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Surgery & Theatres

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Pharmacists Group
    In Practice - Summer 1999

Welcome to this edition of In Practice. Those of you who access our website will have noticed that the entry posted on the Web Site was very much larger than the paper edition. The full text version will continue to be available on the Web Site. However, the Surgery and Pharmacists Group will endeavour to get you better value for money for your UKCPA membership fee. If you want more in In Practice, you need to submit more to pressure the Publications Committee to publish it. (PH)

Committee News

The elections took place in May. Disappointingly, only one person stood for election - me. So Philip Howard was duly re-elected for 3 years. However, we were contacted after the elections by Joanne Spence from Newcastle who is changing job and moving to Glasgow to take up a Surgery job, and was keen to be involved again. Joanne was previously on the committee and has been co-opted for one year. During the UKCPA May symposium, Jayne Davis from the Royal Hallamshire Hospital in Sheffield volunteered to be co-opted for a year. Jayne is probably well known to most of you because of her theatre satellite pharmacy work.

Ann Slee is taking a back seat role for a while because of her other professional commitments. Ann has been a great help over the last two years, and her expertise will be missed. I am sure she will still be active in the background.

The website has a selection of "mug shots" of the committee taken at the May symposium. I haven't put on weight; it's just the way I am sitting. Take a look.

Spring Symposium

The Surgery and Theatres Pharmacists Group did not run any sessions at this Spring Conference but we had a useful fringe meeting and attended a breakfast meeting sponsored by Zeneca.

With your last edition of In Practice, you received a questionnaire regarding the publication. I hope you all completed it requesting more. Currently the Surgery and Theatres Group are restricted to our share of eight sides. The reason for this is that there is not enough content to justify the expense or even to fill twelve sides. I think this is a poor show on behalf of all members. I regularly have people ring me for advice or information, but the same people seem unable to submit just a few lines for publication. Surely, there is something worth sharing with your peers. Every edition, it is the same people writing. In order that In Practice doesn't disappear, please start telling me about what you are doing or reading about. To quote Neo-Darwinian theory - if you don't use it, you lose it!

information exchange

  • Oral ketamine - The Freeman Hospital in Newcastle has an excellent set of guidelines that will be available in the resource centre.

    • This quarter's questions:

    Jayne Davis, Theatres Pharmacist, Royal Hallamshire Infirmary, Sheffield.

    • Has anybody audited flumazenil in the operating theatre setting?
    • What do anaesthetists use for corneal protection during surgery?

    Laura MacLeod, Cheltenham General Hospital

  • Does anybody give antiemetics by the subcutaneous route? If so, what agents do you use? Does anybody have a protocol?

     

    Newsgroup Questions and answers for those not in the Newsgroup.

    •

    Europain has developed "European Minimum Standards for the Management of Postoperative Pain". They are a group of healthcare professionals involved in the treatment of pain.

    You can get a free copy by contacting Pegasus Healthcare International and giving them your address in writing by fax: 44 1491 875060 or Davidbarrow@pegasushealth.demon.co.uk or Tel 44 1491 875100

    • I was wondering if anyone had any guidelines regarding cardiac resus of the transplanted heart, given that it is denervated. Judith Strawbridge, Mater, Dublin
    • Does anybody have a policy in use for Radiographers to hold drug cupboard keys. Either CD or non-CD cupboards.
    • Which centres supply their surgical wards with non-stock drugs pre-labelled for TTO/TTA avoiding the need for further supply?
    • Does anybody organise this in advance from pre-admission clinic?
    • Does anybody successfully use Patients own drugs on ward?

    Rachel Westwood

    • Derby City General - We use patients' own drugs, providing they are suitable, on all our medical
      and surgical wards. All our supplies are as TTOs - as a 28-day supply. We have an agreement with the Health Authority so all patients are discharged with at least 14 days supply of medication and usually 28 days. This also takes place at Derbyshire Royal Infirmary, where pharmacists also work in the Ophthalmic pre-admission clinic. They take drug histories, advise patients to bring in their own drugs and prescribe and supply eye drops for discharge against a set protocol. This is something we would like to extend to all our pre-admission clinics but current resources prevent it. Nicola Wake
    • On Wirral we use POD's where possible and do use prelabelled stocks to aid technician assessment at ward level etc. drugs are all supplied as TTH's, the common TTH requirements e.g. pain control being prelabelled as ward stock. Yes, no, yes. Further details from Katherine or Kath on 0151 6785111 ext2699
    • Re: TTO pre packs & Patients' Own Drugs (PODs) In Southampton the Surgical wards have a full Pharmacy Technician run POD scheme running. This in combination with TTO pre- packs for analgesics & some antibiotics often avoids a TTO needing to be sent to Pharmacy. The Pharmacist transcribes the TTO from the in-patient chart on the ward and all is issued from there. The procedural details vary depending on whether the PODs have already been seen by a Technician - contact Sharron Dua (Pharmacy dept, Southampton General Hospital) if full details are required. (No detailed involvement in pre-admission clinics yet - other centres are much more advanced with this - this is the next step for us - all can be done prior to admission) Anne Cole, Retired Surgical Pharmacist (but still following progress avidly)!

    Anyone currently looking at auditing low flow rate anaesthesia? We would be interested in hearing from anyone who has any experience and suggestions for possible methods. Nicola Ward, Theatres Pharmacist

    • I have audited low flow rates in my theatres and I published a short article in Hospital Pharmacy Practice last year. Give me a ring if you want anymore info. Kath Phillips, Arrowe Park Hospital, 0151 6785111 bleep 2061

    Our hospital has a large ENT department, with ENT surgeons keen to use an alternative to cocaine. Unfortunately, changing to the only licensed alternative that we were aware of (i.e. co-phenylcaine) would have enormous cost implications, making a change at this time financially unviable. The article in Drug Safety however, refers to drugs for which there appear to be no commercially available products licensed for use in ENT surgery - at least as far as I can work out that is! I was wondering if you were aware of any centres that have successfully switched from cocaine? And what they were using?

    Ali Harris, Clinical effectiveness pharmacist, Radcliffe Infirmary, Oxford.

    • We were using the IDIs import from Australia until the Aurum product turned up. It will cost us about £60k more. Because MAL 14 is only at consultation stage, we will probably go back to the IDIS product. Philip Howard, Leeds General Infirmary

    Has anybody got experience with the treatment of rhinocerebral mucormycosis caused by a fungus called rhizopus. We have a young diabetic patient here in Brighton and are treating her with liposomal amphotericine at 3mg/kg/day aiming to go to 5mg/kg/day if tolerated. In addition we are trying to use fungizone packing but I can not find any information about the strength of solution that can be used. Has anybody got experience with topical or nebulised amphotericine? Does anybody know of any other additive treatment except surgical debridement that can be used? Has anybody used H2O2 lavage to increase O2 to tissue and/or hyperbaric oxygen treatment?
    Anja St. Cair-Jones, Brighton Health Care, 01273 696955 bleep 1185

    • I have seen nebulised Amphotericin used a number of times and always followed the Royal Bromptom Hospital Guidelines. I'm sure you probably have the guidelines, but if not I have the details. Judith
      Mater Hospital

    When do people usually recommend vaccinations following emergency splenectomy? Which antibiotics do splenectomy patients get on discharge to take at the first signs of infection, and how many days supply are given?

    Clare Wetherell, Clinical pharmacist - General Surgery, Sunderland Royal Hospital

    • Ideally we would wait two weeks before giving the vaccines but in practice they tend to get given immediately post op. to make sure that the patient does get them. We routinely supply Pen V 250mg twice daily for prophylaxis (erythromycin if penicillin allergic) but don't give any antibiotics to the patient for
      them to take if they get an infection. They are just told to go to their GP. Louise Bailey. Glenfield Hospital Leicester.
    • I recommend giving vaccines (Pneumovac & HIB) when the patient is "better". A sick stressed patient is unlikely to raise an appropriate response to the vaccines, and giving vaccines early probably leaves the prescriber with a
      false sense of security. I have not checked to see if anyone has looked at antibody titres following surgery compared with pre-surgical or when the patient is better. I know that some vaccines are better than others at initiating an immune response, meningococcal vaccines are usually poor. I realise this is vague, but its better than the usual surgeons response of giving it early in case we forget. I write a reminder on the top of the drug chart.       John Dade, St James University Hospital, Leeds.
    • Post splenectomy vaccines were always given 7-10 days after an emergency operation at Addenbrooke's until about 6 months ago - when the consultant surgeon recommended giving them immediately post-op. This was said to be based on some journal 'evidence' - although the DI department did a search for me and could find nothing new on the subject. Is anyone else aware of a change in evidence-based practice? The guidelines for house officers still state 7-10 days post op as far as I am aware, although the change to include only Pneumovax and HIB (and exclude Meningovac) was implemented in the latest edition (reissued every 6 months). As far as antibiotic prophylaxis is concerned, we give 7 days of Pen V or erythromycin if the patient is penicillin-allergic. The usual dose used is 500mg BD in either case. Alison Eggleton (recently ex-Surgical Directorate Pharmacist)
    • Here in Brighton we give Pneumovac and Hib immediately prior to discharge and we give them Pen V 250 BD for ? (Our surgeons can't make up their mind on the length of this). In addition to this we are giving them a rescue pack of Amoxycillin 250 mg three times daily for five days in case they get an infection. Anja St.Clair-Jones, Brighton

    Is there a maximum period of time recommended between pre-admission clinic and surgery actually occurring i.e. if pre-admission clinic occurs with surgery planned for a date and this is delayed, can this data be used at a later date? For how long? Sarah Taylor, Drug Information Manager, Chelsea & Westminster Hospital.

    Are any hospitals using alternatives to glutaraldehyde? Nicola Wake, Derby City Hospital

    Are there any recommended textbooks for surgical pharmacists, or a good general text that is recommended? Rachel Westwood

    Does anyone have any experience with sudden crash in BP (unrecordable) intra-op concerning schiz patients kept on trifluoperazine? This guy went for an aortic valve replacement and almost died on the table. We did not stop his schiz medicines pre-op. What's the reason? Mechanism of action i.e. action on calmodulin? Calcium seems to bring his BP back up. It's known that these drugs cause hypotension but he was on 5mg bid and we thought the ECMO would have washed out most of the drug anyway.
    Lai-San Tham, ICU Pharmacist, National University Hospital, Singapore

    Website review

    DRUG USE GUIDELINES AND PROTOCOLS

    www.nmhc.co.uk/intro.htm This is a website that has been made available for the Eastern Region Senior Pharmacy Managers Support Group. This is evolving to (probably) replace the Anglia and Oxford Group, enthusiastically and well run by John Anthistle, Chief Pharmacist, West Suffolk Hospital.

    You are welcome to pinch ideas from here, adapt them, pass comment etc. but obviously no responsibility can be taken for the validity of these documents in your particular area. Some don't translate in to HTML documents easily and may not be terribly clear (e.g. schizophrenia treatment). All are dated, but may not necessarily have the latest updated version. All the Norfolk Mental Health Care NHS Trust ones are included in the Trust "PIP" (Psychotropic drug Information and Protocols manual) produced every six months within the Trust.

    All examples are listed even though they are not Surgery or Theatres related.

    Norfolk Mental Health Care NHS Trust:

    West Suffolk Hospitals NHS Trust:

    Addenbrookes NHS Trust:

    The pages are managed by Stephen Bazire, Pharmacy Services Director, Norfolk Mental Health Care NHS Trust, email sbazire@compuserve.com

    Case studies

    This is a new section within the SATG columns. I have introduced it because there are often some very interesting cases that we see on our wards that we can share with colleagues. The cases should have a drug related learning point connected to them. We will keep the identity of the author and hospital anonymous for reasons of confidentiality. Hopefully, these cases will encourage some correspondence.

    Journal Review.

    We are looking for members who read some of the specialist journals, to summarise key papers in this column to share with other pharmacists without access to them.

    SATG Web site update.

    We have a new look to the site. The problems with the links in the Website have now been ironed out. We are keen to develop the web site further. To do this we need some feedback from you, and some input into the pages.

    The home page is at: www.users.globalnet.co.uk/~phoward/satg.htm

    If you have not visited it yet, please do and bookmark it.

    The Website now contains a Newsgroup page. Just click on it to join the Newsgroup or submit a question. It will allow members to canvass opinion quickly. If you come across any, please let us know. You can also add a link on our Hotlinks page on our Website.

    Resource centre.

    We have been receiving many calls for items from the Resource Centre. However, there has been very little submitted to the Resource Centre. For the Resource centre to be successful, it has to continually grow and evolve. Obsolete material needs to be withdrawn and be replaced by updates. We would like all people who request items to submit something in return. All hospitals will have some sort of guideline that they can offer. Please help us to help you.

    There have been no additions to the resource Centre since the last edition. This clearly is not compatible with an up to date centre. If all of you sent in one guideline each, we would have 248 additions to report on for the next edition.

    CONFERENCE UPDATE.

    This section is for members to review a conference or study days that they have been to and to share them with us.

    subgroup updates

    Neurosurgery

    Helen Hick at Leeds General Infirmary is keen to contact other pharmacists working in neurosurgery. Helen and another pharmacist cover the three neurosurgical wards and a neuro ICU. Helen is looking to set up a pre-admission clinic and would like to hear from pharmacists working in this area. She is also keen to exchange protocols and ideas. Helen can be contacted on 0113 392 3161.

    The Neurosurgery group now has several active members who are exchanging guidelines and pharmaceutical care profiles for neurosurgery patients. Topics covered so far include the use of high dose Methylprednisolone treatment in acute spinal cord injury and Hydrocortisone regimen in-patients with a Pituitary Tumour.

    Katherine Longden from Preston would be interested to hear from any other Pharmacists who have previous experience of giving Nimodipine to patients with an NG tube by methods other than crushing tablets or
    intravenously.

    The group is keen to hear from Pharmacists working in the field of Neurology since several members cover this speciality in addition to Neurosurgery.

    Other Contacts:
    Ali Harris Radcliffe Infirmary Oxford Tel 01865224483
    Sandra Peters + Rachel King Frenchay Hospital Bristol Tel 01179186521
    Katherine Longden Royal Preston Hospital Preston Tel 01772710234

    Urology Sub Group

    Confused with cystectomies?

    Troubled with TURPS?

    Or are you just vexed with Viagra?

    The Urology Sub Group is here for you!

    If you’d like to share your knowledge, experience and resources contact Nicola Wake either on e-mail (nicola.wake@lineone.net) or via the telephone (01332 340131 ext. 5405).