oC
23 Human Albumin 20% Inj Gonal F
24 Human Anti-O Immunoglobulin Inj Cervagem 1.4-19.7oC
Glucagen 1.4-19.7oC
Zenalt 20
Rhophylac 300 3.5-20oC
Below 25
25 Human Normal Immunoglobulin Inj IVIG-globulin SN 3.5-20oC

26 Idarucizumab Inj Prxabind 2- 8
27 Insulins
28 Interferon Injections Pegasys 3.5-20oC
29 Leucovorin Calcium Inj Calcium Folinate 3.5-20oC
LUCRIN Depot 1.4-19.7oC
30 Leuprorelin Acetate
31 Lidocaine, Hydrocortisone Acetate Xyloproct 2-8
32 Methoxy polyethylene glycol-epoetin Mircera
3.5-20oC
beta Fresofol 1%
33 Octreotide Alcaine 2-8
Octaplex 2-8
34 Oxytocin 1.4-19.7oC
35 Propofol 1% Inj 1.4-19.7oC
36 Proparacaine Hydrochloride Ophthalmic
3.5-20oC
Solution -0.5-20.4oC
37 Prothrombin Complex Concentrate Inj
2-8
38 Ranibizumab Inj Accentrix

39 Reconstituted Antibiotics

40 Rocuronium Bromide Inj Esmeron

41 Streptokinase Inj Streptokinase Biofactor

42 Suxamethonium Chloride Inj
Vaccines

Extemporaneously compounded or
diluted medications

Example of Cold Chain
Medication in IIUMMC

3. Make sure the medications does not directly touch the Fatin Azzyati is the pharmacist in-
surface of the ice packs so that it does not freeze. charge of Drug Information Service
(DIS). She likes reading and plan to
4. Close the cold box lid tightly have self-guided walking holiday
soon. She can be contacted
5. If you need to stop and leave your vehicle, bring the
cool box together. via email : [email protected]

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INTRODUCTION TO NEONATAL
PARENTERAL NUTRITION

What is PN?

PN stands for Parenteral Nutrition, which is the
provision of macronutrient (carbohydrate, lipid and
protein), micronutrient (vitamins, trace elements
and minerals) and fluid requirements through
intravenous nutrient solution.

In neonates, PN is The essential components of the
indicated in the
following conditions: intravenous solution for PN are fluids, carbohydrates,
proteins, lipids, electrolytes, vitamins and trace
• Premature infants of less than 30 weeks elements.
gestation and/or weigh less than 1000g.
The PN solution can be supplied either
• More than 30 weeks gestation but unlikely to as:
achieve full enteral feeds by day 5 of life. 1) An aqueous solution that contains water, proteins,
carbohydrates, electrolytes, water soluble vitamins
• Severe inter-uterine growth restrictions. and trace elements with lipids and lipid soluble
• Birth weight between 1000 to 1500g and vitamins are supplied separately.

anticipated to be not on significant feeding for 2) All in one solution that contains water,
3 or more days. carbohydrates, proteins, lipids, electrolytes, vitamins
• Birth weight more than 1500g and anticipated and trace elements.
to be not on significant feeding for 5 or more
days.
• Necrotising enterocolitis (NEC).
• Gastrointestinal tract anomalies

How PN is administered?

PN can be administered to patient via central vein
or peripheral vein.

The choice of line access for PN delivery is Nur Aina Abu Hassan Shaari is the
usually determined by : pharmacist in - charge of Total
Parenteral Nutrition (TPN) for
• Vein availability Neonates and Paediatric Patients. She
• The concentration of the solution enjoys learning about people and life
• The osmolarity of the solution by travelling to places she finds
• The the length of time the patient will be put on interesting. She also finds happiness through small
things such as her daily dose of caffeine. She can be
PN contacted via email: [email protected].

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