Aim To present a case of an extremely premature infant and the role that the specialist neonatal pharmacist has on the quality of care of these patients.
Method Interventions and recommendations made by the pharmacists over the admission of a triplet born at 23 weeks and 5 days gestation were recorded. The type of interventions were categorised and classified for risk using a consequence/probability matrix.1
Results The patient required admission to the intensive care unit and subsequently the special care unit for a period of 163 days before discharge home. Over the period of admission the patient had a history of a large patent ductus arteriosus, pulmonary hypertension, bilateral grade two intraventricular haemorrhages, neonatal jaundice, hyponatraemia, hyperglycaemia, anaemia of prematurity, retinopathy of prematurity and chronic neonatal lung disease. A pleural effusion developed at day 10 requiring high frequency ventilation. At the age of 3 weeks a pseudomonas sepsis developed together with feed intolerance and abdominal distention. Milk curd syndrome was diagnosed requiring the removal of 30 cm of bowel and placement of a temporary stoma. Long term Parenteral Nutrition was prescribed
Sixteen interventions were recorded – low risk (3), moderate risk (9) and high risk (4).
Clinical advice was provided regarding appropriate dose, therapeutic drug monitoring and administration of antibiotics including gentamicin, meropenem and flucloxacillin to enhance safety and improve efficacy. Owing to the complexity of the medication regimen at times, drug compatibility queries were common. Close liaison with the neonatal consultant, dietician and gastroenterologists was undertaken during long term Parenteral Nutrition and included discussions relating to, administration of additional electrolytes, trace elements and liver function tests. Advice was sought on the dose and administration of loperamide for short gut syndrome and control of diarrhoea. Pharmaceutical advice was provided to ensure medications were optimised for issues associated with drug administration via transpyloric tube to avoid blockage. Calculation of total daily phosphate was undertaken whilst the patient was receiving fortified feeds, to ensure adequate supplementation, to assist normal bone development. Prior to discharge palivizumab prophylaxis was recommended for respiratory syncytial virus Infection. The pharmacist provided advice on administration to the nursing staff and ensured required documentation was completed.
Conclusion The care of the extremely premature neonate involves numerous medication related challenges. This case not only demonstrates the specialist knowledge, skills and attitudes required by a pharmacist working in this complex field but the impact that can be achieved working closely with the neonatal team.