Introduction

This SOP provides clinicians working at the Homeless Health Service with instructional guidance on the use of Intramuscular Pabrinex. It does not replace the need for clinical expertise as part of the management of Alcohol dependency.

Objectives

Pabrinex is a high dose combination of several B vitamins and vitamin C. Intramuscular Pabrinex is used for the prophylaxis of Wernicke’s Encephalopathy (WE), in addition to oral thiamine supplementation. This is an important clinical intervention and intramuscular Pabrinex can be administered in the community/general practice setting.

N.B. Intravenous Pabrinex is used for the treatment of WE, and should not be given in the community for this indication. If WE is suspected, the patient must be transferred immediately to an acute hospital for treatment doses of intravenous Pabrinex.

Procedure

Prescribing Pabrinex

Clinical guidance on prescribing Pabrinex can be accessed here: https://remedy.bnssgccg.nhs.uk/adults/drug-and-alcohol-misuse/alcohol-misuse/

Prescriptions should not be sent to pharmacy or dispensed to patients; doses are administered from HHS stock. Therefore, prescriptions should be printed and signed and then stored in the lockable drugs cupboard to enable Brisdoc to reclaim cost charges as FP34 prescriptions.

Prescribing in outreach setting.

In settings where no printer is available or it is impractical to return fp34s to compass health in a timely way the following procedure should be followed.

Pabrinex should be prescribed but not issued.

An emis task should be sent to the pabrinex team. The duty team team member at compass health can then print the prescription and store as usual and delete the task from emis.

 

Documentation and coding.

Pabrinex injections administered should be coded as ‘Injections’ with free text Pabrinex 1&2 IM and include the expiry date, lot number, manufacturer & site of injection.

 

Storage

Intramuscular Pabrinex should be stored in a refrigerator at 2-8 degrees Celsius. The fridge used must be fitted with a thermometer to ensure the cold chain is not broken and the Pabrinex does not freeze. If the cold chain is broken, the shelf-life is a maximum of one month.

Keep ampule container in carton to protect from sunlight.

Administration

Pabrinex must be administered by a trained healthcare professional.

Pabrinex is presented as a pair of ampoules, a 2ml & 5ml ampoule. Both ampoules must be mixed directly before administration ensuring that that both the Summary of Product Characteristics and ampoule labels refer to the INTRAMUSCULAR injection

 

 

Process

1. Check you have the right patient and that the prescription is correct
2. Check ampoules are in date and labelled for intramuscular use
3. Explain the procedure to the patient and gain consent
   1. This can be a painful injection and the patient should be reassured that this is quite normal
4. Wash hands thoroughly before preparation and after giving injection. Gloves need not be worn for this procedure if the health workers and patients’ skin are intact.
5. Prepare the skin site for the injection (If the patient is physically clean and generally in good health, swabbing the skin is not required).
6. Wipe area with an alcohol wipe for 30 secs, let the area dry for 30 secs.
7. Pabrinex should be drawn up immediately before administration
8. When drawing up the medication from the glass ampoules you should be using a blunt fill needle with 5 micro filters BN 1815F.
9. Draw contents of ampoules 1 and 2 into the same 10 ml syringe to mix, in order to give one 7ml injection.
10. Disperse air bubbles from the syringe.
11. When giving the deep intramuscular injection, it is preferable to use safety needle 21G x 2” (21G x 1 ½” can be used for those patients with less muscle mass).
12. Position patient as per their preference. Usually in prone position, although some patients may prefer to stand and this may be preferable for administration in outreach settings.
13. Select injection site:
    1. This should be high in the gluteal muscle (ventrogluteal site), in the upper outer quadrant of the buttock, 5cm below the iliac crest.
    2. With repeated injections, vary injection sites as much as possible and avoid previous sites by at least 2.5cm.
14. If standing, ask patient to lean their weight into the opposite leg to the injection site.
15. Using Z-track technique, gently pull the skin 2.5-3.75cm, to displace the underlying tissue.
16. Position the needle at 90 degrees to the skin surface and insert.
17. Check for blood by slowly pulling back the plunger. If no blood appears then depress the plunger slowly; this aids absorption of the drug and reduces pain. Wait for 10 seconds to allow the drug to diffuse into the tissue and then quickly withdraw the needle and release skin at the same time.
18. Having already checked for allergies to plasters, apply a small plaster to the injection site as leakage often occurs.
19. Dispose of the used needle in a sharp’s container.
20. Observe the patient for allergic reactions for at 15 minutes following the injection.

 

N.B. Z track technique video can be found here: https://www.youtube.com/watch?v=xEfAF4M8sis

Cautions for use

• Allergic reactions are rare
• Pabrinex should be prescribed with caution in pregnant people.

 

Contraindications

• Intramuscular Pabrinex is contra-indicated if a patient has experienced an allergic reaction from it previously. Initial warning signs of a reaction to intramuscular Pabrinex are sneezing or mild asthma, and those treating patients need to note that the administration of further injections to such patients may give rise to anaphylactic shock. If an allergic reaction is suspected this must be recorded as an allergy in the patients care record. A warning prompt should be added to the generate prescription function on emis.

1. Known allergy to any excipients in the SPC Adverse events Link to SPC for pabrinex Pabrinex Intramuscular High Potency Injection – Summary of Product Characteristics (SmPC) – (emc) (medicines.org.uk)

• If WE is suspected, the patient must be transferred immediately to an acute hospital for treatment doses of intravenous Pabrinex
• If Delirium tremens is suspected, please dial 999 as a medical emergency.
• Adverse events related to Pabrinex should be reported to the MHRA and through BrisDoc internal reporting systems

Outreach settings

Transportation

Where possible Pabrinex should be transported using a medical cool bag or box which follows the manufacturer’s instructions for use to ensure the cold chain between 2-8 degrees Celsius. If the cold chain cannot be ensured, then the Pabrinex must be labelled and used within a month and then discarded.

Adrenaline auto-injectors must be carried to any site where Pabrinex is to be administered. Clinicians must have access to a phone so they can call for help via 999 if anaphylaxis is suspected.

For non-clinical settings, knowledge of public access defibrillators is good practice. A database of registered defibrillators can her accessed here: https://www.nddb.uk/

Monitoring

This SOP will be reviewed subject to any changes in best practice guidance, national evidence or in response to learning. It will also be reviewed in accordance with the date specified.

Version Control

Date	Version	Author	Change Details
6th May 2022	1.0	Rosa Carter	New SOP
18th Sep 2023	1.1	Rosa Carter	New information on Coding. Changes to prescribing process