Category Archives: Departments

DiphenhydrAMINE Injection Shortage 10.15.18

To:            Physicians, Nursing, Pharmacy

From:     Maryna Shayuk, MD, Chair Pharmacy and Therapeutics

                  Alan Mader, Pharmacy Operations Coordinator

Date:        October 15, 2018

Re:            Diphenhydramine Injection Shortage

S

Situation

Diphenhydramine injection supply is critically low. Estimates indicate less than a 2 week supply throughout NM Northwest system.
B

Background

Diphenhydramine has been on shortage. Pharmacy Purchasing has been able to obtain orders up to this point.
A

Assessment

In order to maintain the limited supply for crash cart exchange, sequestering to pharmacy and therapeutic substitution will need to be instituted.
R

Recommendation

Pharmacy will sequester remaining supply from Pyxis machines to the Pharmacy Department.   Therapeutic Substitution will take place as follows:

Injection to PO – For all patients who can take PO in equivalent dose.

If unable to take PO – Therapeutic substitution to Promethazine Injection in equivalent dose.   Doses greater than 25 mg – consult with MD.

 

Sodium Bicarbonate Inj Shortage 10.1.18

To:      Physician, Nursing and Pharmacy Staff
From: Maryna Shayuk, MD, Chair, Pharmacy and Therapeutics
            Alan Mader, PharmD, Pharmacy Clinical Coordinator
Date:   9/26/2018
Re:        Sodium Bicarbonate Injection Shortage

Situation

Sodium Bicarbonate 8.4% Injection 50 mL is currently on shortage. There are different projections on how long this shortage will last, with some continuing until 2019. Sodium Bicarbonate is used for CODE BLUE situations and is available in Crash Carts. It is also used for Open Heart Surgery and for Toxicologic Emergencies.

Background

The supply of Sodium Bicarbonate 8.4% Injection has not been stable for some time.

Assessment

With uncertain supply, steps to maintain availability for Crash Cart Supply and for Open Heart Surgery need to be implemented.

Recommendation

Pharmacy will sequester supply to maintain stock for Crash Carts and for the surgical Open Heart room. When orders are received for sodium bicarbonate infusion, pharmacy will directly provide recommendation with the ordering physician to use sodium acetate injection. Information on the use of sodium acetate infusion is shown below:

Toxicologic Emergencies – Use Sodium Acetate 2 mEq/mL
a. Bolus (if required) – 1 mEq/kg/D5W 500 mL infused over 20 minutes (consistent
with information presented by ASHP). 150 mEq maximum to avoid osmolarity issues.
For patients over 100 Kg, infuse over 30 minutes.
b. Maintenance: Na Acetate 150 mEq/D5W 1000mL infused at 200 mL/hr for adult
patients. 3 bag limit. The same rate would be used for urine alkalinization.

We are anticipating that the shortage will end before supply becomes depleted. If that is not the case, sodium acetate may also be used in Code situations as follows:

Crash Cart/Code situation – Requires dilution/infusion. 50 mEq Sodium Acetate added to 100 mL D5W (125mL TV) administered over 10 minutes

Sodium Phos and Potassium Phos Inj Shortage 10.1.18

To:      Physician, Nursing and Pharmacy Staff
From: Alan Mader, Pharmacy Clinical Coordinator
Date:  10/1/2018
Re:       Sodium Phosphate Injection Shortage
             Potassium Phosphate Injection Shortage

Situation

Both Sodium Phosphate and Potassium Phosphate Injection are on shortage. Currently the system is in very low supply of Sodium Phosphate and pharmacy has transferred supply from the Huntley campus to the McHenry campus. The Sodium Phosphate shortage is projected to last 2 to 4 weeks. The Potassium Phosphate shortage is projected to last until late December.

Background

These shortages have been newly announced.

Assessment

Sodium Phosphate supply is very low within the system (17 vials). While Potassium Phosphate is currently in greater supply, projections indicate that it may remain on the shortage list an additional month longer that Sodium Phosphate.

Recommendation

Please conserve both Sodium and Potassium Phosphate Injection. Wherever possible, please consider oral replacement with Neutra Phos equivalent. Each packet contains: Sodium 160 mg (7.1 mEq), Potassium 280 mg (7.1 mEq), Phosphorus 250 mg (8 mMol).

Allergies will be listed as unknown severity by nursing staff

Nursing and pharmacy will list patient allergies in the EMR. The severity of the allergy cannot be assessed by the nursing and pharmacy staff. Therefore the allergy severity will be listed as “unknown”. This will default to the presumed to be severe for the drug alerting.

Physicians can go and edit the severity based on history and clinical judgement.

Please edit the informant source to physician. This will allow the severity to flow from one admission to the next.

MRSA Isolates and E Test

Centegra lab will now perform an e-test on all MRSA isolates obtained from a sterile site with microscan mic >=2.

With additional testing e-testing many isolates may have lower had mic of <1.5 expanding options for treatment.

This additional step will take an additional day to report out.

Potassium Chloride Injection Shortage UPDATE 7.30.18

Potassium Chloride Injection Shortage – although product is still in short supply, Centegra pharmacies have been successful in obtaining supply.  The manufacturer expects release on 8/23/18.  At this time, we estimate we have at least a 4-week supply and can now begin using without restriction.

Antimicrobial Stewardship – New Program

Starting Feb 2018 we will move to a three tiered system of antimicrobial stewardship. For all the details go to Clinical -> Infection prevention -> Antimicrobial Stewardship.

Clostridium Difficile Guidelines 2017 – Updated

IDSA and SHEA have updated guidelines for 2017. Please see here for details.

For other guidelines

CT Chest ILD Protocol

Please note that the CT Chest ILD protocol is specifically to evaluate for and differentiate between different types of interstitial lung diseases and includes expiratory phase and prone imaging.  Usually this is on patients with known pulmonary fibrosis or longstanding shortness of breath.  Also this is usually ordered by pulmonologists on outpatients.  If a patient is acutely short of breath, has a lung nodule/mass, or in the hospital, usually a CT chest is the more appropriate order. This was previously named “High-Resolution Chest CT,” but the name was changed to better reflect it’s intended use.  All of our CTs are high resolution.

Influenza Vaccination in Patients with Egg Allergy

Guideline Watch | GENERAL MEDICINE, INFECTIOUS DISEASES

January 11, 2018

Influenza Vaccination in Patients with Egg Allergy

David J. Amrol, MD reviewing Greenhawt M et al. Ann Allergy Asthma Immunol 2018 Jan .

All available flu vaccines are safe in all egg-allergic patients.

Sponsoring Organizations: American Academy of Allergy, Asthma, and Immunology (AAAAI); American College of Allergy, Asthma, and Immunology (ACAAI)

Target Audience: All providers who administer influenza vaccines

Background

Historically, patients with egg allergy have been told to avoid flu vaccines, because most flu vaccines are produced in embryonated chicken eggs; the concern was that a vaccine might contain residual egg protein, which could lead to anaphylaxis. Many studies have shown that flu vaccines are safe for egg-allergic patients, but many physicians still have been hesitant to vaccinate such patients. This updated practice parameter incorporates recent data on flu vaccine safety in egg-allergic patients, including children.

Key Recommendations

  • Flu vaccines should be administered annually to patients with egg allergy of any severity, with no need to ask recipients about egg-allergy status and no special precautions beyond those recommended for administering any vaccine to any patient. This recommendation applies to both injected and intranasal formulations (although the latter should not be used in the 2017−2018 flu season).
  • Non−egg-containing vaccines can be used but are not necessary or preferred over standard vaccines.
  • The intranasal live attenuated flu vaccine also might be used, if it’s shown to be efficacious and is approved for use.
Comment

Egg-allergic patients can be vaccinated safely with any available age-appropriate flu vaccine, with no special precautions, regardless of egg-reaction history (including anaphylaxis). Concern for egg allergy only adds another barrier to universal flu vaccination, and this practice parameter concludes by stating the following: “Vaccine providers and screening questionnaires do not need to ask about the egg allergy status of recipients of influenza vaccine.”

Editor Disclosures at Time of Publication

Disclosures for David J. Amrol, MD at time of publication

Consultant / Advisory board CSL Behring; Horizon Pharmaceuticals
Citation(s):

Greenhawt M et al. Administration of influenza vaccines to egg allergic recipients: A practice parameter update 2017. Ann Allergy Asthma Immunol 2018 Jan; 120:49. (http://dx.doi.org/10.1016/j.anai.2017.10.020)