1. Diabetes Management + Insulin Types
Novorapid, Actrapid, Humulin S and Humalog are fast acting, short duration. Humulin M3 is fast acting, long lasting. Humulin I and Insulatard peak slowly and are long lasting. Insulin Detemir and Insulin Glargine are very long acting. In patients in DKA requiring insulin for infusion - short acting insulin eg. Actrapid should be used.
2. Diabetes Management: Prescribing Insulin Safely
If unsure about the correct type of insulin which a patient normally receives - clarify with the GP. If discharging a patient on Insulin in whom steroids have been stopped - advise the patient to increase the frequeny of blood glucose monitoring (risk of hypoglycaemia increases). If discharging a patient on a new insulin regime they should ideally be seen by the diabetes team as an outpatient in 1-3 days.
3. Information Governance
Next of kin does not have a 'right to know' information about a patient. In a "serious offence" situation the doctor can disclose information about a patient to the police as acting in the "public interest". Inadequate clinical records are cited as a factor in approximately 80% of indefensible medico-legal cases. Ward round notes should include: summary of the case, discussion with the patient, examination findings, relevant investigations, impression/diagnosis and management plan.
4. Palliative Management of Nausea
Chemotherapy induced nausea involves the neurotransmitted 5HT3 - large amounts are released when the gut is irradiated. Ondanstron is a powerful 5HT3 antagonist. Opioids can stimulate the chemoreceptor trigger zone (CTZ) - this is best treated with either haloperidol or metoclopramide. Cyclizine has no effect on the CTZ. Cyclizine acts upon the vomiting centre in the brain. Side effects of ondansetron and cyclizine include constipation. For nausea caused by constipation metoclopramide would be the drug of choice. For nausea induced by hypercalcaemia, this should be treated with haloperidol.
5. Pharmacy: Adverse Drug Reactions (ADR)
These are surprisingly common! And can be fatal! Most commonly they are caused by NSAIDS, diuretics (renal impairment, hypotension and electrolyte disturbance) and anti-coagulants. The main way to report adverse drug reactions is via the "Yellow-Card Scheme". In the BNF new medicines are marked with a small black triangle (these often have a higher rate of ADRs. All health care professionals can report adverse drug reactions using this scheme.
6. Pharmacy: Prescribing in Pregnancy
A teratogen is an agent or factor which can cause congenital malformations. Nearly all drugs cross the placenta. The most susceptible period is 3-8 weeks post-conception. Ideally best practice is to rationalise and alter medication prior to pregnancy through planning (eg. stopping certain anti-epileptic drugs such as sodium valprotae). Sources for doctors if they are concerned about the effects of drugs in pregnancy include: the BNF, Toxbase and EMC (http://emc.medicines.org.uk/emc). Trimethorim, for example, is not recommended in pregnancy. Cyclizine is a widely used anti-emetic in pregnancy for the treatment of nausea.
