AS-SAYDALIAH Volume 2 | Issue 1 | Jan-June 2019 Medical Outreach Programme at Orang Asli Village page1 page 3 page 5 Humanitarian Mission in Bangladesh A BULLETIN OF PHARMACY DEPARTMENT, IIUM MEDICAL CENTRE IIUM MEDICAL CENTRE الصيدليه Cold Chain For Beginner : A Mandatory Lesson For All Staff page 9 Cold chain products are very common in our daily activities, especially in the food industry. In the pharmaceutical division, the integrity of the cold chain medicine is equally important. Perceived as an important protocol among pharmacy practices, this subject now gets a lot of attention – especially after a series of cold chain breach incident in IIUMMC were reported to Pharmacy Department since January 2019. This leads me to investigate the reason behind the cases and acknowledged the vital need for further enlightenment of the subject. Cold chain refers to the management of temperature-sensitive products as they move through the supply chain. It is used to maintain optimal conditions during the transport, handling, distributing and storage of cold chain products, from the point of the manufacturer to the point of use, by assuring them to be in cold storage temperature between 2°C to 8°C and sub-zero for freezer item. (continue to page 7) What is Cold Chain? Cover Story: Cold Chain For Beginner Introduction to Neonatal PN
PAGE 2 As-Saydaliah EDITORIAL BOARD Editor and Designer Fatin Azzyati Pakururazi Columnist Asst. Prof. Dr. Norny Syafinaz Ab. Rahman Fatin Azzyati Pakururazi Nur Munirah Zainol Abidin Mery Hu Wei Ying Nur ‘Aina Abu Hassan Shaari Abdul Syahid Bin Dzulkafli Pharmacy Department’s IIUMMC Bulletin welcomes articles from all contributors especially from IIUMMC staff members and IIUM Kuantan students. Please submit contributions to Drug & Poison Information Service Center (DIS), Inpatient Pharmacy, Level 1, IIUM Medical Centre . Email: <[email protected]> I DEAS ARE BORN W I TH W R ITING الصيدليه Editor in Chief Che Rokiah Ismail Advisor Asst. Prof. Dr. Ilyani Mohamed Nazar Asst. Prof. Dr. Norny Syafinaz Ab. Rahman Disclaimer: As-Saydaliah is a newsletter of Pharmacy Department, IIUM Medical Centre, Kuantan. All efforts have been taken to ensure 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. TABLE OF CONTENT Editorial Board Table of Content MRA Humanitarian Mission to Malaysian Field Hospital (MFH), Cox’s Bazar, Bangladesh Page 3 Medical Outreach Program in Post Titom and Post Lenjang Page 5 Cold Chain For Beginner : A Mandatory Lesson For All Hospital Staff Page 7 Introduction to Neonatal Parenteral Nutrition Page 9 Pharmacy in Action Page 10 QUESTIONS? Give Us A Call INPATIENT PHARMACY: 09-5912591/1622/1623 OUTPATIENT PHARMACY: 09-5912577/1352/1353 PRODUCTION PHARMACY: 09-5912567/2544 EMERGENCY PHARMACY: 09-5911233 MEDICAL STORE: 09-5912648 DRUG INFORMATION SERVICES: 09-5912558 SATELLITE PHARMACY: 09-5912652/1047 CLINICAL PHARMACOKINETIC: 09-5912541/1610
PAGE 3 As-Saydaliah الصيدليه MRA Humanitarian Mission to Malaysian Field Hospital (MFH) at Cox’s Bazar, Bangladesh On 16th – 29th December 2018, I was given an opportunity to devote myself as one of the volunteers for Malaysian Relief Agency (MRA) Humanitarian Mission by providing my expertise at Malaysia Field Hospital (MFH) in Ukhia district, Cox’s Bazar, Bangladesh. MFH is one of the busiest field hospitals in which receives an average of 7,000 patients per month from the world’s largest refugee camps. Although it is small, it is well equipped with more than 20 inpatient beds, 2 OT rooms, ICU, Labour Room, laboratory, radiology room, pharmacy as well as ambulatory clinics in which operated by approximately 50 medical colleagues from Malaysia Armed Force. The high flux of patients daily sometimes made the MFH staffs unable to cope with the situation. Despite this situation, they tried their best to provide the best medical services for the unfortunate Rohingya people who faced hardship in their life. As the volunteers, we play our role to help MFH staffs to reduce their workload in giving medical services to the refugees. Throughout my services, I experienced in preparing and dispensing medication with few limitations. One of it is a limited amount of device that will ease the administration of medication to the patient, such as a syringe. In Malaysia, we used to give syringe for patients that need to take syrup preparation in order to avoid any improper dose during drug
PAGE 4 As-Saydaliah الصيدليه administration. Due to the limited syringe at the hospital, we only can give a measurement cup or measurement spoon in which was marked to the closest intended dose taken to the patient. Although medication error might occur due to the inaccuracy of medication administered, we tried our best not to overdose the patient by giving the safest dose with clear instruction to them. Besides, another limitation that we faced was the language barrier. The refugees did not understand any other language except their mother tongue. 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 eyeopener 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. Malaysian Relief Agency (MRA) is a humanitarian organisation registered under the Trustee Act 1952 (PPAB 20/2010), with the primary objective of assisting those affected by natural disasters or armed conflicts, both local and abroad. In 2014, MRA received special consultative status from United Nation – Economic and Social Council (UN – ECOSOC) which enable MRA to participate in UN deliberations. The set up and running of Malaysia Field Hospital (MFH) is one of the manifestations of Malaysia’s assistance to the Rohingya’s refugees. 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]
PAGE 5 As-Saydaliah الصيدليه 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. At 8.00am 11th January 2019, all members and volunteers assembled at Hospital Orang Asli, Gombak for the launching of “Drs for All”. Deputy Minister of Health, YB Dr Lee Boon Chye launched the “Drs for All’’ then proceeded to flag off the convoy with Dr Steven Chow and Director of Hospital Orang Asli, Gombak. The journey to the villages took us off the tarred road, the path was muddy and slippery; we even had to cross a river in order to reach the villages. We reached Kampung Cerewes at late evening, where we were greeted by the Tok Batin (village chief), briefed on logistic and itinerary by members of Raleigh KL and had a quick icebreaking 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. A quick background of the villages that I had received prior to the outreach programmewas: All 3 villages are located 7 hours away from Kuala Lumpur, the nearest town on the way to their village is Pekan Sungai Koyan. A 2.5 hours of muddy trek to reach these 3 villages. They are of the Semai community, second largest tribe in Peninsular Malaysia in the context of Orang Asli Community. Kampung Dayok and Kampung Cerewes have 150 villagers respectively, and Kampung Titom has 200 villagers. All three villages don’t have proper road access, electricity and filtered water, sanitation and telecommunication. Please expect a basic living condition. They have a good mix of Christian, Muslim and Non-Religion in the community.
PAGE 6 As-Saydaliah الصيدليه The next morning, all of us gathered at the Tok Batin’s house, had breakfast and moved to Kampung Titom. A team from the Ministry of Health joined us too. I was given the task to set up the pharmacy, assisted by Dr Tajudin, Major Nor’ain and a medical student. With limited space and resources, we will have to make do with whatever we have and be creative cum resourceful. Using tapes as labels on bottled medications, i.e. syrups and lotions, using measurements such as teaspoon and tablespoon instead of millilitres were among some improvisation that I had encountered. The highlight of the day was Dr Hew Kin Sun (a GP) did a home visit to a patient who claimed had been having stomachache and loss of appetite (I did not manage to follow as was preoccupied at the pharmacy counter). However, I was the one who revisits the home to dispense medications to the patient. At the end of the day, we packed up and returned to Kampung Cerewas. On the third day, the set up was done at the Tok Batin house itself. The doctors and pharmacy counter were stationed inside the Tok Batin house. The camp proceeded smoothly. This medical outreach camp was an eye-opener to me. The journey to the villages itself was both fun 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. Raleigh International Kuala Lumpur (Raleigh KL) is a sustainable, youth- developmental organisation and was founded in 1999 by a group of passionate, young Malaysian individuals who were inspired from the works of Raleigh International, an organization started by HRH Prince Charles in Britain since 1978. They mainly carries out various adventure, community and environmental projects locally. Federation of Private Medical Practitioners’ Associations, Malaysia (FPMPAM) is the national body representing doctors in private practice in Malaysia. Founded in 1989, it consists of seven statelevel associations and has over 5000 members. Mery Hu Wei Ying is the pharmacist in - charge of Outpatient Pharmacy (OPD). She enjoys binge watching anime whenever opportunity arises. She can be contacted through email: [email protected]. Video for this medical camp can be accessed via this link: https://www.youtube.com/watch?v=59WvyoB11s&feature=player_embedded (Drchow Steven’s Youtube Channel)
Cold Chain For Beginner : A Mandatory Lesson For All Hospital Staff PAGE 7 As-Saydaliah الصيدليه In most cases, cold chain breaches must be reported to the pharmacy department as soon as possible. Although pharmacy will replace the breached medication with a new one after an incident report is submitted, staff involved on the incident should not take the leniency for granted. Everyone should be aware that not only the incident placed a financial burden to the hospital, but it depicts a weak understanding among staff on how to protect the cold chain medications and lack of responsibilities upon medication under their care. Kept Frozen: Medications that should be stored below freezing temperature (0°C). Eg: Germeprost Pessary Store in Refrigerator: Medications that require maintenance of temperature in the range of +2°C to +8°C Keep at Room Temperature: Medications that require maintenance of temperature anywhere between +15°C to +25°C Cold chain breach: is the exposure of medication to temperatures outside the recommended range of 2°C to 8°C, excluding fluctuations up to 12°C lasting less than 15 minutes when restocking, cleaning the fridge or stock taking. Definitions WHAT TO DO IF A COLD CHAIN IS BREACHED? How To Maintain The Cold Chain When Transporting From Pharmacy to Ward? 4. Store the medication in a refrigerator as soon as you arrive at your destination 1. Bring ICE BOX/COLD CONTAINER as a carrier when collecting/transporting the medications 2. Inside the ice box, one must place a COOLANT to help maintain the temperature while transporting. 3. To accurately maintain the desired temperature, we encourage the use of TEMPERATURE MONITORING DEVICE. Cold Water Pack Glacier Ice Pack Freeze Alert™ Q Tag® Quad
PAGE 8 As-Saydaliah الصيدليه Three Reasons Why Medications Need To Be Stored In The Refrigerator 1. To maintain the medication’s effectiveness. Medications that need to be kept cold will lose their effectiveness when placed outside the recommended temperature range after a certain period of time. The period of stability is dependent on the type of medication and is usually specified in the package insert. 2. To maintain the medication’s sterility. Sterile means medications are free from microorganisms such as bacteria. Some medications especially eye drops or ear drops that are compounded at healthcare facilities aseptically (free from germ) and without preservatives should always be kept in cold conditions to slow the growth of bacteria. 3. To maintain the physical form of medication. Some medications in suppository form need to be stored in the refrigerator so that they do not melt before use. No. Generic Name Brand Name Optimal Temperature 1 Aflibercept Inj Eylea 2 -8 2 Alprostadil Inj Prostin VR 1.4-19.7oC 3 Amphotericin B (lyophilized) Inj Amphotret 3.5-20oC 4 Anidulafungin Inj Eraxis 3.5-20oC 5 Atosiban Inj Tractocile 2 - 8 6 Atracurium Besylate Inj Atracorium-hamelin 1.4-19.7oC 7 Beclometahsone Diproprionate Inhaler Foster 3.5-20oC 8 Chorionic Gonadotropin Inj Pregnyl 2 - 8 9 Carboprost Tromethamine Inj Hemabate -0.5-20.4oC 10 Chloral Hydrate Chloral Hydrate Crystal 3.5-20oC 11 Chloramphenicol Ear & Eye Drop 2 - 8 12 Clostridium Botulinum Inj Dysport 2 - 8 13 Desmopressin/Terlipressin/Vasopressin Minirin/Terpresin 1.4-19.7oC 14 Denosumab Inj Xgeva 2 - 8 15 Diagnostic Agent Synacten/Tuberculin 3.5-20oC 16 Dinoprostone Pessary Prostine 3.5-20oC 17 GLP-1 injection (Dulaglutide/Liraglutide) Trulicity/Victoza 2 - 8 18 Erythropoietin Injections Recormon 1.4-19.7oC 19 Filgrastim Inj Neupogen -0.5-20.4oC 20 Follitropin Alfa Inj Gonal F 2 - 8 21 Germeprost Pessary Cervagem -10oC 22 Glucagon Inj Glucagen 2 - 8 23 Human Albumin 20% Inj Zenalt 20 1.4-19.7oC 24 Human Anti-O Immunoglobulin Inj Rhophylac 300 -0.5-20.4oC 25 Human Normal Immunoglobulin Inj IVIG-globulin SN 1.4-19.7oC 26 Idarucizumab Inj Prxabind 1.4-19.7oC 27 Insulins 1.4-19.7oC 28 Interferon Injections Pegasys 29 Leucovorin Calcium Inj Calcium Folinate 3.5-20oC 30 Leuprorelin Acetate LUCRIN Depot Below 25 31 Lidocaine, Hydrocortisone Acetate Xyloproct 3.5-20oC 32 Methoxy polyethylene glycol-epoetin beta Mircera 2- 8 33 Octreotide 3.5-20oC 34 Oxytocin 3.5-20oC 35 Propofol 1% Inj Fresofol 1% 1.4-19.7oC 36 Proparacaine Hydrochloride Ophthalmic Solution Alcaine 2 - 8 37 Prothrombin Complex Concentrate Inj Octaplex 3.5-20oC 38 Ranibizumab Inj Accentrix 2 - 8 39 Reconstituted Antibiotics 2 - 8 40 Rocuronium Bromide Inj Esmeron 1.4-19.7oC 41 Streptokinase Inj Streptokinase Biofactor 1.4-19.7oC 42 Suxamethonium Chloride Inj 3.5-20oC Vaccines -0.5-20.4oC Extemporaneously compounded or diluted medications 2-8 Fatin Azzyati is the pharmacist incharge of Drug Information Service (DIS). She likes reading and plan to have self-guided walking holiday soon. She can be contacted via email : [email protected] Example of Cold Chain Medication in IIUMMC How to Pack Medication in Cold Box 1. Arrange the ice packs against the sides of the box. Do not put any ice pack at the bottom of the box or on top of the medication. 2. Put the medication in a plastic bag, in the middle of the cold box to protect them from damage due to condensation. 3. Make sure the medications does not directly touch the surface of the ice packs so that it does not freeze. 4. Close the cold box lid tightly 5. If you need to stop and leave your vehicle, bring the cool box together.
INTRODUCTION TO NEONATAL PARENTERAL NUTRITION PAGE 9 As-Saydaliah الصيدليه 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. PN can be administered to patient via central vein or peripheral vein. The choice of line access for PN delivery is usually determined by : • Vein availability • The concentration of the solution • The osmolarity of the solution • The the length of time the patient will be put on PN The essential components of the intravenous solution for PN are fluids, carbohydrates, proteins, lipids, electrolytes, vitamins and trace elements. The PN solution can be supplied either as: 1) An aqueous solution that contains water, proteins, carbohydrates, electrolytes, water soluble vitamins and trace elements with lipids and lipid soluble vitamins are supplied separately. 2) All in one solution that contains water, carbohydrates, proteins, lipids, electrolytes, vitamins and trace elements. What is PN? In neonates, PN is indicated in the following conditions: How PN is administered? Nur Aina Abu Hassan Shaari isthe pharmacist in - charge of Total Parenteral Nutrition (TPN) for Neonates and Paediatric Patients. She enjoys learning about people and life by travelling to places she finds interesting. She also finds happiness through small things such as her daily dose of caffeine. She can be contacted via email: [email protected]. • Premature infants of less than 30 weeks gestation and/or weigh less than 1000g. • More than 30 weeks gestation but unlikely to achieve full enteral feeds by day 5 of life. • Severe inter-uterine growth restrictions. • Birth weight between 1000 to 1500g and anticipated to be not on significant feeding for 3 or more days. • Birth weight more than 1500g and anticipated to be not on significant feeding for 5 or more days. • Necrotising enterocolitis (NEC). • Gastrointestinal tract anomalies
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