Nebulised Pentamidine - Administration



Canberra Hospital and Health ServicesMedication Guideline Nebulised Pentamidine - Administration Contents TOC \o "1-2" \h \z Contents PAGEREF _Toc440616950 \h 1Introduction PAGEREF _Toc440616951 \h 2Alerts PAGEREF _Toc440616952 \h 2Scope PAGEREF _Toc440616953 \h 2Section 1 – Patient suitability for nebulised pentamidine PAGEREF _Toc440616954 \h 2Section 2 – Risks to staff and patients associated with nebulised pentamidine PAGEREF _Toc440616955 \h 3Section 3 – Personal protective equipment PAGEREF _Toc440616956 \h 4Section 4 – Administration of nebulised pentamidine PAGEREF _Toc440616957 \h 4Implementation PAGEREF _Toc440616958 \h 6Related Legislation, Policies and Standards PAGEREF _Toc440616959 \h 6References PAGEREF _Toc440616960 \h 6Definition of Terms PAGEREF _Toc440616961 \h 7Search Terms PAGEREF _Toc440616962 \h 7IntroductionThis guideline outlines the processes for the use of nebuliser therapy to administer pentamidine at Canberra Hospital and Health Services (CHHS). Pentamidine is an antiprotozoal agent used for the prophylaxis of Pneumocystis jiroveci pneumonia (PJP) in immunocompromised patients. Back to table of contentsAlertsA negative pressure room is required for patients who have active TB. For all other patients, a negative pressure room is the preferred setting. When a negative pressure room is not available, and the patient does not have active TB, nebulised pentamidine may be administered in a well ventilated clinic room, with an extractor fan.Where possible the staff member should not be present in the room during nebulisation. The staff member should return for frequent, brief checks on the patient. If required to remain with the patient for longer periods, staff member must wear a P2 or N95 respirator mask.Back to table of contentsScopeThis document is applicable to all clinicians who provide a service to a patient at the CHHS:All Medical OfficersAll nurses who are working within their scope of practice (Refer to: Nursing and Midwifery Continuing Competence Policy)Back to table of contentsSection 1 – Patient suitability for nebulised pentamidinePentamidine has proven efficacy against PJP but is inferior to sulfamethoxazole/ trimethoprim. Nebulised pentamidine is recommended for immunocompromised patients withsignificant sulphonamide allergy or significant side effects to sulfamethoxazole/ trimethoprim such as severe myelosuppression, and where other alternative agents such as dapsone are unsuitable. Immunocompromised patients for whom nebulised pentamidine is indicated, and recommended duration of therapy, include:patients with HIV infections (including children that may be affected by vertical transmission) until CD4+ count is >200 cells/microlpatients with other conditions increasing susceptibility to PJP including:patients with Acute Lymphoblastic Leukaemia (throughout therapy)patients post allogenic stem cell transplantation (although IV preparations are preferred in terms of efficacy – see below *) for at least 6 months and while on immunosuppressant therapypatients post autologous stem cell transplantation; for 6 months patients receiving fludarabine and/or other T cell depleting agents for at least 6 months or until CD4+ count is >200 cells/microL, whichever occurs firstpatients with Hodgkin lymphoma whilst on therapypatients with non-Hodgkin lymphoma whilst on therapypatients receiving high dose methotrexate regimens (≥1g/m2) whilst on therapypatients on corticosteroid therapy (in those receiving the equivalent of a minimum of prednisolone 20mg daily for more than a month) in combination with other immunosuppressant therapy; cease 2 weeks after cessation of steroidspatients post solid organ transplant.*IV pentamidine is preferred as prophylaxis for PJP in patients post allogeneic stem cell transplantation at a dose of 4mg/kg IV every 2-3 weeks.Note: IV pentamidine is also used therapeutically for suspected or proven PJP as 4mg/kg IV daily therapy for 14-21 days.All patients requiring nebulised pentamidine therapy should be advised to stop smoking. Individuals who smoke have an increased risk of PJP and may have a more complicated treatment course. Back to table of contentsSection 2 – Risks to staff and patients associated with nebulised pentamidineBronchoconstriction due to escape of nebulised particles Staff and patients with a history of asthma or who are smokers have an increased likelihood of bronchospasmTransmission of tuberculosis from patients with active TB.As the effect of inhaled pentamidine is unknown in human pregnancy, staff who are pregnant should avoid handling pentamidine. Back to table of contentsSection 3 – Personal protective equipmentP2 or N95 maskAll clinicians involved in the administration of inhaled pentamidine must wear a P2 or N95 mask to protect against bronchoconstriction and other adverse effects of pentamidine to protect against the possible transmission of respiratory pathogens.In addition, it is important that all staff practice Standard Precautions as follows: Perform hand hygiene before and after patient contact using the 5 moments of hand hygiene.Use protective barriers, which may include gloves, gowns, plastic aprons, masks, eye shields or goggles as well as P2 or N95 mask as above.Ensure appropriate handling and disposal of sharps and other contaminated or infectious waste, and linen.Utilise aseptic techniques.Utilise appropriate antiseptics/disinfectants.Additional Precautions are used for patients who are known or suspected to be infected or colonised with important or highly transmissible pathogens. They must be used in conjunction with Standard Precautions and include:Contact precautions direct with patient/person contactindirect contact (i.e. contact with contaminated surface or equipment)Droplet precautionsAirborne precautions.For specific information on additional Precautions and PPE please refer to the CHHS Healthcare Associated Infections Procedure.Back to table of contentsSection 4 – Administration of nebulised pentamidineEquipmentOptimist Plus disposable nebuliser (for salbutamol)Angled mouth piece, system 22Salbutamol 2.5mg in 2.5mL nebuleSodium chloride 0.9% ampouleOxygen cylinder or wall oxygenRespirgard 11? nebuliser pack (for pentamidine)Pentamidine isethionate 300mg vialSterile water for injection ampouleCall bellRecliner chairBottle/glass of waterDoor sign “Do Not Enter”ProcedureStaff are to perform hand hygiene according to the 5 moments of hand hygiene as set out by Hand Hygiene AustraliaAll Canberra Hospital patients receiving pentamidine must be accompanied by their medication chart, observation chart and notesCheck medication order and collect required medications and equipmentDon Personal Protective Equipment (including P2 or N95 mask) if needed prior to any patient contact as per Additional Precautions (Section 3) Explain the procedure to the patient, including the medications, equipment and possible side effects and obtain verbal consent Record baseline blood pressure, pulse and respiration rate. Seek medical review with concerns Don P2 or N95 mask if not already being used and assist the patient to a sitting or semi-recumbent positionPlace salbutamol 2.5mg into the Optimist Plus disposable nebuliser, add sodium chloride 0.9% to make up to required volume of 4mL, then add mouthpieceAttach the oxygen tubing to cylinder or to wall oxygen and adjust the flow rate (no less than 6L/minute) to achieve a fine mistInstruct the patient to close the lips firmly around the mouthpiece and to inhale through the mouth and exhale through the nose, and to breathe deeply and slowlyWhen salbutamol inhalation is completed, discard the Optimist Plus nebuliserWait 10 minutes before commencing pentamidine Explain that a staff member will be available but will not stay in the room during pentamidine treatment; keep the door closed with a visible “Do Not Enter” sign on the door Ensure the patient can access and use the call bell, and ask them to call if they require assistanceInstruct patient to use nebuliser (as above), how to turn off the oxygen flow if they need to take a break during the pentamidine nebuliser treatment, and how to recommence the nebuliseAsk the patient to recline their chair after the first 10 mins of treatment (being careful not to spill the liquid in the nebuliser) and continue treatment in this position for a further 10 minutes, breathing as above. This change in position helps distribute pentamidine through the lungs. After 10 minutes in the reclined position, the patient should return the chair to the upright position for the remainder of the treatment.Ensure a bottle/glass of water is within patient reachDissolve pentamidine 300mg in 6mL of sterile water for injection and shake well Place diluted pentamidine into nebuliser included in the Respirgard 11? nebuliser packCommence nebulised pentamidine at an oxygen flow rate of 6L/minuteCheck patient intermittently for side effects of pentamidine:Bronchospasm – stop nebuliser and seek urgent MO reviewExcessive cough – ensure oxygen flow rate <10L/min, reduce inspiration rateDizziness – monitor blood pressure, reduce deep breathingWhen nebulisation of pentamidine is complete discard Respirgard 11? nebuliser equipment in clinical waste bin Record post nebuliser blood pressure, pulse and respiration rate. Seek medical review with concerns Back to table of contentsImplementation In-service and multidisciplinary education;Placed on notice boards in tea rooms; andDistributed to staff via email.Back to Table of ContentsRelated Legislation, Policies and StandardsRelated Legislation and Policies (including but not limited to)CHHS Medication Handling PolicyACT Health Waste Management PolicyCHSS Healthcare Associated Infections ProcedureNursing and Midwifery Continuing Competence PolicyBack to table of contentsReferencesNebulisers in eTherapeutic Guidelines (2013). Retrieved 2 September 2013 from , J. (2009) Pneumocystis jirovecii pneumonia in HIV Management in Australasia – a guide to clinical care. Australasian Society for HIV Medicine, Sydney.Vasconcelles MJ, Bernardo MV, King C, Weller EA, Antin JH. Aerosolized pentamidine as pneumocystis prophylaxis after bone marrow transplantation is inferior to other regimens and is associated with decreased survival and an increased risk of other infections. Biol Blood Marrow Transplant. 2000;6(1):35-43.Miguez-Burbano MJ, Ashkin D, Rodriguez A, et al. Increased risk of Pneumocystis carinii and community-acquired pneumonia with tobacco use in HIV disease. Int J Infect Dis. Jul 2005;9(4):208-17)Back to Table of ContentsDefinition of TermsPJP - Pneumocystis jiroveci pneumoniaBack to Table of ContentsSearch Terms Pentamidine, Antiprotozoal, Pneumocystis jiroveci pneumonia (PJP), Nebuliser, Aerosolised Back to Table of ContentsDisclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.Date AmendedSection AmendedApproved ByEg: 17 August 2014Section 1ED/CHHSPC Chair ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download