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  • 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

Parenteral supplementation of calcium and phosphate may be hampered by precipitation in parenteral nutrition solutions treatment of hyperkalemia cheap solian online mastercard. Factors that tend to treatment strep throat discount solian 100 mg overnight delivery increase the risk of precipitation include elevated pH of the solution symptoms 6 days before period purchase solian 100mg visa, excessively high concentrations of calcium and phosphate chi infra treatment generic 100mg solian free shipping, low concentrations of amino acids, high temperature, prolonged standing times, addition of calcium salts first or before final dilution, and use of the chloride salt as the source of calcium. Because these infants are at greater risk for hypocalcemia, serum calcium levels must be closely monitored. Because alkalotic infants (eg, infants being treated for persistent pulmonary hypertension) can be clinically hypocalcemic with tCa levels >7 mg/dL, maintenance calcium therapy should be started when blood pH levels reach 7. The amount of citrate administered with periodic blood replacement usually does not lead to clinical hypocalcemia. However, the rate of citrate given as a result of exchange transfusion is much higher and may reduce serum iCa. Hypocalcemia secondary to blood transfusion can be treated prophylactically (with calcium gluconate) or if symptoms of hypocalcemia are noted (for dosages and other pharmacologic information, see Chapter 80). Low iCa levels and clinical symptoms of hypocalcemia are rarely encountered, even when extra calcium is not given. This loss can be demonstrated by measurement of calcium creatinine ratios in spot urines or tCa in 24-h urine collections. If hypercalciuria exists, an attempt should be made to substitute a thiazide diuretic (most commonly chlorothiazide) for furosemide or bumetanide. However, if a loop diuretic is thought to be essential, a lower dose of furosemide or bumetanide in combination with a thiazide should be used. Thiazides tend to cause calcium retention and can overcome the hypercalciuric effect of the loop diuretics. These efforts will reduce the risk of nephrocalcinosis, which is directly related to the amount of calcium excreted in the urine. However, this combination can cause significant diuresis and increase urinary potassium loss. Fluids and electrolytes must, therefore, be carefully monitored if combination therapy is chosen. If >5 mEq/kg/ day of potassium supplementation is required after diuretics are started, spironolactone therapy should also be started (for dosage, see Chapter 80). Spironolactone has little or no effect on urinary calcium loss but helps to reduce the severity of hypokalemia in infants receiving either furosemide or thiazide therapy. Hypocalcemia can be effectively controlled with close monitoring of calcium, phosphate, and vitamin D intake and urinary calcium losses. The tCa level is not predictive of iCa levels and thus is not a reliable measure of hypercalcemia. Hypercalcemia may be due to parathyroid-related causes or to mechanisms unrelated to the parathyroid. Congenital secondary hyperparathyroidism resulting from maternal hypoparathyroidism (rare). Subcutaneous fat necrosis (which, if extensive, may lead to hypercalcemia when large amounts of calcium are released from subcutaneous fat). Therefore, clinical symptoms are important in establishing the diagnosis of hypercalcemia. Tubular resorption of phosphate is usually reduced when hyperparathyroidism exists. Bone demineralization is typical of hyperparathyroidism, and osteosclerotic lesions are seen with hypervitaminosis D. Hypercalciuria can be very severe with excessive calcium intake or with normal calcium intake plus inadequate phosphate intake. Treatment depends on the cause, but in general the calcium intake should be reduced and vitamin D supplements withheld. After hypercalcemia has resolved, the actual calcium, phosphate, and vitamin D needs can be estimated based on normal bone mineralization without recurrence of hypercalcemia. If the infant is receiving a thiazide diuretic (which increases calcium retention in the kidneys), the drug should be discontinued. When acute symptomatic hypercalcemia exists, furosemide may be effective in reducing serum calcium because of its marked hypercalciuric effect (for dosage, see Chapter 80). In older children and adults, calcitonin has been used for hypercalcemia associated with immobilization (patients in traction) and for acute hypercalcemic states at a dosage of 5-8 units/kg/ dose intravenously or intramuscularly every 12 h. Very rarely, when severe hyperparathyroidism exists, parathyroidectomy may be needed. The most common manifestation of hypomagnesemia is hypocalcemia that fails to respond to calcium therapy. If the level is adequate and there is normal magnesium intake, repeated checks are not necessary unless hypocalcemia occurs. Acute hypomagnesemia should be treated with magnesium sulfate until the magnesium level is normalized or symptoms resolve. The route may be intramuscular or intravenous; however, with intravenous administration, careful electrocardiographic monitoring is indicated because of the risk for arrhythmias (for dosage, see Chapter 80). If feedings are started early, parenteral magnesium is unnecessary; however, if the infant has poor enteral intake, parenteral nutrition should include magnesium. Increased serum magnesium levels depress the central nervous system and decrease skeletal muscle contractility. The most common cause of hypermagnesemia in neonates is treatment of the mother with magnesium sulfate. Less commonly, it can occur with administration of a magnesium-containing antacid, especially when urine output is decreased. Hypermagnesemia can also be caused by magnesium sulfate enemas, which are absolutely contraindicated in neonates. Administration of magnesium-containing antacids to the neonate, especially when urinary output is decreased. These include poor feeding, lethargy, depressed tone, hyporeflexia, apnea, and decreased gastrointestinal motility with abdominal distention. If enteral feedings are not tolerated, maintenance intravenous fluids should be provided, with careful monitoring of serum electrolytes and pH. Exchange transfusion can effectively reduce serum magnesium levels, but this should be reserved for extreme cases. Hypermagnesemia usually resolves spontaneously, provided that renal function is maintained. Chan G: Growth and bone mineral status of discharged very low birth weight infants fed different formulas or human milk. Macmahon P et al: Association of mineral composition of neonatal intravenous feeding solutions and metabolic bone disease of prematurity. Pohlandt F: Prevention of postnatal bone demineralization in very low birth weight infants by individually monitored supplementation with calcium and phosphorus. Shankaran S et al: Mineral excretion following furosemide compared with bumetanide therapy in premature infants. Vascular ring denotes a variety of anomalies of the aortic arch and its branches that create a "ring" of vessels around the trachea and esophagus. Partial obstruction of the trachea or the esophagus, or both, may result from extrinsic compression by the encircling ring of vessels. Dysphagia or stridor (respiratory insufficiency), or both, are the modes of presentation. Diagnosis is by barium swallow, which identifies extrinsic compression of the esophagus in the region of the aortic arch. Management consists of surgical division of a portion of the constricting ring of vessels. The specific surgical plan must be tailored to the particular type of aortic arch anomaly present. Complete esophageal obstruction results in inability of the infant to handle his or her own secretions, producing "excess salivation" and aspiration of pharyngeal contents. After delivery, the infant typically is unable to swallow saliva, which drains from the corners of the mouth and requires frequent suctioning.

The patient should be counseled regarding the indications for induction treatment pink eye buy cheap solian line, the agents and methods of labor stimulation medications pregnancy buy cheapest solian and solian, and the possible need for repeat induction or cesarean delivery medicine ball abs buy cheap solian 100mg on line. Additional requirements for cervical ripening and induction of labor include assessment of the cervix medicine prescription drugs quality 50 mg solian, pelvis, fetal size, and presentation. Each hospitals department of obstetrics and gynecology should develop written protocols for preparing and administering oxytocin solution or other agents for labor induction or augmentation. Personnel who are familiar with the effects of the agents used and who are able to identify both maternal and fetal complications should be in attendance during administration of the induction agent(s). The qualifications of personnel authorized to administer oxytocic agents for this purpose should be described. The methods for assessment of the woman and the fetus before and during administration of these agents should be specified. A physician capable of performing a cesarean delivery should be readily available. Because it is possible to introduce fluid into the uterus at too rapid a rate, each obstetric unit should 182 Guidelines for Perinatal Care establish a protocol for intrauterine pressure monitoring during amnioinfusion, or limitations of the volume and infusion rate when the technique is used. Based on the totality of published data, routine prophylactic amnioinfusion for meconium-stained amniotic fluid is not indicated. However, amnioinfusion is a reasonable approach to treatment of repetitive, variable decelerations irrespec tive of amniotic fluid meconium status. Analgesia and Anesthesia ^ Management of discomfort and pain during labor and delivery is an essential part of good obstetric practice. It is the responsibility of the physician or certi fied nursemidwife, in consultation with the anesthesiologist, if appropriate, to develop the most appropriate response to the womans request for analgesia or anesthesia. Analgesia or anesthesia during labor and delivery has no lasting effect on the physiologic status of the neonate. No evidence exists that suggests that the administration of analgesia or anesthesia during childbirth per se has an effect on the childs later mental and neurologic development. In the absence of a medical contraindication, maternal request is a sufficient medical indication for pain relief during labor. Some patients tolerate the pain of labor by using techniques learned in childbirth preparation programs. Although specific techniques vary, classes usually seek to relieve pain through the general principles of education, sup port, relaxation, paced breathing, focusing, and touch. The staff at the bedside should be knowledgeable about these pain management techniques and should be supportive of the patients decision to use them. Available Methods of Analgesia and Anesthesia Available methods of obstetric analgesia and anesthesia include parenteral agents and regional, general, and local anesthesia. The choice and availability of analgesic and anesthetic techniques depends on the experience and judgment of the obstetrician and anesthesiologist, the physical condition of the patient, the circumstances of labor and delivery, and the personal preferences of the patient. Parenteral Agents Various opioid agonists and opioid agonistantagonists are available for sys temic analgesia and can be administered during prodromal and early labor to allow the patient to rest. These agents can be given in intermittent doses on patient request or via patient-controlled administration. The decision to use Intrapartum and Postpartum Care of the Mother 183 parenteral agents to manage labor pain should be made in collaboration with the patient after a careful discussion of the risks and benefits. Reports suggest that the analgesic effect of parenteral agents used in labor is limited, and a primary mechanism of action is sedation. Although regional anal gesia provides superior pain relief, some women are satisfied with the level of analgesia provided by narcotics when adequate doses are used. Patients exposed to high doses of narcotics are at increased risk of aspiration and respiratory arrest. High doses potentially are depressing to the woman, fetus, and particu larly the newborn immediately after delivery. There has been some concern about fetal safety with the use of nalbuphine hydrochloride; however, there is insufficient evidence at this time to recommend a change in practice with the use of this medication. Regional Anesthesia Regional (neuraxial) anesthesia is another option for management of pain, and several methods of administration are available: epidural, spinal, and combined spinalepidural. In obstetric patients, regional analgesia refers to a partial to complete loss of pain sensation below the T8T10 level. In addition, a vary ing degree of motor blockade may be present, depending on the agents used. Ambulation to some extent may be possible when using regional analgesia, depending on the technique used, the experience of the anesthesiologist, and the patients response. Data indicate that low-dose neuraxial analgesia adminis tered in early labor does not increase the rate of cesarean delivery and some tech niques may shorten the duration of labor for some patients. Thus, there seems to be little justification to withhold this form of pain relief from women in early labor until an arbitrary cervical dilation is achieved (ie, 4-cm cervical dilation). When regional anesthesia is administered during labor, the patients vital signs should be monitored at regular intervals by a qualified member of the health care team. It also should be noted that a low-grade maternal fever might be associated with a normal epidural anesthetic reaction in the absence of infection. In the absence of intra-amniotic infection, neonatal surveillance blood cultures in patients exhibiting this response are negative, indicating no evidence of infection. Epidural analgesia offers one of the most effective forms of intrapar tum pain relief and is used in some form by most women in the United States. A catheter is placed in the epidural space, allowing for a continuous infusion or intermittent injection of pain medication during labor. The advantage of this method of analgesia is that the medication may be titrated over the course of labor as needed. In addition, epidural catheters placed for labor may be dosed and used for cesarean delivery, postpartum tubal ligation, postcesarean pain control, or for repair of obstetric lacerations following vaginal delivery, if needed. Spinal techniques usually involve a single injection of medication into the cerebrospinal fluid and can provide excellent surgical anesthesia for pro cedures of limited duration, such as cesarean delivery or postpartum tubal ligation, as well as analgesia of limited duration during labor. Spinal labor analgesia using primarily opioids with very low doses of local anesthetics can provide excellent analgesia with rapid onset during labor. Placement of a cath eter directly into the subarachnoid space can be used to provide continuous spinal analgesia. Because of the relatively high incidence of postdural puncture headache after this technique, it usually is used only for specific indications. Use of higher-dose local anesthetics can provide sensory anesthesia and motor blockade for vaginal delivery. Such higher dose techniques typically result in profound sensory and motor blockade, which may impair maternal expulsive efforts. Therefore, spinal anesthesia usually is not administered until delivery is imminent or the physician has made a decision to perform an opera tive delivery. Combined spinalepidural analgesia offers the advantages of the rapid onset of spinal analgesia along with the ability to use the indwelling epidural catheter to prolong analgesia and titrate medication throughout labor. The technique also may be used and dosed to provide anesthesia for a cesarean delivery and the catheter dosed for postcesarean pain control before being removed. General Anesthesia Because general anesthesia results in a loss of maternal consciousness, it must be accompanied by airway management by trained anesthesia personnel. General Intrapartum and Postpartum Care of the Mother 185 anesthesia is rarely used or necessary for vaginal delivery and should be used only for specific indications. At the time of delivery, local anesthetics may be injected into the tissues of the perineum and the vagina to provide anesthesia for episiotomy, and repair of vaginal and perineal lacerations. Local anesthetics also may be injected to perform pudendal nerve block in patients who did not receive regional anesthesia during labor. This regional block may provide adequate anesthesia for outlet operative deliv eries and performance of any necessary episiotomy or repair. Cesarean Deliveries For most cesarean deliveries, properly administered regional or general anesthe sia are both effective and have little effect on the newborn. Because of potential risks associated with airway management, intubation and the possibility of aspiration during induction of general anesthesia, regional anesthesia is usually the preferred technique and should be available in all hospitals that provide obstetric care. The advantages and disadvantages of both techniques should be discussed with the patient as completely as possible.

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Subtle seizures are more commonly associated with an electroencephalographic seizure in premature infants than in full-term infants medicine 4 times a day proven 100 mg solian. They consist of tonic horizontal deviation of the eyes with or without jerking; eyelid blinking or fluttering; sucking symptoms zinc overdose purchase solian 100mg with amex, smacking 911 treatment for hair effective solian 100mg, or drooling; "swimming medications migraine headaches order solian line," "rowing," or "pedaling" movements; and apneic spells. Apnea accompanied by electroencephalographic abnormalities has been called convulsive apnea. It is differentiated from nonconvulsive apnea (which is due to sepsis, lung disease, or metabolic abnormalities) by the absence of electroencephalographic abnormalities. Apnea as a manifestation of seizures is usually accompanied or preceded by other subtle manifestations. Clonic seizures are more common in full-term infants than in premature infants and are commonly associated with an electroencephalographic seizure. Well-localized, rhythmic, slow, jerking movements involving the face and upper or lower extremities on one side of the body or the neck or trunk on one side of the body. Several body parts seize in a sequential, nonjacksonian fashion (eg, left arm jerking followed by right leg jerking). Sustained posturing of a limb, asymmetric posturing of the trunk or neck, or both. Most commonly, these occur with a tonic extension of both upper and lower extremities (as in decerebrate posturing) but may also present with tonic flexion of the upper extremities with extension of the lower extremities (as in decorticate posturing). Myoclonic seizures are seen in both full-term and premature infants and are characterized by single or multiple synchronous jerks. Focal seizures typically involve the flexor muscles of an upper extremity and are not commonly associated with electroencephalographic seizure activity. Multifocal seizures exhibit asynchronous twitching of several parts of the body and are not commonly associated with electroencephalographic seizure activity. Generalized seizures present with bilateral jerks of flexion of the upper and sometimes the lower extremities. Jitteriness is not accompanied by abnormal eye movements, and movements cease on application of passive flexion. Although it is often difficult to obtain a thorough history in infants transported to tertiary care facilities from other hospitals, the physician must make a concerted effort to elicit pertinent historical data. A positive family history of neonatal seizures is usually obtained in cases of metabolic errors and benign familial neonatal convulsions. Details of the delivery provide information regarding maternal analgesia, the mode and nature of delivery, the fetal intrapartum status, and the resuscitative measures used. Information regarding maternal infections during pregnancy points toward an infectious basis for seizures in an infant. A thorough general physical examination should precede a well-planned neurologic examination. Neurologic evaluation should include assessment of the level of alertness, cranial nerves, motor function, primary neonatal reflexes, and sensory function. Some of the specific features to look for are the size and "feel" of the fontanelle, retinal hemorrhages, chorioretinitis, pupillary size and reaction to light, extraocular movements, changes in muscle tone, and status of primary reflexes. When seizures are noted, they should be described in detail, including the site of onset, spread, nature, duration, and level of consciousness. In selecting and prioritizing laboratory tests, one must use the information obtained by history taking and physical examination and look for common and treatable causes. Estimations of serum glucose, calcium, sodium, blood urea nitrogen, and magnesium and blood gas levels must be performed. Respiratory alkalosis is seen as a result of direct stimulation of the respiratory center by ammonia. Experience with this technique suggests that valuable information is obtained in term infants with seizures, especially when seizures are asymmetric. Electroencephalography is valuable in confirming the presence of seizures when manifestations are subtle or when neuromuscular paralyzing agents have been given. Because repeated seizures may lead to brain injury, urgent treatment is indicated. Hypoglycemic infants with seizures should receive 10% dextrose in water, 2-4 mL/kg intravenously, followed by 6-8 mg/kg/min by continuous intravenous infusion. Hypocalcemia is treated with slow intravenous infusion of calcium gluconate (for dosage and other pharmacologic information, see Chapter 80). Conventional anticonvulsant treatment is used when no underlying metabolic cause is found. Phenobarbital is usually given first (for dosage and other pharmacologic information, see Chapter 80). Neither gestational age nor birth weight seems to influence the loading or maintenance dose of phenobarbital. Gilman et al (1989) found that sequentially administered phenobarbital controlled seizures in term and preterm newborns in 77% of cases. If seizures are not controlled at a serum phenobarbital level of 40 mcg/ mL, Gilman et al recommend administering a second agent (eg, phenytoin [Dilantin]). Diazepam (Valium) has not been used extensively in the control of neonatal seizures. Lorazepam (Ativan), given intravenously, has been quite effective and safe, even when repeated 4-6 times in a 24-h period (for dosage and other pharmacologic information, see Chapter 80). Intravenous midazolam and oral carbamazepine have been found to be effective (for dosage information, see Chapter 80). Paraldehyde, given rectally, has been used as an effective anticonvulsant (for dosage and other pharmacologic information, see Chapter 80). Although some clinicians recommend continuation of phenobarbital for a prolonged period, others recommend stopping it after seizures have been absent for 2 weeks. As a result of improved obstetric management and modern neonatal intensive care, the outcome of infants experiencing seizures has improved. The mortality rate has decreased from 40 to 20% (Volpe, 1995), but neurologic sequelae are still seen in 25-35% of cases. Infants with hypocalcemic convulsions have an excellent prognosis, whereas those with seizures secondary to congenital malformations have a poor prognosis. Seventeen percent of patients with neonatal seizures have recurrent seizures later in life. In normal development, the closure of the neural tube occurs at about the 29th day postconception. Most likely, the closure starts at several distinct sites rather than as one continuous process. Anencephaly is defective closure of the upper or rostral end of the anterior neural tube. Hemorrhagic and degenerated neural tissue is exposed through an uncovered cranial opening extending from the lamina terminalis to the foramen magnum. Infants with anencephaly have a typical appearance with prominent eyes when viewed face on. Craniorachischisis totalis (a neural plate-like structure without skeletal or dermal covering resulting from complete failure of neural tube closure) and myeloschisis or rachischisis (in which the spinal cord is exposed posteriorly without skeletal or dermal covering because of failure of posterior neural tube closure) are other, less frequent open lesions. Encephalocele (herniation of brain tissue outside the cranial cavity resulting from a mesodermal defect occurring at or shortly after anterior neural tube closure) is usually a closed lesion. Myelomeningocele is often also referred to as spina bifida (protrusion of the spinal cord into a sac on the back through deficient axial skeleton with variable dermal covering). In contrast to myelomeningoceles, meningoceles (closed lesions involving the meninges only) usually do not result in neurologic deficits. Spina bifida occulta and occult spinal dysraphism are disorders of the caudal neural tube that are covered by skin (skin dimples or only very small skin lesions are present). These dysraphic disturbances range from cystic dilation of the central canal (myelocystocele), over bifid spinal cords with or without a separating bony, cartilaginous, or fibrous septum (diastematomyelia or diplomyelia), to a tethered cord with a dermal sinus or other visible changes such as hair tufts, lipomas, or hemangiomas. The risk is approximately doubled for infants born to Hispanic women compared with white women. Some populations with frequent consanguineous matings (eg, Indian Sikhs or Palestinian Muslim Arabs) have an increased risk. The risk for African-Americans and Asians is lowest (but the incidence in northern China is higher: 6 in 1000 births). The risk is increased in infants of particularly young or particularly old mothers of lower socioeconomic class. This increase may be related to nutritional factors considering the observation by the March of Dimes that, among women surveyed in 2001, those least likely to consume a vitamin preparation containing folic acid were women 18-24 years old, those who did not attend college, and those with annual incomes <$25,000.

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Withdraw the tube if choking or coughing occurs nose to symptoms 4 dpo buy solian 50 mg otc the ear lobe and then to medications 44 175 cheap 50 mg solian visa the xiphoid process medications at 8 weeks pregnant solian 50 mg low price, during placement medications during breastfeeding cheap 100mg solian visa. The length of orogastric tube needed is estimated by extending the tubing from CoMpliCations16 the corner of the mouth to the ear lobe and then to Intracranial, esophageal or bronchial insertion the xiphoid process Perforation with hemorrhage Neonates (39 kg): size 58 French Epistaxis Young children (1014 kg): size 810 French Aspiration Child (1522 kg): size 1014 French Older child (24 kgadult): size 1418 French ContraindiCations for a nasoGastriC tuBe13 Severe facial trauma Recent nasal surgery Coagulation abnormality (relative contraindication) Esophageal stricture (relative contraindication) Alkaline ingestion (relative contraindication) 2010 Pediatric Clinical Practice Guidelines for Nurses in Primary Care Pediatric Procedures 27 Wound Closure Contraindications Lacerations crossing joints or mucocutaneous junctions loCal anestHetiCs for suturinG Puncture wound General Wounds that have been present longer than 12 hours Human or animal bite Lidocaine (1%, without epinephrine) is the local Stellate lacerations (that is, arranged or shaped like anesthetic of choice a star; radiating from a centre), as they have a higher To avoid systemic toxic effects, instil no more than infection rate than smaller, linear lacerations 3 to 4 mg/kg (0. Practice universal precautions against contamination Effcient and less invasive method of wound with childs body substances (for example, gloves, closure possibly goggles). This will also help avoid gluing Does not require anesthesia unless needed for your own skin to the clients skin or hair. They may be Scalp or hair-bearing areas having lacerations stretched slightly at top and bottom of the wound. Pediatric Clinical Practice Guidelines for Nurses in Primary Care 2010 28 Pediatric Procedures 11. Hold wound in approximated position for at No soaking/washing of the wound or swimming for least one minute after fnal application to allow 710 days suffcient drying time. Care must be taken to avoid the or dehiscence edges of the recently closed lacerations as this will If a chronic illness is present, monitor the wound cause dehiscence of the wound. If a glove accidentally gets glued to the wound, cutting the portion of the glove off and leaving it in the wound will not delay healing. The Hospital for Sick Children internet Guidelines, stateMents handbook of pediatrics. Core curriculum for primary care pediatric nurse Confrming nasogastric tube position in the practitioners. Ambulatory care procedures for the nurse Core curriculum for primary care pediatric nurse practitioner. This article provides a brief update on the pharmacology, adverse effects and clinical applications of these drugs, as well as the role of vasoconstrictors. I Each dentist in Canada injects approximately 1,800 the onset and duration of action of local anesthetics are cartridges of local anesthetic yearly,1 and it has been esti in uenced by several factors, as summarized in Table 1. The pH may drop in sites of all dentists should have expertise in local anesthesia. This infection, which causes onset to be delayed or even article provides a brief overview of local anesthetics to rein prevented. Clinically, there are no signi cant differences in force dentists knowledge of these agents. Proximity of the deposition of local anesthetic to the W hat follows here is a brief synopsis of the pharmacol nerve can also be a factor, which is why in ltration is asso ogy of local anesthetics. Dentists should be familiar with ciated with rapid onset whereas the Gow-Gates block is sources that provide more detailed information on this relatively slow. Local anesthesia is induced when propagation of action W ithin limits, higher concentration and greater lipid solu bility improve onset to a small degree. Local anesthetics cause vasodilatation, which blocking the entry of sodium ions into their channels, leads to rapid diffusion away from the site of action and thereby preventing the transient increase in permeability of results in a very short duration of action intraorally when the nerve membrane to sodium that is required for an these drugs are administered alone. These include a lipophilic group, duration anesthesia for soft tissue in both the arches and joined by an amide or ester linkage to a carbon chain pulp of mandibular teeth. All last longer than in ltrations, and soft-tissue anesthesia lasts local anesthetics available in dental cartridges in Canada longer than pulpal anesthesia. The proto Prilocaine is also metabolized in the plasma and kidney, and type for the ester group is procaine (Novocain, Abbot), one of its metabolites may lead to methemoglobinemia, as 546 October 2002, Vol. Esters are biotransformed by plasma Psychogenic Reactions cholinesterase, also known as pseudocholinesterase. Patients Anxiety-induced events are by far the most common with the genetic disorder pseudocholinesterase de ciency can adverse reaction associated with local anesthetics in be expected to metabolize procaine at a much slower rate. These may manifest in numerous ways, the most However, little clinical effect would be expected unless the common of which is syncope. Psychogenic reactions are often misdiagnosed as patients with severe liver dysfunction. Reduced hepatic allergic reactions and may also mimic them, with signs such function predisposes the patient to toxic effects but, unlike as urticaria, edema and bronchospasm. In this context, it must be remem Patient reports of allergic reactions to local anesthetics bered that hepatic function does not affect the duration of are fairly common, but investigation shows that most of action of local anesthesia, which is determined by redistrib these are of psychogenic origin. Therefore, a patient with is exceedingly rare, whereas the ester procaine is somewhat liver disease needs the standard amount of local anesthetic more allergenic. Therefore, another ester, as the allergenic component is the breakdown when treating a patient with signi cant liver disease, it is product para-aminobenzoic acid, and metabolism of all prudent to treat one quadrant at a time, thereby minimiz esters yields this compound. Use of an ester may not offer any advantage, amide does not rule out use of another amide. W ith regard to efficacy, no studies have shown any A patient may be allergic to other compounds in the signi cant differences among the agents. For example, methylparabens are appropriate to assume that each of the 5 amides is equally preservatives necessary for multidose vials and were present efficacious. Allergy to Adverse Reactions para-aminobenzoic acid would rule out use of esters and Local anesthetics should be considered relatively safe, methylparabens. It may be best to avoid a vasoconstrictor if but with the high number of injections given yearly, adverse there is a true documented allergy to sul tes, as metabisul reactions are seen (Table 3). Vasoconstrictor can be used in patients with an of action of local anesthetics allergy to the sulfonamide antibacterials, commonly called sulfa, as there is no cross-allergenicity with sul tes. High blood levels of the drug may be due to Concentration of drug repeated injections or could result from a single inadvertant Lipid solubility of drug intravascular administration. This is one reason why Table 2 Expected duration of action of local anestheticsa Duration of action (min) Maxillary in ltration Inferior alveolar block Formulation Pulp Soft tissue Pulp Soft tissue Articaine 4% with epinephrine 1:100,000 or 1:200,000 60 190 90 230 Bupivacaine 0. Syncope (most common) dose of cartridges Hyperventilation Articaine 7 mg/kg (up to 500 mg) 7 Nausea, vomiting 5 mg/kg in children Alterations in heart rate or blood pressure Mimicking of an allergic reaction Bupivacaine 2 mg/kg (up to 200 mg) 10 Allergic (potential allergens) Lidocaine 7 mg/kg (up to 500 mg) 13 Esters (true amide allergy is very rare) Mepivacaine 6. The signs Higher blood levels may result in tremors, respiratory and symptoms of toxicity are summarized in Table 3. M aximum doses are much more relevant in Paresthesia the pediatric patient, and it is important to note how little Apparently more common with articaine and prilocaine 14 anesthetic should be given to a child. The high-concentration solutions, namely prilocaine and articaine, will reach toxic levels with fewer injections than is the case for the other drugs. Table 5 Example calculations of maximum M ethemoglobinemia local anesthetic doses for a this uncommon adverse reaction is associated most 15-kg (33-lb) child notably with prilocaine but may also occur with articaine or Articaine the topical anesthetic benzocaine. M ethemoglobinemia is 5 mg/kg maximum dose 15 kg = 75 mg induced by an excess of the metabolites of these drugs and 4% articaine = 40 mg/mL manifests as a cyanotic appearance that does not respond to 75 mg/(40 mg/mL) = 1. Paresthesia Mepivacaine Prolonged anesthesia or paresthesia of the tongue or lip 6. Articaine and prilocaine were reported as more likely than other anesthetics to be associ Prilocaine ated with paresthesia, a difference that was statistically 8 mg/kg 15 kg = 120 mg signi cant when their distribution of use was taken into 4% prilocaine = 40 mg/mL 120 mg/(40 mg/mL) = 3 mL account. Previous recommendations, now (Visken), propranolol (Inderal), sotalol (Sotacor), timolol known to be wrong, precluded the use of speci c local anes (Blocadren, Timoptic) thetics in these patients. Today it is well accepted that all Interaction may result in increased blood pressure local anesthetics are safe for patients who are susceptible to Reduced use of vasconstrictor is warranted malignant hyperthermia. This concern can be General anesthetic (halothane [Fluothane]) minimized by use of low doses and careful monitoring, Interaction may result in serious cardiac dysrhythmia Anesthetist should be advised as to whether epinephrine is needed consistent with the standard of care for oral sedation. There are clear indications for their use, of which Interaction may result in increased blood pressure and cardiac dysrhythmias improving the depth and duration of anesthesia are the aBrand names are included only as examples and not to promote any one most important. The manufacturers are as follows: Corgard, Squibb; Trasicor, very short duration of action intraorally. The presence of a vaso Aventyl, Lilly; Sinequan, P zer; Vivactil, Merck and Company; Fluothane, constrictor may also reduce systemic toxic effects and can Wyeth-Ayerst. The most common agent for this purpose is epinephrine, which is available in formulations of 1:50,000, 1:100,000 and 1:200,000. It is beyond the scope of this article to cover the phar Table 7 Treatment modi cations to consider macology of epinephrine, but the cardiovascular actions of if there are concerns regarding this drug should be noted. Vasoconstriction is due to vasoconstrictors epinephrines stimulation of 1 receptors in mucous Monitor blood pressure and heart rate preoperatively membranes. However, it also stimulates the 1 receptor in Minimize administration of epinephrine or levonordefrin the heart, increasing heart rate, strength of contraction and Monitor blood pressure and heart rate 5 min after injection myocardial oxygen consumption, and the 2 receptors, May re-administer epinephrine or levonordefrin if blood pressure and heart rate are stable vasodilating blood vessels in the skeletal muscle. These Continue to monitor as required actions form the basis for potential interactions with other Consider limiting epinephrine to 0. Contrary to Avoid epinephrine 1:50,000 Never use epinephrine-impregnated retraction cord the information in certain drug monographs, epinephrine can be given to patients receiving monoamine oxidase inhibitors. Levonordefrin is contraindi vasoconstrictors cated for patients receiving tricyclic antidepressants. Ratio concentrations represent grams per millilitre Epinephrine dosage should sometimes be minimized, 1:100,000 = 0.

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