Gems of CDR & TPN

[This post is contributed by Lai Peng]

CDR
1. If patient is on FOLFOX regimen (IV Oxaliplatin 85mg/m2, IV Folinic acid 200 mg/m2, IV bolus 5FU 400 mg/m2, IVI 5FU 600 mg/m2 )
• Then we have to dilute Folinic acid into Dextrose 5% instead of NS 0.9%. This is because Oxaliplatin is diluted with D 5%, so Folinic acid & Oxaliplatin can run concurrently (according to Malaysia oncology guidelines)
• IV infusion of 5FU is a 22-hour infusion


2. 5 FU is a low emetic agent, so can give IV Metoclopramide TDS, no need to give IV Granisetron

3. Cisplatin never give in bolus form, it is always given as infusion
• Premedication must be given with cisplatin : Granisetron, MgSO4, Dexamethasone
• MgSO4 is given because pt might get hypoMg2+
• If pt is on intermediate or high dose of cisplatin, then need to supply 2 MgSO4
• Hydration protocol always give to pt undergo cisplatin tx i.e. give NS0.9% before & after cisplatin infusion
• Low dose: 20-39 mg/m2
• Intermediate dose: 40-80 mg/m2
• High dose : 80-120 mg/m2


TPN
1. For paed case, lipid cannot be added into the TPN bag because the TPN bag for paeds is very small as the volume should be small & lipid is unstable.

2. Infusion time of lipid in paeds pt is 16 or 20 hours with a break of 4-8hours.
• the break time is for liver to clear things up as it will metabolise the lipid & liver in neonates is not fully developed
• lipid & bilirubin can compete for the binding with albumin. Thus, break is needed during infusion, if not neonates will get jaundice(high % in neonates)

3. When compounding TPN bags, lipid is the last to be added.
• It is white colour, thus cannot see if there is any particle inside the bags
• Lipid has negative charge, thus it may interact with electrolytes & dextrose and thus unstable
• Light & Dextrose 50% can cause creaming so unstable

4. Amino acids that are available in TPN are Vamin, Glamin, Aminoplasmal & Vaminolact
• Vamin & glamin are used for pt > 11 yrs old
• Aminoplasmal for pt > 2 yrs old
• Vaminolact for neonates
• Glamin contains Glutamine (non-essential AA in body), it helps in immune system & protects gut lining. It will become conditionally essential for patient who is in severe stress, e.g. trauma, pt with muscle wasting & pt in ICU.

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More information on...
Vamin at http://www.rxmed.com/b.main/b2.pharmaceutical/b2.1.monographs/CPS-%20Monographs/CPS-%20(General%20Monographs-%20V)/VAMIN.html

Glamin at http://www.health.gov.il/units//pharmacy/trufot/alonim/4042.pdf

Aminoplasmal at http://www.nutrition-partner.com/doc/doc_request.cfm?43CCF8C132FF4B70BD798A38A78D1D33

Vaminolact at http://www.health.gov.il/units//pharmacy/trufot/alonim/4351.pdf