Nursing Care
Patient preparation for treatment:
Choice of medicines: Signs of severe illness and underlying diagnosis should be checked. Patients with edematous malnutrition, HIV co-infection, impaired renal status, liver dysfunction and cardiac illnesses are better treated with safe medicine such as AmBisome than antimonials.
Patient education: at the time of diagnosis and during treatment, it is important to provide health education for patients regarding visceral leishmaniasis, mechanism of transmission, means of prevention and the treatment. Attendants should also be provided with health education to help increase the general awareness about the disease in the community. Patients need to be informed about the treatment duration and potential adverse events.
Drug doses and preparations:
Antimonials: 20mg/kg/dose (minimum 200mg, there is no limit to maximum dose).
- Sodium Stibogluconate has 100mg/ml preparation. For a 40kg person, the dose will be 40kgX20mg/Kg=800mg. This calculated dose will be divided to 100mg/ml to get the volume of drug to be given for the patient i.e. 8ml.
- Glucantime preparation is 85mg/ml. Thus, the calculated dose (800mg) should be divided to 81mg/ml i.e. 9.9ml.
Liposomal amphotericin B (AmBisome®): preparations are 50mg powder. This has to be reconstituted with 12ml of distilled water to give 4mg/ml concentration. There are different kinds of regimens with AmBisome. Commonly used dosing is 3-5mg/kg/dose and 6 to 8 doses. To prepare with 5mg/kg for a 40kg patient, the dose required is 200mg. To convert this to ml, 200mg/4mg/ml=50ml. As each via is 12ml, it means 4 vials and 2ml from the fifth vial is needed to make the total dose of 200mg.
Paromomycin (Aminosidine): Preparation is 500mg/ml vial injection. The dose is 15mg/kg/day salt (sulphate form) (equivalent to 11mg/kg base). For a 40kg person, 40kgX15mg/Kg= 600mg i.e. 1.2ml per dose.
Miltefosine: 50mg tables are the available formulations. The dose is 2-3mg/kg per day; and 100mg for those weighing above 25Kg. It is recommended to be given twice per day with fatty meals. It is good to provide food like milk during the ingestion of the tablet to increase the absorption. Allometric dosing is recommended for children (weight <25Kg) as pharmacokinetic studies have shown 50mg per day dose to be low for children. Allometric dosing takes into account the metabolic rate of the drug as well as the excretion. This is not directly proportional to the weight in the children and needs specific calculations taking into account the metabolic rate.
Nursing follow up during treatment
Patients should be given their daily medicines and watched for possible complications. It is good to enquire the patient’s symptoms and observe during drug administration. Warning symptoms for possible drug related adverse events are:
SSG – abdominal pain, nausea, vomiting may show pancreatitis. Decrease in urine output is a sign of renal failure. Cardiotoxicity may lead to sudden cardiac arrest. ECG may show QT prolongation and should be done in patients suspected of cardiac problems and electrolyte abnormalities.
AmBisome – Back pain, chills and rigors during drug administration. Severe fatigue and muscular pain may be a sign for hypokalemia.
Paromomycin – decreased hearing
Miltefosine – nausea and vomiting
Taking vital signs (temperature, blood pressure, pulse rate and respiratory rate) should be frequently monitored