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By: Sarah A. Nisly, PharmD, BCPS

  • Associate Professor, Department of Pharmacy Practice, Butler University, College of Pharmacy and Health Sciences
  • Clinical Specialist—Internal Medicine, Indiana University Health Methodist Hospital, Indianapolis, Indiana

Apt test: to treatment chlamydia purchase keppra with visa differentiate maternal from fetal blood if swallowed maternal blood is suspected medicines360 keppra 250 mg mastercard. The test is performed as follows: Mix equal parts of the bloody material with water and centrifuge it 97110 treatment code effective 500 mg keppra. If the fluid remains pink symptoms migraine buy cheapest keppra and keppra, the blood is fetal in origin because hemoglobin F stays pink. Hemoglobin A from maternal blood is hydrolyzed and changes color from pink to yellow-brown. Coagulation studies should be performed to rule out disseminated intravascular coagulation or a bleeding disorder. The usual studies are partial thromboplastin time, prothrombin time, fibrinogen level, and platelet count. This test is done to establish an inflammatory response and to check for thrombocytopenia and anemia. Look for an abnormal gas pattern, a thickened bowel wall, pneumatosis intestinalis, or perforation. If a suspicious area appears on the abdominal x-ray film in the right upper quadrant, it is usually not stool. Because of the abnormal interface between free air and the peritoneum, the shape resembles a football. The initial plan is to address the loss of volume and give aggressive volume replacement if hypotension is present. In most cases of bloody stool involving nasogastric tubes, trauma is mild and requires only observation. If the tube is too large, replacing it with a smaller one may resolve the problem. If there has been significant bleeding, gastric lavages are helpful; it is controversial whether tepid water or normal saline is best. This diagnosis is difficult to document, so it is usually made if the patient has remission of symptoms when the formula is eliminated. Treatment usually consists of ranitidine or cimetidine (for dosages and other pharmacologic information, see Chapter 80). Use of antacids in neonates is controversial; some clinicians believe that concretions may result from the use of antacids. Is the mother too sick or uncomfortable to be able to adequately participate in the discussion? In this situation, other family members are essential to participate in the discussion. Although a neonatologist can be called on to counsel expectant parents in a variety of circumstances, the following are common problems that are discussed with parents before delivery. Obtain the following information: age of both parents, obstetric history, history of the current pregnancy, medication history, pertinent laboratory and sonographic data, family history, social background and supports, and communication ability. Review current fetal information with the obstetrician: abnormalities of fetal heart rate and fetal tracing, biophysical profile, fetal scalp pH (if done), and any other pertinent tests. Parent counseling before delivery is often performed under less than ideal circumstances. Every effort should be made to communicate effectively, explaining all medical terms and avoiding abbreviations and percentages as much as possible. Most important, repetition may be necessary in order for parents to comprehend all this information, and an opportunity to review the information should be provided. Specific and detailed survival and outcome statistics are beyond the scope of this book but are contained in neonatal and obstetric textbooks. The more immature the infant, the greater are the risks of death and all the complications of prematurity, health sequelae, and neurodevelopmental disabilities. Current data, drawn from many published outcome studies, are presented in Table 32-1, although quoting percentages to parents should be avoided. This is the most important question because morbidity and mortality are so closely tied to maturity. Both gestational age and birth weight have been used as proxies for maturity in predicting survival and outcome. However, only gestational age is available when counseling parents in labor and delivery. The very reason for preterm delivery affects infant outcome and the likelihood of delaying delivery (eg, delay is contraindicated with suspected chorioamnionitis). Survival at the lower limit of viability requires intubation and mechanical ventilation, but these efforts may merely prolong death. All the complications of prematurity are most common in infants born at the lower limit of viability, and their frequency decreases with increasing gestational age. Complications of prematurity include respiratory distress syndrome, metabolic problems, infection, necrotizing enterocolitis, patent ductus arteriosus, intraventricular hemorrhage, and apnea and bradycardia. Chronic complications include chronic lung disease, periventricular leukomalacia or intraparenchymal cysts, hydrocephalus, poor nutrition, retinopathy of prematurity, and hearing impairment. Although the risk of disability is higher in preterm children than in the general population, the majority of preterm children do not develop a major disability (see Table 32-1), such as cerebral palsy or mental retardation. The frequency of neurodevelopmental disability is highest at the lower limit of viability. Learning disability, attention deficit disorder, minor neuromotor dysfunction, and behavior problems are also more frequent in school-age preterm children than in full-term controls. The normal fetus initially compensates for fetal deprivation of supply, but when these compensatory mechanisms are overwhelmed, progressive damage to fetal organs occurs, leading to fetal death in utero if there is no intervention. Fetal alcohol and fetal hydantoin syndromes are well defined and carry an increased risk of mental retardation but are often difficult to diagnose in the neonatal period. Infants exposed in utero to opiates or cocaine may demonstrate neonatal withdrawal syndrome. These infants will have to be closely observed and may require medications to help them through the withdrawal period. Infants with central nervous system infarctions resulting from cocaine exposure are at risk for cerebral palsy, especially hemiplegia. There are many different signs of fetal distress, including changes in fetal heart rate patterns, fetal reactivity, meconium staining of amniotic fluid, and decreased fetal movements as well as composite fetal measures (eg, biophysical profile). The type, severity, and duration of insult are important for prognosis, but these cannot be accurately determined. Infants with chronic intrauterine hypoxia are at increased risk for persistent pulmonary hypertension and neurodevelopmental disability (whether or not they require extracorporeal membrane oxygenation; see Table 32-1). Infants with severe hypoxic-ischemic encephalopathy who develop a disability tend to have severe multiple disabilities. Nevertheless, the majority of infants who demonstrate signs of fetal distress or acute perinatal depression do not develop hypoxic-ischemic encephalopathy, persistent pulmonary hypertension of the newborn, or neurodevelopmental disability. Robertson C, Finer N: Term infants with hypoxic-ischemic encephalopathy: outcome at 3-5 years. Sommerfelt K: Long-term outcome for non-handicapped low birth weight infants: is the fog clearing? Cyanosis becomes visible when there is more than 3g of desaturated hemoglobin per deciliter. Therefore, the degree of cyanosis will depend on oxygen saturation and hemoglobin concentration. Cyanosis will be visible with much less degree of hypoxemia in the polycythemic compared with the anemic infant. If the infant has increased respiratory effort with increased rate, retractions, and nasal flaring, respiratory disease should be high on the list of differential diagnoses. Cyanotic heart disease usually presents without respiratory symptoms but can have effortless tachypnea (rapid respiratory rate without retractions). Transposition of the great vessels can present without a murmur (approximately 60%). Is the cyanosis continuous, intermittent, sudden in onset, or occurring only with feeding or crying? Intermittent cyanosis is more common with neurologic disorders, because these infants may have apneic spells alternating with periods of normal breathing. Continuous cyanosis is usually associated with intrinsic lung disease or heart disease. Cyanosis with feeding may occur with esophageal atresia and severe esophageal reflux.

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Gram stain: Most bacteria body may spread further through the phagocytic cells treatment of tuberculosis discount 500 mg keppra with visa, blood ii symptoms 9f diabetes buy 250mg keppra overnight delivery. Generally treatment zoster ophthalmicus purchase genuine keppra line, the Factors Relating to medications mitral valve prolapse order keppra on line amex Host organism is looked for at the advancing edge of the lesion in the section rather than in the necrotic centre (Fig. They survive and the alimentary tract and gastric acidity prevent bacterial damage the host in a variety of ways such as by generation colonisation. Natural passages of the hollow organs capsule that resists attachment to macrophages. Obstruction in any of these passages promotes bacterial diseases and their etiologic agents. Direct identification of the organism in Some of the common diseases produced by pathogenic tissues is possible by fluorescence antisera methods. Each group of Plague has been a great killer since 14th century and is microorganisms discussed here is accompanied by a Table known to have wiped out populations of cities. These lists of diseases the modern Europe is plague free, possibly due to are in no way complete but include only important and widespread use of arsenic as rat poison. No attempts will be made to give details over, Vietnam and Tanzania have most cases of plague. Instead, salient clinico Western part of India in 1994 alarmed the world once again pathologic aspects of these diseases are highlighted. Plague is a zoonotic disease and spreads by rodents, Methods of Identification primarily by rats, both wild and domestic; others being the organisms causing infections and parasitic diseases may squirrels and rabbits. Humans are incidental hosts other than be identified by routine H & E stained sections in many rodents. However, confirmation in most cases requires Infection to humans occurs by rat-flea or by inhalation. In draining lymph nodes where, rather than being phago addition, culture of lesional tissue should be carried out for cytosed by phagocytic cells, they proliferate rapidly giving 176 Figure 7. Lobar pneumonia (Chapter 17) Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, Klebsiella pneumoniae 13. Bacterial endocarditis (Chapter 16) Staphylococcus aureus, Streptococcus viridans 16. If Masses of proliferating bacilli in sinusoids of lymph untreated, death occurs from disseminated intravascular nodes. This is a form of progressive, Microscopically, the features are as under: fulminant bacterial infection associated with profound Effaced architecture of lymph nodes due to necrosis septicaemia in the absence of apparent regional in and around the affected nodes. The disease is of primary extensive necrotising pneumonia and widely prevalent in cattle and sheep but human infection is haemorrhagic mediastinitis which is invariably fatal. Intestinal anthrax is rare in human beings and is quite been gained owing to fear of use of these bacteria for military similar to that seen in cattle. Septicaemia and death often purpose by rogue countries or for bio-terrorism? (other results in this type too. The lesions consist of mucosal microbial diseases in this list include: botulism, pneumonic oedema, small necrotic ulcers, massive fluid loss and plague, smallpox). In India, i) Smear examination: Gram stained smear shows rod-shaped, anthrax in animals is endemic in South due to large spore-forming, gram-positive bacilli. The causative organism, Bacillus ii) Culture: Anthrax bacteria grow on sheep blood agar as anthracis, is a gram-positive, aerobic bacillus, 4. The disease occurs as an equipment must be decontaminated with 5% hypochlorite exogenous infection by contact with soil or animal products or 5% phenol. The the mechanism of infection includes spread of bacilli organisms proliferate here and stimulate the bronchial from the portal of entry to the regional lymph nodes through epithelium to produce abundant tenacious mucus. There is delayed 7-10 days after exposure, catarrhal stage begins which is the accumulation of polymorphs and macrophages. There is low grade fever, rhinorrhoea, Macrophages also play a role in expression of bacterial conjunctivitis and excess tear production. The characteristic lesions pertussis produces a heat-labile toxin, a heat-stable endotoxin, of anthrax are haemorrhage, oedema and necrosis at the and a lymphocytosis-producing factor called histamine portal of entry. Cutaneous anthrax is the most common and occurs in two forms: one type is characterised by necrotic lesion due Microscopically, the lesions in the respiratory tract consist to vascular thrombosis, haemorrhage and acellular of necrotic bronchial epithelium covered by thick necrosis, while the other form begins as a pimple at the mucopurulent exudate. The peripheral blood shows more often in the region of hands and the head and neck. Regional Granuloma inguinale is a sexually-transmitted disease lymph nodes are invariably involved along with profound affecting the genitalia and inguinal and perianal regions septicaemia. Impetigo is yet another staphylococcal skin infection 179 common in school children in which there are multiple pustular lesions on face forming honey-yellow crusts. Breast abscess may occur following delivery when staphylococci are transmitted from infant having neonatal sepsis or due to stasis of milk. Small children under 2 years of age get staphylococcal infections of the respiratory tract commonly. These include pharyngitis, bronchopneumonia, staphylococcal pneumonia and its complications. The incubation history of trauma or infection may develop acute period varies from 2 to 4 weeks. Acute and subacute bacterial a few weeks, it develops into a raised, soft, painless, reddish endocarditis are complications of infection with Staph. Surgical procedures on central and inguinal folds, or in the perianal and anal area respecti nervous system may lead to staphylococcal meningitis vely. The dermis and subcutaneous tissues are infiltrated by numerous histiocytes containing many bacteria called Donovan bodies, and lymphocytes, plasma cells and neutrophils. Staphylococcal infections are among the commonest antibiotic-resistant hospital-acquired infection in surgical wounds. The infection begins from lodgement of cocci in the hair root due to poor hygiene and results in obstruction of sweat or sebaceous gland duct. Further spread of infection horizontally under the skin and subcutaneous tissue causes carbuncle or cellulitis. Styes are staphylococcal infection of the sebaceous glands of Zeis, the glands of Moll and eyelash Figure 7. Group D or Streptococcus faecalis, also called enterococci are important in causation of urinary tract infection, bacterial endocarditis, septicaemia etc. Pneumococci or Streptococcus pneumoniae are etiologic agents for bacterial pneumonias, meningitis and septicaemia. These organisms may undergo vegetative division under anaerobic conditions, and sporulation under aerobic conditions. On degeneration of these microorganisms, the plasmids are liberated which produce many toxins responsible for the following clostridial diseases depending upon the species (Fig. Toxic shock syndrome is a serious healthy skeletal muscle due to elaboration of myotoxins by complication of staphylococcal infection characterised by some species of clostridia. Generally, traumatic wounds and some brands which when kept inside the vagina cause surgical procedures are followed by contamination with absorption of staphylococcal toxins from the vagina. The prevention of gas gangrene lies in Streptococci are also gram-positive cocci but unlike debridement of damaged tissue in which the clostridia thrive. The been identified and implicated in different streptococcal spores of the microorganism present in the soil enter the body diseases (Fig. The degenerated microorganisms tract infection and cutaneous infections (erysipelas). In liberate the tetanus neurotoxin which causes neuronal addition, beta haemolytic streptococci are involved in stimulation and spasm of muscles. The incubation period of autoimmune reactions in the form of rheumatic heart disease the disease is 1-3 weeks. Group B or Streptococcus agalactiae produces infections in backward arching or opisthotonos. Death occurs due to the newborn and is involved in non-suppurative post spasm of respiratory and laryngeal muscles. Necrotising entero 181 colitis or pig bel? is caused by beta-enterotoxin produced by C.

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Samples of seminal fluid obtained by masturbation are best collected at the laboratory symptoms viral meningitis keppra 500 mg lowest price. Samples obtained by coitus interruptus are collected in clean medicine names buy keppra 250 mg line, dry test Figure 11 treatment algorithm buy on line keppra. The container is capped or covered treatment modalities order discount keppra online, labelled and transported to All material for cytological examination must be properly the laboratory where smears are prepared. All aspirated bronchial employed: secretions, lavage, washings and brushings must be Material for exfoliative cytodiagnosis is usually wet-fixed despatched to the laboratory without delay. These smears are then stained with Papanicolaou fixative (50% ethanol in volumes equal to that of the sample). The mouth is rinsed with water or Sometimes, exfoliative cytology smears are air-dried for normal saline and the buccal mucosa scraped vigorously with use with the Romanowsky stains as are used in haematologic a wooden or metal tongue depressor. In Romanowsky staining, fixation is effected during directly onto labelled glass slides which are placed in fixative. However, the flammability of ether specimen is collected during fibreoptic endoscopy of the part makes it hazardous. Where ethanol is not available, 100% methanol, 95% denatured alcohol, or 85% isopropyl alcohol 8. Smears prepared at the bedside as well as those prepared After initial morning voiding (which is discarded), in the laboratory from fluid samples are immediately placed samples of about 50 to 100 ml are collected on three in 95% ethanol without allowing them to dry prior to fixation. Hydration by forced intake of fluids (1 glass Drying causes distortion of cells and induces cytoplasmic of water every 30 minutes over 3 hour period) is recom staining artefacts. Fixation time of 10 to 15 minutes at room mended by some workers for production of high volume temperature is adequate. If delay is anticipated in despatch to the fixative for 24 hours or more without any detrimental effect laboratory, the sample should be collected in an equal volume as regards cytomorphological detail. For the same reason, aerosol-sprays or with a dropper to the surface of freshly prepared smears. The 277 cytospray) are available, a standard hairspray with a high retained fluid is then processed. Smears while excessive amounts of blood, erythrocytes may be lysed by still wet, are placed face-up on a table and sprayed with the the addition of 1 ml of glacial acetic acid for every 50 ml of nozzle held at a distance of 10 to 12 inches. The sample is poured into 50 ml centrifuge are to be transported over long distances. With a rotating radius of 25 cm the required employed for some staining procedures. Samples of smears prepared from the sediment or cell button by fluids are best submitted to the laboratory in a fresh state for recovering the material with a glass pipette or a platinum immediate processing. Smear preparation from samples collected in a despatch to the laboratory or in processing, the sample is preservative require albuminised slides as cell adhesiveness collected in a suitable preservative for prefixation? so that is reduced by prefixation. The interested reader is referred to specialised texts for descriptions of these methods. Staining of Smears cerebrospinal fluid) deteriorate in 1 to 2 hours even if refrigerated. Three cent ethanol precipitates proteins and hardens the sediment solutions are used comprising a nuclear stain and two making smear preparation difficult; it is used only for gastric cytoplasmic counter-stains. Solutions containing ether and acetone are not the orange and cyanophilic tints to cytoplasm respectively. Processing of Samples in the Laboratory nuclear stain, and eosin is the cytoplasmic counterstain. Romanowsky stains used in and wet-fixed in ethanol need no further processing in the haematological preparations may also be used for cytological laboratory prior to staining. The sample is prepared as under: i) the sample is placed in a petridish and inspected against a dark background. This branch includes fine needle of ropy mucus are also selected (exfoliated cells adhere to aspiration cytology, imprint cytology, crush smear cytology mucus strands). Large volumes of fluid received gained wide acceptance in the last four decades and is are allowed to stand in the refrigerator for half to one hour. The standard 21 gauge disposable sampled are: breast masses, enlarged lymph nodes, enlarged needle of 38 mm length is suitable for routine transcutaneous thyroid and superficial soft tissue masses. Poorly-prepared smears with distorted cellular morphology will frustrate the best efforts of the most competent cytopathologist, and often result in errors of interpretation or in failure to arrive at any specific diagnosis. Plunger is retracted after needle enters the i) Aspirates deposited on the slide are inspected with the mass (B). Even and ii) the target area is thoroughly palpated and the firmest gentle pressure is required to avoid traumatising cells. Droplets of fluid or bloody material are gathered under the iii) the skin is cleaned with an alcohol pad. Particulate material, which collects along or by an assistant; gloves may be used for protection of the the edges and at the end of the smear, is then crush-smeared operator and the assistant. Half the the lesion, the plunger of the syringe is retracted and at least number of smears are immediately immersed in 95% ethanol, 10 ml of suction applied while moving the needle back and transported to the laboratory in the fixative, and used for forth within the lesion; the direction or angle of the needle Papanicolaou or H&E staining. Most cytopathologists use both diagnostic purposes, cellular material contained within the wet-fixed and air-dried smears?the wet-fixed smears needle is more than adequate; material drawn into the barrel provide excellent nuclear detail while the air-dried smears of the syringe is not recovered since it is of no use for cytologic yields information about the cytoplasm and the background. The general properties of wet-fixed and air-dried smears vii) On completion of aspiration, suction is released and outlined in Table 11. Withdrawing the needle with Special and Ancillary Studies negative pressure or suction results in blood being aspirated and cellular material being sucked into the barrel of the Aspirates may also be studied by special stains and tech syringe, thus lost to interpretation. Semisolid aspirates are crush-smeared by flat pressure with cover slip or glass slide (A). Fluid or blood droplet is collected along edge of spreader (B), and pulled as for peripheral blood films (C). Wet-fixed smears are used for a require greater expertise and additional material as variety of special stains such as Alcian blue, mucicarmine outlined below. Aspirates may also be and collected in test tube for centrifugation and smear submitted for viral, fungal, mycobacterial and bacterial preparation. When infection is suspected, an additional aspirate fluid, a fresh syringe is used for additional aspiration of the is obtained and expressed into a sterile culture tube. Lesions of the thyroid are aspirated with the sterile isotonic saline or foetal calf serum and the rinsed fluid patient either sitting up or lying supine with the neck submitted for microbial culture. Aspirated material may be processed as fingers, while a diffusely enlarged lobe is fixed by asking surgical pathology material by preparing paraffin blocks the patient to swallow and applying two fingers to the base from cell button of the centrifuged deposit. The patient is asked recognition of histologic patterns and can also be used for to avoid swallowing during aspiration. Since these long techniques when applied to cytological smears bring needles are flexible they are rotated during insertion to enable quantitation and objectivity to cytodiagnosis. Determination of ploidy status and A custom-made or commercially available needle guide (such S phase fraction of tumour cells using flow cytometry as the Franzen needle guide) may be used. Alternatively, a enhances the diagnostic and prognostic information available 16 gauge blunt-tipped venous cannula may serve as a needle on routine cytology. Transrectal aspiration in acute prostatitis may cause bacteraemia/septicaemia and is contraindicated. Firm inadvisable as it may sometimes provoke extreme fluctua finger pressure for 2 to 3 minutes immediately after the tions in blood pressure. Transcutaneous aspiration of the lung cells, nuclear and cytoplasmic features of individual cells or causes pneumothorax in about 20% of cases; most resolve groups of cells, and comment on the background spontaneously although intercostal intubation may be morphology. Transient haemoptysis may also Understandably, it is beyond the scope of this book to be associated with lung aspiration. Local dissemination by seeding of applications in lymph node (tuberculous lymphadenitis, malignant cells along the needle tract is a rare complication Fig. Knowledge which surgical biopsy specimens are despatched to the of the exact site from where the aspirate has been obtained laboratory. It is imperative for the student in pathology as well as the Imprints may also be obtained from draining sinuses or clinician to be familiar with the advantages and limitations ulcerated areas. Smears cannot be diagnostic procedures are now avoided by rational use of prepared from fixed specimens. The technique is or advise the use of core biopsy or open biopsy, wherever used in the intraoperative diagnosis of malignancy as a appropriate. However, with wide acceptance of the (leucocytes) and the platelets (thrombocytes). Their concentration is normally marrow, followed by discussion on erythroid series of maintained within well-defined limits unless the balance is disorders.

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A blood sample is obtained from the fetal presenting part (usually the scalp but sometimes the buttocks) symptoms lyme disease order keppra on line amex, and the fetal blood pH is determined symptoms lead poisoning discount keppra 500mg mastercard. Complications of this test are scalp infections (in <1% of infants) and soft tissue damage to medications related to the female reproductive system order 250mg keppra the scalp treatment eczema purchase keppra american express. An acceleration in fetal heart rate in response to either manual stimulation of the fetal presenting part or vibroacoustic stimulation through the maternal abdomen has been associated with a fetal pH of >7. These tests are often used in labor to determine fetal well-being in lieu of a scalp blood sampling; however, a lack of fetal response to stimulation is not predictive of acidemia. This promising new technique is designed as an adjunct to nonreassuring fetal heart rate tracings in order to reduce the number of unnecessary interventions. A pulse oximetry reading of at least 30% has good correlation with a fetal pH of at least 7. Lecithin, a saturated phosphatidylcholine (the condensation product of a phosphatidic acid and choline), can be measured specifically in amniotic fluid and is a principal active component of surfactant. Sphingomyelin is a phospholipid found predominantly in body tissues other than the lungs. The L-S ratio compares levels of lecithin, which increase in late gestation, with levels of sphingomyelin, which remain constant. Some disorders are associated with delayed lung maturation, and higher than normal L-S ratios may be needed before fetal lung maturity is ensured. The two most common disorders are diabetes mellitus (an L-S ratio of 3: 1 is usually accepted as indicating maturity) and Rh isoimmunization associated with hydrops fetalis. Acceleration of fetal lung maturity is seen in sickle cell disease, maternal narcotic addiction, prolonged rupture of membranes, chronic maternal hypertension, intrauterine growth restriction, and placental infarction. Phosphatidylglycerol appears in amniotic fluid at ~35 weeks, and levels increase at 37-40 weeks. Care in choosing analgesic and anesthetic agents can often prevent respiratory depression in the newborn, especially in high-risk deliveries. Drugs administered to the mother may affect the fetus via placental transfer or, less commonly, may cause a maternal disorder that affects the fetus (eg, maternal drug induced hypotension may cause fetal hypoxia). Most anesthetic and analgesic drugs have a high degree of lipid solubility, a low molecular weight (<500), and variable protein-binding and ionization capabilities. Local anesthetics and narcotics (lipid-soluble, un-ionized) cross the placenta easily, whereas neuromuscular blocking agents (highly ionized) are transferred slowly. Paracervical block may be associated with severe fetal bradycardia caused by uterine vasoconstriction and is now rarely used. Paracervical blocks are used in the first stage of labor and pudendal blocks in the second stage. All intravenously administered opioids are rapidly transferred to the fetus and cause dose-related respiratory depression and alterations in the Apgar and neurobehavioral scores. Meperidine (Demerol) can cause severe neonatal depression (measured by Apgar scoring) if the drug is administered 2-3 h before delivery (Kuhnert, 1979). Depression is manifested as respiratory acidosis, decreased oxygen saturation, decreased minute ventilation, and increased time to sustained respiration. Fetal normeperidine (a meperidine metabolite that may cause significant respiratory depression) increases with longer intervals between drug administration and delivery. Levels are highest 4 h after intravenous administration of the drug to the mother. The half-life of meperidine is 13 h in neonates, whereas that of normeperidine is 62 h (Kuhnert, 1985b). Morphine has a delayed onset of action and may cause greater neonatal respiratory depression than meperidine (Jouppila, 1982). Butorphanol (Stadol) and nalbuphine (Nubain) are agonist-antagonist narcotic agents that cause less respiratory depression than morphine, particularly when used in high doses. Naloxone should never be administered to neonates of women who have received chronic opioid therapy over a long period because it may precipitate acute withdrawal symptoms. Naloxone may be used to reverse respiratory depression caused by acute maternal opioid administration during labor. Barbiturates cross the placenta rapidly and can have pronounced neonatal effects (eg, somnolence, flaccidity, hypoventilation, and failure to feed) lasting for days. This is usually not an issue when barbiturates are used as an induction to general anesthesia for an emergent cesarean delivery. These agents cross the placenta rapidly and equilibrate within minutes after intravenous administration. Diazepam given in low doses (<10 mg) may cause decreased beat-to-beat variability and tone but has little effect on Apgar scores and blood gas levels. Larger doses of diazepam may persist for days and can cause hypotonia, lethargy, decreased feeding, and impaired thermoregulation, with resulting hypothermia. All benzodiazepines share these features; however, diazepam is the most thoroughly studied of the benzodiazepine series. In addition, benzodiazepines are less frequently used because they induce childbirth amnesia in the mother. Anesthetic induction with midazolam is safe for the mother, although low 1-min Apgar scores and transient neonatal hypotonia may be seen (Ravlo, 1989). Phenothiazines are rarely used today, because they may induce hypotension via central alpha blockade. Innovar, a combination drug containing the narcotics fentanyl and droperidol, may be safe because of the relatively short half-life of the agents. Lumbar epidural analgesia is the most frequently used invasive anesthetic technique for childbirth. Maternal pain and catecholamine levels are reduced (catecholamines cause prolonged incoordinate labor and decreased uterine blood flow), which may lead to diminished maternal hyperventilation and improved fetal oxygen delivery. Vasospasm of uterine arteries in pregnancy-induced hypertension may be corrected (Jouppila, 1982; Shnider, 1979). Labor epidural analgesia lasting longer than 4 h is associated with maternal temperature increases of up to 1 C. This may lead to neonatal sepsis evaluation and antibiotic treatment if these treatments are done on the basis of intrapartum maternal temperature (Lieberman, 1997). Local anesthetic (eg, bupivacaine, lidocaine) is usually continuously infused through an epidural catheter placed in the L2-L3 interspace. Maternal hypotension caused by sympathetic blockade is easily treated with fluid administration or intravenous ephedrine. Intrathecal opioids (sufentanil or fentanyl with or without morphine) provide first-stage labor analgesia with minimal motor and sympathetic nerve block. Intrathecal opioids are frequently administered when the fetal head is still high in the pelvis. Transient fetal heart rate changes occur in 10-15% of cases, usually without adverse neonatal outcome (Cohen, 1993), although cesarean delivery has been necessary in some cases (Gambling, 1998). Caudal epidural analgesia blocks the sacral nerve roots and provides excellent pain relief in the second stage of labor. Caudal analgesia is not used during the first stage of labor because the large doses needed to block the T11-T12 nerve roots increase pelvic muscle relaxation and impair fetal head rotation. Because fetal intracranial local anesthetic injection can occur, this technique is now rarely used. All of the regional anesthetic/analgesic techniques (eg, epidural or spinal) and local blocks (eg, pudendal) depend on the use of local anesthetic agents. Placental transfer of lidocaine is significant, but Apgar scores are not affected in healthy neonates (Abboud, 1982). Acidotic fetuses accumulate larger amounts of lidocaine through pH-induced ion trapping. Bupivacaine is theoretically less harmful than lidocaine for the fetus because it has a higher degree of ionization and protein binding than lidocaine. Maternal toxicity leading to convulsions and cardiac arrest has been reported after inadvertent intravascular injection. Bupivacaine, in very low concentrations, is the most commonly used local anesthetic agent for continuous labor analgesia. After systemic absorption, chloroprocaine is rapidly broken down by pseudocholinesterase; thus, very little reaches the placenta or fetus. Neurobehavioral studies indicate no difference between controls and neonates whose mothers were given chloroprocaine. However, because of its short duration and significant motor blockade, chloroprocaine is not useful for continuous labor analgesia. Ropivacaine, a new agent, is similar to bupivacaine but produces less motor block and maternal cardiotoxicity.

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On the other hand medications of the same type are known as order keppra with a visa, too low a slip can cause the film to medicine 1950 discount keppra 250 mg overnight delivery stick to treatment quality assurance unit purchase keppra 250 mg with amex hot surfaces or folding box surfaces and can cause the product not to symptoms vertigo 500mg keppra amex slide down to the bottom of the pack, also affecting pack sealing and presentation. The product should be able to slide back and forward in the pack relatively easily for tight sealing at both ends. This section also serves to introduce and describe the primary packaging plastics. This results in long branched chains, weakly linked to each other by van der Waals forces (but strong overall force due to length). Thus, neighboring chains can slip past each other, allowing the material to bend easily (flexible). However, many plas tics with poor printability can be made printable by corona treatment, in which an ionic discharge is used to sensitize one side of the plastic. This irregularity in structure also results in a lower melting point and a less crystalline (ordered chain) structure. It resists most chemicals below 60?C, and it resists water moderately, but not gases (poor O2 bar rier). It is used for bag manufacture (bread, diapers), for low-temperature storage (due to its low barrier properties), and for packaging rice. This gives rise to an ordered molecular structure, which is called an isotactic polymer. Higher temperatures are required to produce ther moplasticity (melting point, 134?C). Such films have high strength, flexibility, clarity, and especially barrier properties, and are used for bag-in-the-box, pouches, cups and lids, etc. It has high crystallinity (high clarity and gloss), is Types of Packaging Materials Used for Foods 923 hard, heat resistant (higher softening point, 150?C), exhibits good memory, flex crack resistance, punc ture resistance, and stiffness. It is difficult to cut as it lacks stiffness, so is hard to machine by itself and is too expensive for use as a pure monofilm (except for household use). It resists chemicals, has low water, gas, aroma, and flavor permeability (due to chlo rine ions), and high strength. It is used in laminates and is an important shrink film, with excellent cling properties. This makes coextrusion lamination difficult as well, although it can still be easily used in coating from solution. When used in coextrusion, it must be copolymerized first (for example, with vinyl chloride) to give better temperature stability. Since the bonds C?C and C?F are strong, this material is extremely inert and has a high softening point (340?C). It is used in coating cookware (nonstick surfaces) and forming and packaging where easy-to-clean nonstick surfaces are required. It is often used for loose bulk packaging, especially for packing fragile materials. In general, they have reasonable clarity and poor feel and printability, but are strong, versatile, with good heat resistance. This is useful for boil-in-the-bag-type applications, where the plastic must sus tain temperatures of 100?C without deforming or softening. It is used for blow-molded bottles and some films, increasingly for thermoformed trays, for shrink-wraps, and for boil-in-the-bag products. It is only used in 12 and 15 m gauges for film and is com monly used as the outer layer of a laminate structure due to its gloss and temperature stability (melting point, 254?C). There is a growing interest in recycling poly esters due to their initially high cost. The bottle is molded as follows: the closure is first injection molded, producing a little bottle with the screw top already formed, then transferred hot to a blow-mold die. Cellulose is clear, stiff, printable, and glossy, but has poor feel and moisture resistance. Cellulose is still widely used today, due to the addition of coatings that have given cellophane great adaptability. It is able to retain folds (called dead fold), so that if it is twisted, it retains that twist, making it ideal for individual candy wrappings. It is used for cookies, confectionery, and pastries in situations where vapors may need to breathe? to prevent surface molding. Cellulose is sold on the basis of weight per unit area, not thick ness, due to the variation in thickness that occurs with moisture absorption. Cellulose acetate has good clarity, is printable in sheet form, but has poor feel and barrier properties. It is becoming obsolete, although it is still used in laminates and thermoformed blister packs. Other thermoplastics: Other biodegradable biopolymers are being developed but have not yet become competitive. The raw material for the new thermoplastics is usually starch, which is blended with con ventional oil-based polymers. Polyamides are used for boil Code Explanation in-the-bag-type products, frozen foods, fish, meat, veg A Anchored (describes lacquer coating) etables, and processed meat and cheese, always in /A Copolymer coated from dispersion lamination. C Colored Polyvinylidene-coated or metallized nylon is about twice D Coated one side only the price of pure nylon film. As a film, S Heat sealable it must be biaxially oriented to give printing and machin /S Copolymer coated ing stability. T Transparent Polycarbonates: these are formed from condensation U For adhesive tape manufacture of carbonic acid in the presence of aliphatic or aromatic X Copolymer coated on one side dihydroxy compounds. Pliofilm: this is a rubber hydrochloride formed by combining polyisoprene (natural rubber) with hydrochloric acid. It is a printable, good-feel, opaque film with good heat-sealing characteristics and grease resistance. Pliofilm is no longer used much as it is not easy to machine and is not very durable. Ethylene vinyl alcohol: this film has high oxygen-barrier properties, but hydroxyl groups make it hydrophilic, which increases its permeability. Ionomers: Surlyn is the brand name of a range of Du Pont ionomer resins (invented by Rees in 1961). Surlyn is used for shrink-wrapped meat, cheese blocks, fish, individual candy wrapping, pet food bags, potato chips, snack foods, drink Tetra Pak cartons, margarine tubs, cookies, frozen foods, nuts, etc. Depending on how the individual monomers combine, a great variety of properties can result. Lamination is a technique for bonding films together to give a film with the properties of both constituents. Each layer in the resulting laminate may exhibit different prop erties from its free state, such as mutual layer reinforcement in which cracks in a brittle layer are pre vented from propagating by a high elongation (elastic) layer. To be coextruded, the melt flow viscosi ties should be similar (a ratio of within 3: 1), otherwise one of the plastics will flow with respect to the other, preventing bonding. If all these factors are not present, then an adhesive layer is necessary and the plastics may be cold bonded with a tie layer of resin adhesive. Properties of outside layer: high gloss, printable, good lamination, pos sibly metallized, high slip. Properties of middle layer: strength, stiffness, barrier properties, possibly opaque. Properties of inner layer: easy to seal (hot seal, good hot-tack properties, or good cold-seal prop erties), low migration rates, barrier properties. Continuous feed roll with a feeder on-the-fly? splicer, which can cut off the old roll and join on the new (there may be several rolls feeding film into the machine at once)? Lamination stage where the primary and secondary webs are combined (a web refers to the film as it passes through the machinery)? A take-up (rewind) roller to collect the final laminate Note that plastics can be laminated with papers and foils as well as plastics. Laminations with paper will tend to use water-based adhesives, since the solvent (water) will absorb into the paper base away from the adhesion zone, allowing the glue to set quickly. Lamination also allows reverse print ing, where one plastic layer is printed (in mirror image) before lamination to sandwich the printing inside the laminate for greater protection. Adhesive lamination, where a continuous glue source is fed as a flat film between consecutive layers of the laminate.

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