Pediatrics Week 2 and 3

Standard

Tasks performed:

Vancomycin Calculations
Gentamicin Calculations
Antibiotic teaching to medical students with my preceptor
Witnessed lumbar puncture on the pediatric ward
Counselled patient and family on blood pressure medications (patient had a pacemaker)
Attended daily patient care rounds

Journal Club JCPediatrics Rotation Vicks Vaporub vs. petrolatum vs. no treatment
Rx Files Summary: http://www.rxfiles.ca/rxfiles/uploads/documents/OTC-Vapor-Rub-Trial-Summary.pdf

Drug Information Questions:

Why do infants not acquire C. difficile infection even though most of them are colonized with it?

Clinical infection is rarely reported in infants as their gut is not sensitive to the effect of toxin A and B (toxins bind to receptors on the luminal-facing plasma membrane of colonocytes). After 1-2 years, the C difficile carrier state disappears and the child acquires barrier flora. Other proposed mechanisms:
1. Relatively low numbers for the pathogen in the infant gut
2. Preferential colonization of the infant by nontoxigenic or less pathogenic C difficile strains
3. Absence of toxin receptors or downstream signaling pathways in the immature gut mucosa, and protective factors in breast milk and neonatal gut flora.

Source: http://journals.lww.com/jpgn/Fulltext/2010/07000/Asymptomatic_Colonization_by_Clostridium_difficile.2.aspx

Topics discussed:

1. Neonatal sepsis (risk factors, treatment)
Risk factors for early onset neonatal sepsis:
Over 18 hour rupture of membranes
Pyrexia >38 C
Premature labour @ <36 weeks
GBS bacteriuria at anytime during pregnancy
Previous child with invasive GBS disease
Chorioamnionitis

2. Meningitis (risk factors, common pathogens, treatment, chemoprophylaxis)
3. Attended asthma device teaching conducted by my preceptor to Family Practice Residents
Pearls:
Inform parents that untreated asthma results in shorter height vs. in patients who use steroids for asthma control
If the child is crying, it is better as deeper breathing leads to more drug deposition.

4. Vitamin D requirements in children: According to the dietitian all babies birth to 12 months of age need 400 IU of Vitamin D every day. Breastfed babies need vitamin D from supplements but formula-fed babies get it from infant formula: 1000 mL of formula has 400 IU of vitamin D. If the baby drinks both breast milk and formula, he needs 400 IU of vitamin D supplement every day. Breastfed toddlers 12 months and older need 600 IU of vitamin D every day.
5. Dehydration

Midpoint evaluation, strong points:
– Responsiveness to feedback (willingness to "try new things")
– Eager to learn and once taught, can apply the knowledge
– Ability to self-reflect, set goals for herself and strive to make herself better in terms of clinical pharmacotherapeutics

Most of the pediatric patients reach steady state around third dose unless in renal failure
Hallmarks of bronchiolitis: Wheeze + crackles
Vomiting can lead to metabolic alkalosis
Normal weight gain in neonates: 20-30 g/day

Dehydration signs/symptoms:
CNS: Lethargy or coma (with severe dehydration)
HEENT:sunken fontanelle, little or no tears, sunken eyes, dry or sticky mouth
CVS: low BP, rapid heart rate, decrease in blood pressure from sitting down to standing up
RR: Tachypnea
GI/GU/Renal: low urine output, harder stools, increase in BUN and SCr, ketones in urine
MSK/Skin/Extremities: poor skin turgor, delayed capillary refill
Fluids/Lytes/Heme: increase in sodium
Goals for my last week:

1. To speak more loudly and confidently during rounds
2. Be more proactive in my approach while working up the patient. Questions to think about: What can happen? What are the options if the patient does not improve on the current regimen? What if the IV line comes out?
3. As pharmacists we are drug experts, use your knowledge of pharmacokinetics and pharmacodynamics to make the best possible decision for the patient.
4. Try my best to engage the patients and interact with them as if they weren't sick. I love kids and I felt the first two weeks, it didn't show while interacting with me. I just need to be normal self and talk to them like I do with other kids.
5. The more patients I see, the more practice I do the better it would be for me in the future.
6. No to rely on others to help me come up with the FINAL solution/recommendation. I need to improve on not "second guessing herself". The patients I am following are MY patients, therefore I am responsible for any decisions or outcomes.
7. Identifying DRPs and priortizing them

About rajwantminhas

I just finished my pharmacy degree at UBC. I am excited to be part of Lower Mainland Pharmacy Services. My goal is to get exposed to different kinds of disease states, medications and become better at applying my knowledge. Patient interaction is another aspect that I am going to strive to get better at. I am looking forward to this intense year and learning tonnes!

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