Surgical Pharmacology and Anesthesia Commonly Used Drugs in Surgery

CLASSIFICATION ANTIINFECTIVES Antibiotics Aminoglycosides Gentamicin Kanamycin Neomycin Streptomycin Tobramycin Cephalosporins Cefazolin Cefonicid Cefotaxime Quinolones Ciprofloxacin Macrolides Erythromycin Penicillins Ampicillin Penicillin G potassium Amoxicillin Mezlocillin Carbenicillin Ticarcillin DRUGS

Tetracyclines Doxycycline Tetracycline Sulfonamides (antimicrobial) Sulfamethoxazole Glycylcycline Tygacil Lipopeptides Daptomycin Oxazolidinones Linezolid Ketolide Telithromycin AUTONOMIC NERVOUS SYSTEM AGENTS Adrenergic Agonists Alpha- and beta-adrenergic agonists Epinephrine Isoproterenol Adrenergic Antagonists Antidysrhymics Propranolol

Anticholinergics

Muscarinics Atropine sulfate Glycopyrrolate Scopolamine

Anticoagulants

Anticoagulants Heparin Warfarin Enoxaparin Protamine

ANTICOAGULANTS AND COAGULANTS Antiplatelet Agents Aspirin Ticlopidine Coagulant Hemostatics CENTRAL NERVOUS SYSTEM AGENTS Analgesics Narcotics Morphine Meperidine Fentanyl BENZODIAZEPINES Antianxiety Medications Sedatives Diazepam Lorazepam Midazolam THROMBOLYTICS Thrombolytic Streptokinase Urokinase Alteplase SURGICAL DYES AND CONTRAST Dyes Methylene blue Thrombin

Indigo carmine Brilliant green Gentian violet Contrast Media Iohexol Vasovist MRI contrast Diatrizoate meglumine Tissue Stains Lugols iodine solution Monsels ferric solution

SEDATION AND ANESTHESIA

Sedation and anesthesia have four levels: minimal sedation, moderate sedation, deep sedation, and anesthesia. Standards of care for each level have been set by JCAHO. A surgical procedure may also be performed using anesthetic agents that suspend sensation in parts of the body (local, regional, epidural, or spinal anesthesia). For the patient, the anesthesia experience consists of having an intravenous line inserted, if it was not inserted earlier; receiving a sedating agent prior to induction with an anesthetic agent; losing consciousness; being intubated, if indicated; and then receiving a combination of anesthetic agents. Typically the experience is a smooth one and the patient has no recall of the events.

Minimal Sedation The minimal sedation level is a drug-induced state during which the patient can respond normally to verbal commands. Cognitive function and coordination may be impaired, but ventilatory and cardiovascular functions are not affected.

Moderate Sedation Moderate sedation is a form of anesthesia that may be produced intravenously. It is defined as a depressed level of consciousness that does not impair the patients ability to maintain a patent airway and to respond appropriately to physical stimulation and verbal command. Its goal is a calm, tranquil, amnesic patient who, when sedation is combined with analgesic agents, is relatively painfree during the procedure but able to maintain protective reflexes. Sedation can be administered by an anesthesiologist, anesthetist, other physician, or nurse. When administered by an anesthesiologist or anesthetist, moderate sedation is referred to as monitored anesthesia care. The medications permitted for use in moderate sedation vary with the credentials of the person administering the sedative. In addition, state departments of health are very specific about who may administer

moderate sedation and about the training required for those individuals. These regulations vary greatly from state to state. Midazolam (Versed) or diazepam (Valium) is used frequently for intravenous sedation. In some states, the physician must administer the first dose; a nurse with special training can administer subsequent doses. Other medications used include analgesic agents (eg, morphine, fentanyl) and reversal agonists, such as naloxone (Narcan). A nurse who is knowledgeable and skilled in detecting dysrhythmias, administering oxygen, and performing resuscitation must continuously monitor the patient who receives sedation. The patient receiving this form of anesthesia is never left alone and is closely monitored for respiratory, cardiovascular, and central nervous system depression using such methods as pulse oximetry, ECG, and frequent measurement of vital signs. The level of sedation is monitored by the patients ability to maintain a patent airway and to respond to verbal commands. Moderate sedation may be used alone or in combination with local, regional, or spinal anesthesia. Its use is increasing as more surgical procedures and diagnostic studies are performed in ambulatory and same-day settings with the expectation that the patient will be discharged home a few hours after the procedure.

Deep Sedation Deep sedation is a drug-induced state during which a patient cannot be easily aroused but can respond purposefully after repeated stimulation (JCAHO, 2001). The difference between deep sedation and anesthesia is that the anesthetized patient is not arousable. Deep sedation and anesthesia are achieved when an anesthetic agent is inhaled or administered intravenously. Inhaled anesthetic agents include volatile liquid agents and gases. Volatile liquid anesthetics produce anesthesia when their vapors are inhaled. Included in this group are halothane (Fluothane), enflurane (Ethrane), isoflurane (Forane), sevoflurane (Ultrane), and desflurane (Suprane). All are administered with oxygen, and usually with nitrous oxide as well. Gas anesthetics are administered by inhalation and are always combined with oxygen. Nitrous oxide is the most commonly used gas anesthetic. When inhaled, the anesthetics enter the blood through the pulmonary capillaries and act

on cerebral centers to produce loss of consciousness and sensation. When anesthetic administration is discontinued, the vapor or gas is eliminated through the lungs. Table 19-1 lists the advantages, disadvantages, and implications of the different volatile liquid and gas anesthetics.

ANESTHESIA
General anesthesia consists of four stages, each associated with specific clinical manifestations. When opioid agents (narcotics) and neuromuscular blockers (relaxants) are administered, several of the stages are absent. The anesthesia level consists of general anesthesia and spinal or major regional anesthesia but does not include local anesthesia. Anesthesia is a state of narcosis (severe central nervous system depression produced by pharmacologic agents), analgesia, relaxation, and reflex loss. Patients under general anesthesia are not arousable, even to painfulstimuli. They lose the ability to maintain ventilatory function and require assistance in maintaining a patent airway. Cardiovascular function may be impaired as well.

STAGE I: BEGINNING ANESTHESIA As the patient breathes in the anesthetic mixture, warmth, dizziness, and a feeling of detachment may be experienced. The patient may have a ringing, roaring, or buzzing in the ears and, though still conscious, may sense an inability to move the extremities easily. During this stage, noises are exaggerated; even low voices or minor sounds seem loud and unreal. For this reason, the nurse avoids making unnecessary noises or motions when anesthesia begins. STAGE II: EXCITEMENT The excitement stage, characterized variously by struggling, shouting, talking, singing, laughing, or crying, is often avoided if the anesthetic is administered smoothly and quickly. The pupils dilate, but contract if exposed to light; the pulse rate is rapid, and respirations may be irregular. Because of the possibility of uncontrolled movements of the patient during this stage, the anesthesiologist or

anesthetist must always be assisted by someone ready to help restrain the patient. A strap may be in place across the patients thighs, and the hands may be secured to an armboard. The patient should not be touched except for purposes of restraint, but restraints should not be applied over the operative site. Manipulation increases circulation to the operative site and thereby increases the potential for bleeding. STAGE III: SURGICAL ANESTHESIA Surgical anesthesia is reached by continued administration of the anesthetic vapor or gas. The patient is unconscious and lies quietly on the table. The pupils are small but contract when exposed to light. Respirations are regular, the pulse rate and volume are normal, and the skin is pink or slightly flushed. With proper administration of the anesthetic, this stage may be maintained for hours in one of several planes, ranging from light (1) to deep (4), depending on the depth of anesthesia needed. STAGE IV: MEDULLARY DEPRESSION This stage is reached when too much anesthesia has been administered. Respirations become shallow, the pulse is weak and thready, and the pupils become widely dilated and no longer contract when exposed to light. Cyanosis develops and, without prompt intervention, death rapidly follows. If this stage develops, the anesthetic is discontinued immediately and respiratory and circulatory support is initiated to prevent death. Stimulants, although rarely used, may be administered; narcotic antagonists can be used if overdosage is due to opioids. During smooth administration of an anesthetic, there is no sharp division between the first three stages, and there is no stage IV. The patient passes gradually from one stage to another, and it is only by close observation of the signs exhibited by the patient that an anesthesiologist or anesthetist can control the situation. The responses of the pupils, the blood pressure, and the respiratory and cardiac rates are probably the most reliable guides to the patients condition.

METHODS OF ANESTHESIA
ADMINISTRATION
Anesthetics produce anesthesia because they are delivered to the brain at a high partial pressure that enables them to cross the bloodbrain barrier. Relatively large amounts of anesthetic must be administered during induction and the early maintenance. As these sites become saturated, smaller amounts of the anesthetic agent are required to maintain anesthesia because equilibrium or near equilibrium has been achieved between brain, blood, and other tissues. Anything that diminishes peripheral blood flow, such as vasoconstriction or shock, may reduce the amount of anesthetic required. Conversely, when peripheral blood flow is unusually high, as in the muscularly

active or the apprehensive patient, induction is slower and greater quantities of anesthetic are required because the brain receives a smaller quantity of anesthetic.

Inhalation
Liquid anesthetics may be administered by mixing the vapors with oxygen or nitrous oxide oxygen and then having the patient inhale the mixture. The vapor is administered to the patient through a tube or a mask. The inhalation anesthetic may also be administered through a laryngeal mask, a flexible tube with an inflatable silicone ring and cuff that can be inserted into the larynx. The endotracheal technique for administering anesthetics consists of introducing a soft rubber or plastic endotracheal tube into the trachea, usually by means of a laryngoscope. The endotracheal tube may be inserted through either the nose or mouth. When in place, the tube seals off the lungs from the esophagus so that if the patient vomits, stomach contents do not enter the lungs.

Intravenous Anesthesia
General anesthesia can also be produced by the intravenous injection of various substances, such as barbiturates, benzodiazepines, nonbarbiturate hypnotics, dissociative agents, and opioid Agents. These medications may be administered for induction (initiation) or maintenance of

anesthesia. They are often used along with inhalation anesthetics but may be used alone. They can also be used to produce moderate sedation. Intravenous anesthetics are presented in Table 19-2. An advantage of intravenous anesthesia is that the onset of anesthesia is pleasant; there is none of the buzzing, roaring, or dizziness known to follow administration of an inhalation anesthetic. For this reason, induction of anesthesia usually begins with an intravenous agent and is often preferred by patients who have experienced various methods. The duration of action is brief, and the patient awakens with little nausea or vomiting. Thiopental is usually the agent of choice, and it is often administered with other anesthetic agents in prolonged procedures. Intravenous anesthetic agents are nonexplosive, they require little equipment, and they are easy to administer. The low incidence of postoperative nausea and vomiting makes the method useful in eye surgery because vomiting would increase intraocular pressure and endanger vision in the operated eye. Intravenous anesthesia is useful for short procedures but is used less often for the longer procedures of abdominal surgery. It is not indicated for children, who have small veins and require intubation because of their susceptibility to respiratory obstruction. A disadvantage of an intravenous anesthetic such as thiopental is its powerful respiratory depressant effect. It must be administered by a skilled anesthesiologist or anesthetist and only when some method of oxygen administration is available immediately in case of difficulty. Sneezing, coughing, and laryngospasm are sometimes noted with its use. Intravenous neuromuscular blockers (muscle relaxants) block the transmission of nerve impulses at the neuromuscular junction of skeletal muscles. Muscle relaxants are used to relax muscles in abdominal and thoracic surgery, relax eye muscles in certain types of eye surgery, facilitate endotracheal intubation, treat laryngospasm, and assist in mechanical ventilation. Purified curare was the first widely used muscle relaxant; tubocurarine was isolated as the active ingredient. Succinylcholine was later introduced because it acts more rapidly than curare. Several other agents are also used (Table 19-3). The ideal muscle relaxant has the following characteristics:

 It is nondepolarizing (noncompetitive agent), with an onset and duration of action similar to succinylcholine but without its problems of bradycardia and cardiac dysrhythmias. It has a duration of action between those of succinylcholine and pancuronium. It lacks cumulative and cardiovascular effects. It can be metabolized and does not depend on the kidneys for its elimination.

Regional Anesthesia
Regional anesthesia is a form of local anesthesia in which an anesthetic agent is injected around nerves so that the area supplied by these nerves is anesthetized. The effect depends on the type of nerve involved. Motor fibers are the largest fibers and have the thickest myelin sheath. Sympathetic fibers are the smallest and have a minimal covering. Sensory fibers are intermediate. Thus, a local anesthetic blocks motor nerves least readily and sympathetic nerves most readily. An anesthetic cannot be regarded as having worn off until all three systems (motor, sensory, and autonomic) are no longer affected. The patient receiving spinal or local anesthesia is awake and aware of his or her surroundings unless medications are given to produce mild sedation or to relieve anxiety. The nurse must avoid careless conversation, unnecessary noise, and unpleasant odors; these may be noticed by the patient in the OR and may contribute to a negative view of the surgical experience. A quiet environment is therapeutic. The diagnosis must not be stated aloud if the patient is not to know it at this time.

Conduction Blocks and Spinal Anesthesia There are many types of conduction blocks, depending on the nerve groups affected by the injection. Epidural anesthesia is achieved by injecting a local anesthetic into the spinal canal in the space surrounding the dura mater (Fig. 19-2). Epidural anesthesia also blocks sensory, motor, and autonomic functions, but it is differentiated from spinal anesthesia by the injection site and the amount of anesthetic used.

Epidural doses are much higher because the epidural anesthetic does not make direct contact with the cord or nerve roots. An advantage of epidural anesthesia is the absence of headache that occasionally results from subarachnoid injection. A disadvantage is the greater technical challenge of introducing the anesthetic into the epidural rather than the subarachnoid space. If inadvertent subarachnoid injection occurs during epidural anesthesia and the anesthetic travels toward the head, high spinal anesthesia can result; this can produce severe hypotension and respiratory depression and arrest. Treatment of these complications includes airway support, intravenous fluids, and use of vasopressors. Other types of nerve blocks include: Brachial plexus block, which produces anesthesia of the arm Paravertebral anesthesia, which produces anesthesia of the nerves supplying the chest, abdominal wall, and extremities Transsacral (caudal) block, which produces anesthesia of the perineum and, occasionally, the lower abdomen

Spinal anesthesia is a type of extensive conduction nerve block that is produced when a local anesthetic is introduced into the subarachnoid space at the lumbar level, usually between L4 and L5 (see Fig. 19-2). It produces anesthesia of the lower extremities, perineum, and lower abdomen. For the lumbar puncture procedure, the patient usually lies on the side in a kneechest position. Sterile technique is used as a spinal puncture is made and the medication is injected through the needle. As soon as the injection has been made, the patient is positioned on his or her back. If a relatively high level of block is sought, the head and shoulders are lowered. The spread of the anesthetic agent and the level of anesthesia depend on the amount of fluid injected, the speed with which it is injected, the positioning of the patient after the injection, and the specific gravity of the agent. If the specific gravity is greater than that of cerebrospinal fluid (CSF), the agent moves to the dependent position of the subarachnoid space. If the specific gravity is less than that of CSF, the anesthetic moves away from the dependent position. The anesthesiologist or anesthetist controls the spread of the agent.

Generally, the agents used are procaine, tetracaine (Pontocaine), lidocaine (Xylocaine), and bupivacaine (Marcaine) (Table 19-4). A few minutes after induction of a spinal anesthetic, anesthesia and paralysis affect the toes and perineum and then gradually the legs and abdomen. If the anesthetic reaches the upper thoracic and cervical spinal cord in high concentrations, a temporary partial or complete respiratory paralysis results. Paralysis of the respiratory muscles is managed by mechanical ventilation until the effects of the anesthetic on the respiratory nerves have worn off. Nausea, vomiting, and pain may occur during surgery when spinal anesthesia is used. As a rule, these reactions result from manipulation of various structures, particularly those within the abdominal cavity. The simultaneous intravenous administration of a weak solution of thiopental and inhalation of nitrous oxide may prevent such reactions. Headache may be an after-effect of spinal anesthesia. Several factors are involved in the incidence of headache: the size of the spinal needle used, the leakage of fluid from the subarachnoid space through the puncture site, and the patients hydration status. Measures that increase cerebrospinal pressure are helpful in relieving headache. These include keeping the patient lying flat, quiet, and well hydrated. In continuous spinal anesthesia, the tip of a plastic catheter remains in the subarachnoid space during the surgical procedure so that more anesthetics may be injected as needed. This technique allows greater control of the dosage, but there is greater potential for postanesthetic headache because of the large-gauge needle used.

Local Infiltration Anesthesia

Infiltration anesthesia is the injection of a solution containing the local anesthetic into the tissues at the planned incision site. Often it is combined with a local regional block by injecting the nerves immediately supplying the area. The advantages of local anesthesia are as follows: It is simple, economical, and nonexplosive. Equipment needed is minimal. Postoperative recovery is brief.

 Undesirable effects of general anesthesia are avoided. It is ideal for short and superficial surgical procedures. Local anesthesia is often administered in combination with epinephrine. Epinephrine constricts blood vessels, which prevents rapid absorption of the anesthetic agent and thus prolongs its local action. Rapid absorption of the anesthetic agent into the bloodstream, which could cause seizures, is also prevented. Types of local anesthetic agents are listed in Table 19-5.

Local anesthesia is the anesthesia of choice in any surgical procedure in which it can be used. However, contraindications include high preoperative levels of anxiety, because surgery with local anesthesia may increase anxiety. A patient who requests general anesthesia rarely does well under local anesthesia. For some surgical procedures, local anesthesia is impractical because of the number of injections and the amount of anesthetic that would be required (breast reconstruction, for example). The skin is prepared as for any surgical procedure, and a smallgauge needle is used to inject a modest amount of the anesthetic into the skin layers. This produces blanching or a wheal.

Additional anesthetic is then injected in the skin until an area the length of the proposed incision is anesthetized. A larger, longer needle then is used to infiltrate deeper tissues with the anesthetic. The action of the agent is almost immediate, so surgery may begin as soon as the injection is complete. Anesthesia lasts 45 minutes to 3 hours, depending on the anesthetic and the use of epinephrine.

Commonly used General Anesthetic Agents

GENERIC NAME Nitrous oxide TRADE NAME None ADMINISTRATION CHARACTERISTICS Inhalation USES induction recovery; procedures muscle

Inorganic nonvolatile Rapid gas; slight potency; and pleasant, odor; fruitlike short

nonirritating; when but relaxation

nonflammable supports combustion;

unimportant; poor adjunct to potent agents. Should be mixed with 30% oxgwn to prevent hypoxia.

muscle relaxation

Halothane

Fluothane

Inhalation

Halogenated volatile Rapid liquid; pleasant nonirritating; cardiovascular respiratory depressant; incomplete relaxation; potentially toxic to liver muscle

induction;

potent; wide spectrum for odor; maintenance; depth of anesthesia and easily rapid altered; reversal.

Rarely used.

Enflurane

Ethrane

Inhalation

Halogenated

ether; Rapid

induction

potent; some muscle and recovery; wide relaxation; respiratory depressant Desflurane Suprane Inhalation Halogenated liquid spectrum maintenance. Rarely used. Not used for in for

with low solubility; induction

desflurane has faster children. Can be uptake by inhalation used and elimination maintenance adults children. Sevoflurane Ultane Inhalation Volatile liquid form, Used for adults and nonflammable and children. Rapid for in and

nonexplosive; noted elimination. for its rapid

induction and rapid emergence qualities Isoflurane Forane Inhalation Halogenated methyl Rapid induction

ether; potent; muscle and recovery with relaxant; respiratory depressant; metabolized in liver Thiopental sodium Pentothal sodium Intravenous profound minimal aftereffects; spectrum maintenance. induction recovery; wide for

Barbiturate; potent; Rapid short acting with and

cumulative rapid

effect; short by when

procedures muscle not basal

uptake

circulatory

system; relaxation

no muscle relaxation; needed; respiratory depressant Methohexital Brevital Intravenous Barbiturate; potent; Rapid circulatory respiratory depressant Propofol Diprivan Intravenous Alkylphenol; potent Rapid short-acting sedative-hypnotic; cardiovascular depressant and short alone; anesthetic.

induction;

and brief anesthesia

induction recovery; procedures prolonged in

anesthesia

combination with inhalation or opioids. Ketamine Ketaject, ketalar Intravenous, intramuscular Dissociative profound drug; Rapid amnesia short induction; procedures muscle not children agents

and analgesia; may when cause psychological relaxation problems emergence Fentanyl Sublimaze Intravenous Opioid; during needed;

and young adults potent High-dose narcotic

narcotic; metabolizes anesthesia slowly;

in

respiratory combination with oxygen potent Premedication;

depressant Sufentanil Sufenta Intravenous Opioid;

narcotic; respiratory high-dose narcotic depressant anesthesia in

combination with oxygen Fentanyl droperidol and Innovar Intravenous Combination narcotic and Neuroleptanalgesia

tranquilizer; potent; long acting Diazepam Valium Intravenous, intramuscular Benzodiazepine; tranquilizer; produces Premedication; awake intubation;

amnesia; induction

sedation, and muscle relaxation Midazolam Versed Intravenous, intramuscular Benzodiazepine; sedative; acting central system respiratory depressant Premedication;

short- conscious amnesic; sedation; induction nervous in children and

Local and Regional Anesthetic Agents

GENERIC NAME AMINO AMIDES Bupivacaine Marcaine; Local 0.25% 0.50% - 2 to 3 400 mg TRADE NAME USES CONCENTRA TION DURATION MAXIMUM DOSAGE

Sensorcain infiltration*; e Regional block*; Surgical epidural Dibucaine Nupercain e; Percaine; Local infiltration; Peripheral

0.05% - 0.1%

3 to 3

30 mg

Cinchocain nerves e Etidocaine Duranest Peripheral nerves; epidural Lidocaine Xylocaine; Topical; 2% - 4% 0.5% 1% - 2% to 2 200 mg or 4 mg/kg; 500 mg or 7 mg/kg mixed when with 0.5% - 1% 2 to 3 500 mg

Lignocaine Infiltration*; Peripheral nerves*; Nerve block*; Spinal; Epidural

vasoconstrict or

Mepivacaine

Carbocain e

Infiltration; Peripheral nerves;

0.5% - 1% 1% - 2%

to 2

500 mg

Epidural Prilocaine Citanest Infiltration; Peripheral nerves; Regional block; Epidural 1% - 2% 2% - 3% to 2 600 mg

Ropivacaine

Naropin

Infiltration; Field block; Nerve block; Epidural; Postoperative pain and

0.2% 0.5% 0.75% 1%

2 surgical

for 200 mg for analgesia; 300

analgesia; 6 mg for nerve t0 10 for block surgical nerve block

management; not used for Bier block

AMINO ESTERS Chloroprocaine Nesacaine Infiltration*; Peripheral nerves*; 0.5% 2% to 1000 mg

Nerve block*; Epidural; Topical

2%

2% - 3% 4% - 10% 200 mg of 4 mg/kg weight body

Cocaine; Procaine

Novocain

Infiltration; Peripheral nerves; Spinal

0.5% 1% - 2%

to

1000 mg or 14 mg/kg

body weight

Tetracaine

Cetacaine Pontocain e

Topical; Spinal

2% 1%

2 to 4

20 mg

*Epinephrine may be used.

General Anesthesic Agents

NITROUS OXIDE
Nitronox, Entonox Drug class Anesthetic Gas

N2O, Nitrous Oxide or laughing gas, is the most commonly used inhalation anesthetic in dentistry and is commonly used in emergency centers and ambulatory surgery centers as well. When used alone, it is incapable of producing general anesthesia reliably, but it may be combined with other inhalation and/or intravenous agents in deep sedative or general anesthestic techniques. However, as a single agent, it is excellent for providing minimal and moderate sedation for apprehensive dental patients. It is also used with such other drugs as thiopental to produce surgical anesthesia and has the fastest induction and recovery time. It is regarded as the safest inhalation anesthetic because it does not slow respiration or blood flow to the brain.

THERAPEUTIC ACTIONS Nitrous oxide is eliminated unchanged from the body mostly by the lungs. Induction with nitrous oxide is relatively rapid, but a concentration of about 70% is needed to produce unconsciousness at sea level. At higher altitudes, unconsciousness will not be produced in healthy robust patients. Nitrous oxide is a low potency inhalation anaesthetic and not readily soluble. High concentrations, not greater than 70%, are used for induction of anaesthesia and recovery occurs quickly. INDICATIONS For the relief of severe pain, usually in emergency situations, by inhalation with 50% oxygen to prevent hypoxia. Only during induction and maintenance of anaesthesia, in controlled situations.

CONTRAINDICATIONS Nitrous oxide should not be used with any condition where air is entrapped within a body and where its expansion might be dangerous such as: o Artificial, traumatic or spontaneous pneumothorax o Air embolism o Decompression sickness o Following a recent dive o Following air encephelography o Severe bullous emphysema o Use during myringoplasty o Gross abdominal distension

The safety in pregnancy and lactation has not been established. Nitrous oxide should not be used as an analgesic anaesthetic agent for more than 24 hours without monitoring of peripheral blood for features of megaloblastic anaemia and leukopenia.

DOSAGE AND DIRECTIONS FOR USE Distinguish between adults, children and the elderly and between different clinical indications. For the production of general anaesthesia nitrous oxide is administered by inhalation through a suitable anaesthetic apparatus in concentrations up to 70% with oxygen as the balance. In neonates and elderly patients, an increased susceptibility to anaesthesia may be observed. There are no essential differences between the adult and child.

ROUTES OF ADMINISTRATION Nitrous oxide is administered through a face mask or tracheal tube by means of an anaesthetic apparatus. The gas is breathed in by the patient and absorbed through the lungs. SIDE EFFECTS AND SPECIAL PRECAUTIONS Anaesthetic agents should be used with caution in patients with cardiac, respiratory, renal, or hepatic impairment. Hypoxic anaesthesia is dangerous, and nitrous oxide should always be administered with oxygen. Nitrous oxide diffuses into gas-filled body cavities, and care is essential when using it in patients at risk from such diffusion, such as those with abdominal distension, pneumothorax, or similar cavities in the peritoneum or pericardium. The use of nitrous oxide causes inactivation of vitamin B12 which is a co-factor of methionine synthase. Folate metabolism is consequently interfered with and DNA synthesis is impaired following prolonged nitrous oxide administration. These disturbances result in megaloblastic marrow changes. Exceptionally heavy occupational exposure and addiction have resulted in myeloneuropathy and subacute combined degeneration. In patients with normal bone marrow, stores of mature granulocytes will normally be adequate to prevent leucopenia during exposure for up to 3 days : in patients exposed to nitrous oxide for longer periods of time, leucopenia will develop, and exposure for 4 days or longer can result in agranulocytosis.

Repeat exposure to nitrous oxide at intervals of less than 3 days will have a cumulative effect on DNA synthesis, and megaloblastic marrow changes have been reported following multiple short-term exposures.

Depletion of methionine has been implicated inthe neurological deficit seen in chronic abusers of nitrous oxide.

Oxygen should be administered during emergence from prolonged anaesthesia with nitrous oxide to prevent diffusion, hypoxia where the alveolar oxygen is diminished

Nitrous oxide is known to have an ozone depleting potential. It is a greenhouse gas and may contribute to global warming.

NURSING RESPONSIBILITIES Administration of nitrous oxide, more frequently than every 4 days should be accompanied by routine blood cell counts for evidence of megaloblastic change in red cells and hypersegmentation of neutrophils. Nitrous oxide should never be given with less than 21% oxygen. A minimum of 30% oxygen should be used during anaesthesia. At high altitudes and in the presence of disorders affecting oxygenation, higher concentrations of oxygen will be needed. Scavenging of waste nitrous oxide gas should be used to reduce operating theatre and equivalent treatment room levels to a level below 200 ppm of ambient nitrous oxide. At the end of a nitrous oxide / oxygen anaesthesia, withdrawal of the mask leads to an outpouring of nitrous oxide from the lungs and consequent dilution of oxygen in incoming air. This results in "diffusion hypoxia" and is counteracted by giving 100% oxygen for a few minutes when the flow of nitrous oxide is stopped.

PROPOFOL
(PRO-puh-FOLE) Diprivan Drug Class General Anesthetic THERAPEUTIC ACTIONS Propofol has been proposed to have several mechanisms of action, both through potentiation of GABAA receptor activity, thereby slowing the channel-closing time, and also acting as a sodium channel blocker. Recent research has also suggested that the endocannabinoid system may contribute significantly to propofol's anesthetic action and to its unique properties. PHARMACOKINETICS Propofol is highly protein-bound in vivo and is metabolised by conjugation in the liver. Its rate of clearance exceeds hepatic blood flow, suggesting an extrahepatic site of elimination as well. The half life of elimination of propofol has been estimated at between 2 and 24 hours. However, its duration of clinical effect is much shorter, because propofol is rapidly distributed into peripheral tissues. When used for IV sedation, a single dose of propofol typically wears off within minutes. Propofol is versatile; the drug can be given for short or prolonged sedation as well as for general anesthesia. Its use is not associated with nausea as is often seen with opioid medications. These characteristics of rapid onset and recovery along with its amnestic effects have led to its widespread use for sedation and anesthesia.

EEG research upon those undergoing general anesthesia with propofol finds that it causes a prominent reduction in the brain's information integration capacity at gamma wave band

CONTRAINDICATIONS AND INTERACTIONS The respiratory effects of propofol are potentiated by other respiratory depressants, including benzodiazepines.[25] As with any other general anesthetic agent, propofol should be administered only where appropriately trained staff and facilities for monitoring are available, as well as proper airway management, a supply of supplemental oxygen, artificial ventilation and cardiovascular resuscitation. ADVERSE EFFECTS Aside from low blood pressure related to vasodilation, and transient apnea following induction doses, one of propofol's most frequent side effects is pain on injection, especially in smaller veins. This pain can be mitigated by pretreatment with lidocaine.[5] Patients show great variability in their response to propofol, at times showing profound sedation with small doses. A more serious but rare side effect is dystonia.[6] Mild myoclonic movements are common, as with other intravenous hypnotic agents. Propofol appears to be safe for use in porphyria, and has not been known to trigger malignant hyperpyrexia. It has been reported that the euphoria caused by propofol is unlike that caused by other sedation agents, "I even remember my first experience using propofol: a

young woman who was emerging from a MAC anesthesia[7] looked at me as though I were a masked Brad Pitt and told me that she felt simply wonderful." C.F. Ward, M.D.[8] NURSING RESPONSIBILITIES Propofol has reportedly induced priapism in some individuals. Propofol (Diprivan) is indicated for use only in intubated mechanically ventilated adult patients. Administration of Propofol (Diprivan) is to be performed only by staff who have been educated on its specific considerations/properties, who have successfully completed ACLS training, and who are skilled in the management of critically ill patients. Continuous Propofol infusion will be administered only in the Medical/Surgical/ Neuroscience ICU and Cardiovascular Intensive Care (CVICU). It may also be administered in the PACU. The Cath Lab and Radiology Nursing can monitor and titrate the infusion, but will NOT initiate the infusion. In the Cath Lab and Radiology, a propofol infusion may be initiated by a critical care nurse for postprocedural sedation, but not for procedural moderate sedation. Propofol will not be administered to patients who: a.have known allergies to Propofol, soybean oil, egg lecithin, or glycerol. b. Are 12 years of age or less. c. Are pregnant or lactating mothers. d. Are NOT intubated AND mechanically ventilated (unless a member of the Anesthesia Dept. is present)

Caution will be used in patients with: a. Hyperlipidemia or those at risk to develop hyperlipidemia. b. Patients who are concurrently receiving TPN/Lipids. When Propofol is initiated, the physician will need to reduce the amount of lipids the patient is receiving, as 1ml of Propofol contains approximately 0.1g of fat (1.1 Kcal). Nutrition consult suggested. c. Patients with pancreatitis. d. Patients who are hypotensive, hypovolemic, or chemodynamically unstable.

Prior to initiating Propofol infusion, the nurse will: a. Validate physicians desired level of sedation on the Propofol Protocol. (The physician must specify the desired level of sedation if different from a Richmond Agitation Sedation Scale of -3.) b. Perform a baseline assessment for: 1) LOC/anxiety 2) Vital signs c. Assess patients level of pain; ensure concomitant IV analgesia has been ordered.

A Bolus of Propofol may be administered by an anesthesiologist, CRNA, or critical care pulminologist/intensivist. NO BOLUS of Propofol will be given by an RN. RNs

may administer Propofol by continuous IV infusion, via infusion pump through a dedicated line. Though a central line is preferred, it can be infused via a peripheral site. If a dedicated line is not possible, Propofol may be given with TPN and intralipids as long as a separate pump with a three way stopcock is utilized.

STRICT ASEPTIC technique must be maintained during handling, as Propofol ontains no antimicrobial preservatives. The vial rubber stopper will be disinfected using 70% isopropyl alcohol, prior to spiking the bottle with a sterile vent spike and sterile tubing. Infusion must commence immediately.

The Propofol infusion will be initiated at 5mcg/kg/min. a. No increase in the infusion rate will be made during the first 10 minutes of infusion. Assess the patient for hemodynamic response and level of sedation. b. If the patient is hemodynamically stable, increase the infusion rate at 5mcg/kg/min. no faster than every 5 minutes until the desired level of sedation (specified by the physician) is attained. Most adult patients require maintenance rates of 5-50 mcg/kg/min. to maintain adequate levels of sedation. If patient is requiring more than 75 mcg/kg/min. notify the physician and reassess sedation options.

KETAMINE
(Ket-ah-meen) Narketan Drug Class Anesthetic Induction

THERAPEUTIC ACTIONS The precise mechanism of action is unknown. Ketamine has been shown to block afferent impulses associated with the affective-emotional component of pain perception within the medial medullary reticular formation, to suppress spinal cord activity, and to interact with several central nervous system (CNS) transmitter systems. Ketamine blocks the N-methyl-D-aspartate (NMDA) glutamate receptor by a dual mechanism, blocking both the closed channel from the aqueous phase and the closed channel from the membrane phase. INDICATIONS Anesthesia, generalKetamine is indicated to provide anesthesia for short diagnostic and surgical procedures that do not require skeletal muscle relaxation. It is also indicated to induce anesthesia prior to administration of other general anesthetics. Ketamine may be used for the induction and/or maintenance of anesthesia in pediatric patients. However, in many cases, other anesthetic agents may be more appropriate for the maintenance of anesthesia in pediatric patients. Anesthesia, general, adjunctKetamine is indicated to supplement low-potency anesthetics such as nitrous oxide

[Anesthesia, local, adjunct]Ketamine is indicated as a supplement to local and regional anesthesia.

[Sedation and analgesia Ketamine is indicated to provide sedation and analgesia for painful procedures, including labor and vaginal delivery

[Sedation]Ketamine is indicated for sedation during painful procedures in the emergency department in pediatric patients.

CONTRAINDICATIONS Lack of knowledge of the drug, lack of resuscitative equipment, Inability to maintain a patent airways, allergy to ketamine, history of psychosis, cerebro-vascular disease Patients. For whom hypertension is hazardous.

SIDE EFFECTS Blurred vision; confusion; drowsiness; increased or decreased blood pressure or heart rate; mental or mood changes; nausea; nightmares; vomiting. Seek medical attention right away if any of these SEVERE side effects occur when using Ketamine: Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); difficulty talking; irregular heart rhythms; muscle tightness; pain, redness, or swelling at the injection site; slowed breathing.

NURSING CONSIDERATIONS Close monitoring of vital signs during the initial dosage and follow-up observations of the effectiveness of the medications. Vital signs are checked every four hours after the initial dosage along with evaluation of the effectiveness of the dosage and observation for signs of oxygenation of tissue. Ketamine should be administered slowly (over a period of 60 seconds). More rapid administration may result in respiratory depression and enhanced pressor response. Since aspiration may occur with ketamine and since protective reflexes may also be diminished by supplementary anesthetics and muscle relaxants, the possibility of aspiration should be controlled.

FENTANYL
(fen' ta nil) Actiq; Duragesic 25, 50, 75, 100; Sublimaze Drug class Opioid agonist analgesic

THERAPEUTIC ACTIONS Acts at specific opioid receptors, causing analgesia, respiratory depression, physical depression, euphoria. INDICATIONS Analgesic action of short duration during anesthesia and immediate postoperative period Analgesic supplement in general or regional anesthesia Administration with a neuroleptic as an anesthetic premedication, for induction of anesthesia, and as an adjunct in maintenance of general and regional anesthesia For use as an anesthetic agent with oxygen in selected high-risk patients Transdermal system: Management of chronic pain in patients requiring opioid analgesia Actiq: Treatment of breakthrough pain in cancer patients being treated with and tolerant to opioids CONTRAINDICATIONS AND CAUTIONS Contraindicated with hypersensitivity to opioids, diarrhea caused by poisoning, acute bronchial asthma, upper airway obstruction, pregnancy.

Use cautiously with bradycardia, history of seizures, lactation, renal dysfunction; history of drug addiction.

ADVERSE EFFECTS CNS: Sedation, clamminess, sweating, headache, vertigo, floating feeling, dizziness, lethargy, confusion, light-headedness, nervousness, unusual dreams, agitation, euphoria, hallucinations, delirium, insomnia, anxiety, fear, disorientation, impaired mental and physical performance, coma, mood changes, weakness, headache, tremor, seizures CV: Palpitation, increase or decrease in BP, circulatory depression, cardiac arrest, shock, tachycardia, bradycardia, arrhythmia, palpitations. Dermatologic: Rash, hives, pruritus, flushing, warmth, sensitivity to cold EENT: Diplopia, blurred vision GI: Nausea, vomiting, dry mouth, anorexia, constipation, biliary tract spasm GU: Ureteral spasm, spasm of vesical sphincters, urinary retention or

hesitancy, oliguria, antidiuretic effect, reduced libido or potency Local: Phlebitis following IV injection, pain at injection site; tissue irritation and induration (subcutaneous injection) Respiratory: Slow, shallow respiration, apnea, suppression of cough

reflex, laryngospasm, bronchospasm Other: Physical tolerance and dependence, psychological dependence; local skin irritation with transdermal system

NURSING CONSIDERATIONS CLINICAL ALERT! Name confusion has occurred between fentanyl and sufentanil; use extreme caution. Administer to women who are nursing a baby 46 hr before the next scheduled feeding to minimize the amount in milk. WARNING: Keep opioid antagonist and facilities for assisted or controlled respiration readily available during parenteral administration. Prepare site for transdermal form by clipping (not shaving) hair at site; do not use soap, oils, lotions, alcohol; allow skin to dry completely before application. Apply immediately after removal from the sealed package; firmly press

the transdermal system in place with the palm of the hand for 1020 sec, making sure the contact is complete. Must be worn continually for 72 hr. Note that the patch does not work quickly. It may take up to 12 hr to get the full therapeutic effect. Breakthrough medications need to be used. Do not use Actiq in patients who never received opioids before; should be used only in opioid-tolerant patients. Use caution with Actiq form to keep this drug out of the reach of children (it looks like a lollipop) and follow the distribution restrictions in place with this drug very carefully.

Enflurane
Forane Drug Class General Inhalation Anesthetic

THERAPEUTIC ACTIONS Enflurane induces a reduction in junctional conductance by decreasing gap junction channel opening times and increasing gap junction channel closing times. Enflurane also activates calcium dependent ATPase in the sarcoplasmic reticulum by increasing the fluidity of the lipid membrane. It also appears to bind the D subunit of ATP synthase and NADH dehydogenase. Enflurane also binds to and angonizes the GABA receptor, the large conductance Ca2+ activated potassium channel, the glycine receptor, and antagonizes the glutamate receptor receptor. These yield a decreased depolarization and therefore, tissue excitability which results in anesthesia. INDICATIONS Used for the induction and maintenance of general anaesthesia during surgery and cesarean section and also used for analgesia during vaginal delivery. Enflurane may be used for induction and maintenance of general anesthesia. Enflurane may be used to provide analgesia for vaginal delivery. Low concentrations of Enflurane may also be used to supplement other general anesthetic agents during delivery by Cesarean section. Higher concentrations of Enflurane may produce uterine relaxation and an increase in uterine bleeding

CONTRAINDICATIONS Known or suspected susceptibility to malignant hyperthermia. Porphyria. Seizure disorders Known sensitivity to Enflurane or other halogenated

SIDE EFFECTS Malignant hyperthermia Motor activity exemplified by movements of various muscle groups and/or seizures may be encountered with deep levels of Enflurane anesthesia, or light levels with hypocapnia Hypotension, respiratory depression and hypoxia have been reported. Arrhythmias, shivering, nausea and vomiting have been reported. Elevation of the white blood count has been observed Mild, moderate and severe liver injury, including hepatic failure, may rarely follow anesthesia with Enflurane DOSAGE & ADMINISTRATION

The concentration of Enflurane being delivered from a vaporizer during anesthesia should be known. This may be accomplished by using:

1) vaporizers calibrated specifically for Enflurane; 2) vaporizers from which delivered flows can be calculated.

Preanesthetic Medication Preanesthetic medication should be selected according to the need of the individual patient, taking into account that secretions are weakly stimulated by Enflurane and that Enflurane does not alter heart rate. The use of anticholinergic drugs is a matter of choice.

Surgical Anesthesia Induction may be achieved using Enflurane alone with oxygen or in combination with oxygen-nitrous oxide mixtures. Under these conditions some excitement may be encountered. If excitement is to be avoided, a hypnotic dose of a short-acting barbiturate should be used to induce unconsciousness, followed by the Enflurane mixture. In general, inspired concentrations of 2.0 to 4.5% Enflurane produced surgical anesthesia in 7 to 10 minutes.

Maintenance Surgical levels of anesthesia may be maintained with 0.5 to 3% Enflurane Maintenance concentrations should not exceed 3%. If added relaxation is required supplemental doses of muscle relaxants may be used. Ventilation to maintain the tension of carbon dioxide in arterial blood in the 35 to 45 mm Hg range is preferred. Hyperventilation should be avoided in order to minimize possibleCNS excitation. The level of blood pressure during maintenance is an inverse function of Enflurane concentration inthe absence of other complicating problems. Excessive decreases (unless related to hypovolemia) may be due to depth of anesthesia and in such instances should be corrected by lightening the level of anesthesia.

Analgesia Enflurane 0.25 to 1% provides analgesia for vaginal delivery equal to that produced by 30 to 60% nitrous oxide These concentrations normally do not produce amnesia. Enflurane should ordinarily be administered in the concentration range of 0.5 to 1% tosupplement other general anesthetics.

DIAZEPAM
(dye az' e pam) Apo-Diazepam (CAN), Diastat, Diazemuls (CAN), Diazepam Intensol, Valium, Vivol (CAN) Drug classes Benzodiazepine Anxiolytic Antiepileptic Skeletal muscle relaxant (centrally acting)

THERAPEUTIC ACTIONS Exact mechanisms of action not understood; acts mainly at the limbic system and reticular formation; may act in spinal cord and at supraspinal sites to produce skeletal muscle relaxation; potentiates the effects of GABA, an inhibitory neurotransmitter; anxiolytic effects occur at doses well below those necessary to cause sedation, ataxia; has little effect on cortical function.

INDICATIONS Management of anxiety disorders or for short-term relief of symptoms of anxiety Acute alcohol withdrawal; may be useful in symptomatic relief of acute agitation, tremor, delirium tremens, hallucinosis Muscle relaxant: Adjunct for relief of reflex skeletal muscle spasm due to local pathology (inflammation of muscles or joints) or secondary to

trauma;spasticity caused by upper motoneuron disorders (cerebral palsy and paraplegia); athetosis, stiff-man syndrome Parenteral: Treatment of tetanus

Antiepileptic: Adjunct in status epilepticus and severe recurrent convulsive seizures (parenteral); adjunct in convulsive disorders (oral)

Preoperative (parenteral): Relief of anxiety and tension and to lessen recall in patients prior to surgical procedures, cardioversion, and endoscopic procedures

Rectal: Management of selected, refractory patients with epilepsy who require intermittent use to control bouts of increased seizure activity

Unlabeled use: Treatment of panic attacks

CONTRAINDICATIONS AND CAUTIONS Contraindicated with hypersensitivity to benzodiazepines; psychoses, acute narrow-angle glaucoma, shock, coma, acute alcoholic intoxication; pregnancy (cleft lip or palate, inguinal hernia, cardiac defects, microcephaly,

pyloric stenosis when used in first trimester; neonatal withdrawal syndrome reported in newborns); lactation. Use cautiously with elderly or debilitated patients; impaired liver or kidney function.

ADVERSE EFFECTS CNS: Transient, mild drowsiness initially; sedation, depression, lethargy, apathy, fatigue, light-headedness, disorientation, restlessness, confusion,crying, delirium, headache, slurred speech, dysarthria, stupor, rigidity, tremor, dystonia, vertigo, euphoria, nervousness, difficulty in concentration, vivid dreams, psychomotor retardation, extrapyramidal symptoms; mild paradoxical excitatory reactions,

during

first

wk

of

treatment, visual

and

auditory

disturbances, diplopia, nystagmus, depressed hearing, nasal congestion CV: Bradycardia, tachycardia, CV collapse, hypertension and hypotension, palpitations, edema Dependence: Drug dependence with withdrawal syndrome when drug is discontinued (common with abrupt discontinuation of higher dosage used for longer than 4 mo); IV diazepam: 1.7% incidence of fatalities; oral benzodiazepines ingested alone; no well-documented fatal overdoses Dermatologic: Urticaria, pruritus, skin rash, dermatitis GI: Constipation; diarrhea, dry mouth; salivation; nausea; anorexia; vomiting; difficulty in swallowing; gastric disorders; elevations of blood enzymesLDH, alkaline phosphatase, AST, ALT; hepatic dysfunction; jaundice GU: Incontinence, urinary retention, changes in libido, menstrual irregularities Hematologic: Decreased hematocrit, blood dyscrasias Other: Phlebitis and thrombosis at IV injection sites, hiccups, fever, diaphoresis, paresthesias, muscular disturbances, gynecomastia; pain, burning, and redness after IM injection

NURSING CONSIDERATIONS WARNING: Do not administer intra-arterially; may produce arteriospasm, gangrene. Change from IV therapy to oral therapy as soon as possible. Do not use small veins (dorsum of hand or wrist) for IV injection.

Reduce dose of opioid analgesics with IV diazepam; dose should be reduced by at least one-third or eliminated.

Carefully monitor P, BP, respiration during IV administration. WARNING: Maintain patients receiving parenteral benzodiazepines in bed for 3 hr; do not permit ambulatory patients to operate a vehicle following an injection.

Monitor EEG in patients treated for status epilepticus; seizures may recur after initial control, presumably because of short duration of drug effect.

Monitor liver and kidney function, CBC during long-term therapy. Taper dosage gradually after long-term therapy, especially in epileptic patients. Arrange for epileptic patients to wear medical alert ID indicating that they are epileptics taking this medication.

Discuss risk of fetal abnormalities with patients desiring to become pregnant.

Regional Anesthesic Agents

LIDOCAINE HYDROCHLORIDE
Local anesthetic preparations: Octocaine, Xylocaine HCl (injectable) Drug classes Antiarrhythmic Local anesthetic

THERAPEUTIC ACTIONS Type 1 antiarrhythmic: Decreases diastolic depolarization, decreasing automaticity of ventricular cells; increases ventricular fibrillation threshold. Local anesthetic: Blocks the generation and conduction of action potentials in sensory nerves by reducing sodium permeability, reducing height and rate of rise of the action potential, increasing excitation threshold, and slowing conduction velocity.

INDICATIONS As antiarrhythmic: Management of acute ventricular arrhythmias during cardiac surgery and MI (IV use). Use IM when IV administration is not possible or when ECG monitoring is not available and the danger of ventricular arrhythmias is great (singledose IM use, for example, by paramedics in a mobile coronary care unit) As anesthetic: Infiltration anesthesia, peripheral and sympathetic nerve blocks, central nerve blocks, spinal and caudal anesthesia, retrobulbar andtranstracheal injection; topical anesthetic for skin disorders and accessible mucous membranes CONTRAINDICATIONS AND CAUTIONS Contraindicated with allergy to lidocaine or amide-type local anesthetics,

CHF, cardiogenic shock, second- or third-degree heart block (if no artificial pacemaker), Wolff-Parkinson-White syndrome, Stokes-Adams syndrome.

Use cautiously with hepatic or renal disease, inflammation or sepsis in the region of injection (local anesthetic), labor and delivery (epidural anesthesia may prolong the second stage of labor; monitor for fetal and neonatal CV and CNS toxicity), and lactation.

ADVERSE EFFECTS Injectable local anesthetic for epidural or caudal anesthesia CNS: Headache, backache, septic meningitis, persistent sensory, motor, or autonomic deficit of lower spinal segments, sometimes with incomplete recovery CV: Hypotension due to sympathetic block Dermatologic: Urticaria, pruritus, erythema, edema GU: Urinary retention, urinary or fecal incontinence

Topical local anesthetic Dermatologic: Contact dermatitis, urticaria, cutaneous lesions Hypersensitivity: Anaphylactoid reactions Local: Burning, stinging, tenderness, swelling, tissue irritation, tissue sloughing and necrosis Other: Methemoglobinemia, seizures (children)

NURSING CONSIDERATIONS INTERVENTIONS WARNING: Check drug concentration carefully; many concentrations are available. Reduce dosage with hepatic or renal failure. Continuously monitor response when used as antiarrhythmic or injected as local anesthetic.

WARNING: Keep life-support equipment and vasopressors readily available in case severe adverse reaction (CNS, CV, or respiratory) occurs whenlidocaine is injected.

WARNING: Establish safety precautions if CNS changes occur; have IV diazepam or shortacting barbiturate (thiopental, thiamylal) readily available in case of seizures.

WARNING: Monitor for malignant hyperthermia (jaw muscle spasm, rigidity); have lifesupport equipment and IV dantrolene readily available.

Titrate dose

to

minimum

needed

for

cardiac

stability,

when

using lidocaine as antiarrhythmic. Reduce dosage when treating arrhythmias in CHF, digitalis toxicity with AV block, and geriatric patients. Monitor fluid load carefully; more concentrated solutions can be used to treat arrhythmias in patients on fluid restrictions. Have patients who have received lidocaine as a spinal anesthetic remain lying flat for 612 hr afterward, and ensure that they are adequately hydrated to minimize risk of headache. WARNING: Check lidocaine preparation carefully; epinephrine is added to solutions of lidocaine to retard the absorption of the local anesthetic from the injection site. Be sure that such solutions are used only to produce local anesthesia. These solutions should be injected cautiously in body areas supplied by end arteries and used cautiously in patients with peripheral vascular disease, hypertension, thyrotoxicosis, or diabetes. Use caution to prevent choking. Patient may have difficulty swallowing following use of oral topical anesthetic. Do not give food or drink for 1 hr after use of oral anesthetic. WARNING: Treat methemoglobinemia with 1% methylene blue, 0.1 mg/kg, IV over 10 min. Apply lidocaine ointments or creams to a gauze or bandage before applying to the skin. WARNING: Monitor for safe and effective serum drug concentrations (antiarrhythmic use: 15 mcg/mL). Doses > 610 mcg/mL are usually toxic.

TETRACAINE HYDROCHLORIDE
Drug Class Local Anesthetic Agents

THERAPEUTIC ACTIONS:

Local anesthetic of the ester type, related to procaine. Stabilizes neuronal membrane; prevents initiation and transmission of nerve impulses thereby effecting local anesthesia.

Usually does not dilate the pupil, disturb accommodation, or increase intraocular pressure when applied to conjunctiva

Approximately equipotent to proparacaine hydrochloride.

INDICATIONS: Ophthalmic Anesthesia Applied topically to the eye to produce local anesthesia for diagnostic and therapeutic procedures (e.g., tonometry, gonioscopy, removal of foreign bodies or sutures from the cornea, conjunctival and corneal scraping for diagnostic purposes, paracentesis of the anterior chamber, thorough examination and irrigation of painful injuries, short procedures involving the cornea and conjunctiva). Rhinolaryngeal Anesthesia Applied topically to produce anesthesia of the nose and throat. Used to abolish laryngeal and esophageal reflexes prior to diagnostic procedures (e.g., bronchoscopy, bronchography, esophagoscopy).

CONTRAINDICATIONS Spinal anesthesia with Tetracaine hydrochloride is contraindicated in patients with known hypersensitivity to Tetracaine hydrochloride or to drugs of a similar chemical configuration (ester-type local anesthetics), or aminobenzoic acid or its derivatives; and in patients for whom spinal anesthesia as a technique is contraindicated. The decision as to whether or not spinal anesthesia should be used for an individual patient should be made by the physician after weighing the advantages with the risks and possible complications. Contraindications to spinal anesthesia as a technique can be found in standard reference texts, and usually include generalized septicemia, infection at the site of injection, certain diseases of the cerebrospinal system, uncontrolled hypotension, etc. ADVERSE EFFECTS Systemic adverse reactions to Tetracaine hydrochloride are characteristic of those associated with other local anesthetics and can involve the central nervous system and the cardiovascular system. Systemic reactions usually result from high plasma levels due to excessive dosage, rapid adsorption, or inadvertent intravascular injection. A small number of reactions to Tetracaine hydrochloride may result from hypersensitivity, idiosyncrasy or diminished tolerance to normal dosage. Central nervous system effects are characterized by excitation or depression. The first manifestation may be nervousness, dizziness, blurred vision, or tremors, followed by drowsiness, convulsions, unconsciousness and possibly respiratory and cardiac arrest. Since excitement may be transient or absent, the first manifestation may be drowsiness, sometimes merging into unconsciousness and respiratory and cardiac arrest. Other central

nervous system effects may be nausea, vomiting, chills, constriction of the pupils, or tinnitus. Cardiovascular system reactions include depression of the myocardium, blood pressure changes (usually hypotension), and cardiac arrest. Allergic reactions, which may be due to hypersensitivity, idiosyncrasy, or diminished tolerance, are characterized by cutaneous lesions (eg. urticaria), edema, and other manifestations of allergy. Detection of sensitivity by skin testing is of limited value. Severe allergic reactions including anaphylaxis have rarely occurred and are not usually doserelated. Reactions Associated with Spinal Anesthesia Techniques: Central Nervous System: postspinal headache, meningismus, arachnoiditis, palsies, or spinal nerve paralysis. Cardiovascular: hypotension due to vasomotor paralysis and pooling of the blood in the venous bed. Respiratory: respiratory impairment or paralysis due to the level of anesthesia extending to the upper thoracic and cervical segments. Gastrointestinal: nausea and vomiting.

Dosage and Administration As with all anesthetics, the dosage varies and depends upon the area to be anesthetized, the number of neuronal segments to be blocked, individual tolerance, and the technique of anesthesia. The lowest dosage needed to provide effective anesthesia should be administered. For specific techniques and procedures, refer to standard textbooks. The extent and degree of spinal anesthesia depend upon dosage, specific gravity of the anesthetic solution, volume of solution used, force of the injection, level of puncture, position of the patient during and immediately after injection, etc.

When spinal fluid is added to 1% Tetracaine hydrochloride injection, some turbidity results, the degree depending on the pH of the spinal fluid, the temperature of the solution during mixing, as well as the amount of drug and diluent employed. Liberation of base (which is completed within the spinal canal) is held to be essential for satisfactory results with any spinal anesthetic.

The specific gravity of spinal fluid at 25C/25C varies under normal conditions from 1.0063 to 1.0075. The 1% concentration in saline solution has a specific gravity of 1.0060 to 1.0074 at 25C/25C.

A hyperbaric solution may be prepared by mixing equal volumes of the 1% solution and Dextrose Solution 10%.

Examine ampules carefully before use. Do not use solution if crystals, cloudiness, or discoloration is observed.

This formulation of Tetracaine hydrochloride does not contain antimicrobial or bacteriostatic agents; therefore, unused portions should be discarded.

Sterilization of Ampules The Tetracaine hydrochloride injection is sterile within an undamaged ampule. To destroy bacteria on the exterior of ampules use heat sterilization (autoclaving) before opening. Immersion in antiseptic solution is not recommended.

Autoclave at 15-pounds pressure, at 121C (250F), for 15 minutes. Autoclaving increases likelihood of crystal formation. Unused autoclaved ampules should be discarded. Under no circumstances should unused ampules which have been autoclaved be returned to stock.

MEPIVACAINE HYDROCHORIDE
Drug Class Local Anesthetic Agent

THERAPEUTIC ACTIONS: Local anesthetics block the generation and the conduction of nerve impulses, presumably by increasing the threshold for electrical excitation in the nerve, by slowing the propagation of the nerve impulse, and by reducing the rate of rise of the action potential. In general, the progression of anesthesia is related to the diameter, myelination, and conduction velocity of affected nerve fibers. Clinically, the order of loss of nerve function is as follows: pain, temperature, touch, proprioception, and skeletal muscle tone. INDICATIONS:

TOP: pruritis, sunburn, toothache, sore throat, cold sores, rectal paint and irritation, control of gagging prior to performing bronchoscopy or esophagoscopy

OPHTH: cataract extraction, tonometry, gonioscopy, removal of foreign objects, corneal suture removal, glaucoma surgery

INJ: spinal anesthesia

CONTRAINDICATIONS: Complete heart block. Porphyria. Do not inject through infected skin when using for epidural anaesthesia. Hypersensitivity to ester anesthetics; application to large areas Infants less than 1 year

ADVERSE EFFECTS: Restlessness, excitement, nervousness, paraesthesias; dizziness, tinnitus, blurred vision; nausea, vomiting; muscle twitching, tremors, convulsions; numbness of the tongue and perioral region; lightheadedness, drowsiness, respiratory failure, coma, hypotension. Potentially Fatal: Myocardial depression, bradycardia, cardiac arrhythmias, cardiac arrest.

PROCAINE HYDROCHLORIDE
Novocaine Drug Class Local Anesthetic Agent

INDICATIONS: Indicated for the production of local or regional analgesia and anesthesia by local infiltration and peripheral nerve block techniques. ROUTE AND DOSAGE: Spinal Anaesthesia Adult: SC 10% solution diluted with NS at 1ml/5sec. Infiltration Anaesthesia/ Peripheral Nerve Block Adult: SC 0.25-0.5% solution NURSING RESPONSIBILITIES: Be aware that reactions, during dental procedure are usually mild, transient, and produced by epinephrine added to local anesthetic (e.g, headache, palpitation, tachycardia, hypertension, and dizziness). Uses procaine with epinephrine with caution in the body areas with limited blood supply (e.g., fingers, toes, ears, and nose). If used, inspect particular area for evidence of reduced perfusion (vasospasm): pale, cold, sensitive. Hypotension is the most important complication of spinal anesthesia. Risk period is during first 30 min. After induction and is intensified by changes in position that promote decreased venous return, or by pre-existing hypertension, pregnancy, pregnancy, old age, or hypovlemia.

MICARIUM CHLORIDE
Mivacron Drug class Non depolarizing Skelatal Muscle Relaxant

INDICATIONS: Adjunct to general anesthesia to facilitate tracheal intubation, and to provide skeletal muscle relaxant during surgery or mechanical ventilation.

ROUTE AND DOSAGE: Tracheal intubation and mechanical Ventilation Adult: IV loading Dose 0.15-0.25 mg/kg given over 5-15 sec (over 60 sec in pt. With cardiovascular disease). Maintenance Dose 0.1 mg/kg generally q 15min. IV Continuous Infusion Initial infusion of 9-10 mcg/kg/min, then 6-7 mcg/kg/min Child: IV Loading Dose 2-12 y, 0.2 mg/kg given over 5-15 sec (range: 0.09-0.2mg/kg/min)

NURSING RESPONSIBILITIES: Assess pt. With neuromuscular disease carefully and adjust drug dosage using a peripheral nerve stimulator when they experience prolonged neuromuscular blocks. Monitor hemodynamic status carefully with significant cardiovascular disease or those with potentially greater sensitivity to release of histamine-type mediators (asthma). Monitor significant drop in BP because overdose may increase the risk of Hemodynamic adverse effect.

Glossary
Acetylcholine (ACH, Ach) - The neurotransmitter substance at cholinergic synapses, which causes cardiac inhibition, vasodilation, gastrointestinal peristalsis, and other parasympathetic effects. It is liberated from preganglionic and postganglionic endings of parasympathetic fibers and from preganglionic fibers of the sympathetic as a result of nerve injuries, whereupon it acts as a transmitter on the effector organ; it is hydrolyzed into choline and acetic acid by acetylcholinesterase before a second impulse may be transmitted. Active immunization -The act of artificially stimulating the body to develop antibodies against infectious disease by the administration of vaccines or toxoids. Adenopathy - Swelling or morbid enlargement of the lymph nodes. Aleukia - Absence or extremely decreased number of leukocytes in the circulating blood. Analgesic - 1. A compound capable of producing analgesia, i.e., one that relieves pain by altering perception of nociceptive stimuli without producing anesthesia or loss of consciousness. 2. Characterized by reduced response to painful stimuli. Anaphylaxis - The term is commonly used to denote the immediate, transient kind of immunologic (allergic) reaction characterized by contraction of smooth muscle and dilation of capillaries due to release of pharmacologically active substances (histamine, bradykinin, serotonin, and slow-reacting substance), classically initiated by the combination of antigen (allergen) with mast cell-fixed, cytophilic antibody (chiefly IgE). Anticonvulsant - An agent which prevents or arrests seizures. Antitoxin - An antibody formed in response to and capable of neutralizing a biological poison; an animal serum containing antitoxins. Arthralgia - Severe pain in a joint, especially one not inflammatory in character. AST - Abbreviation for aspartate aminotransferase, a liver enzyme. Asthenia - Weakness or debility.

Ataxia - An inability to coordinate muscle activity during voluntary movement, so that smooth movements occur. Most often due to disorders of the cerebellum or the posterior columns of the spinal cord; may involve the limbs, head, or trunk. Atelectasis - Absence of gas from a part or the whole of the lungs, due to failure of expansion or resorption of gas from the alveoli. Atropine - An anticholinergic, with diverse effects (tachycardia, mydriasis, cycloplegia, constipation, urinary retention) attributable to reversible competitive blockade of acetylcholine at muscarinic type cholinergic receptors; used in the treatment of poisoning with organophosphate insecticides or nerve gases. Bilirubin - A red bile pigment formed from hemoglobin during normal and abnormal destruction of erythrocytes. Excess bilirubin is associated with jaundice. Blood agar - A mixture of blood and nutrient agar, used for the cultivation of many medically important microorganisms. Bronchiolitis - Inflammation of the bronchioles, often associated with bronchopneumonia. Bronchitis - Inflammation of the mucous membrane of the bronchial tubes. Brucella - A genus of encapsulated, nonmotile bacteria (family Brucellaceae) containing short, rod-shaped to coccoid, Gram-negative cells. These organisms are parasitic, invading all animal tissues and causing infection of the genital organs, the mammary gland, and the respiratory and intestinal tracts, and are pathogenic for man and various species of domestic animals. They do not produce gas from carbohydrates. Bubo - Inflammatory swelling of one or more lymph nodes, usually in the groin; the confluent mass of nodes usually suppurates and drains pus. Bulla, gen. and pl. bullae - A large blister appearing as a circumscribed area of separation of the epidermis from the subepidermal structure (subepidermal bulla) or as a circumscribed area of separation of epidermal cells (intraepidermal bulla) caused by the presence of serum, or occasionally by an injected substance.

Carbuncle - Deep-seated pyogenic infection of the skin and subcutaneous tissues, usually arising in several contiguous hair follicles, with formation of connecting sinuses; often preceded or accompanied by fever, malaise, and prostration. Cerebrospinal - Relating to the brain and the spinal cord. Chemoprophylaxis - Prevention of disease by the use of chemicals or drugs. Cholinergic - Relating to nerve cells or fibers that employ acetylcholine as their neurotransmitter. CNS - Abbreviation for central nervous system. Coagulopathy - A disease affecting the coagulability of the blood. Coccobacillus - A short, thick bacterial rod of the shape of an oval or slightly elongated coccus. Conjunctiva, pl. conjunctivae - The mucous membrane investing the anterior surface of the eyeball and the posterior surface of the lids. CSF - Abbreviation for cerebrospinal fluid. Cutaneous - Relating to the skin. Cyanosis - A dark bluish or purplish coloration of the skin and mucous membrane due to deficient oxygenation of the blood, evident when reduced hemoglobin in the blood exceeds 5 g per 100 ml. Diathesis -The constitutional or inborn state disposing to a disease, group of diseases, or metabolic or structural anomaly. Diplopia -The condition in which a single object is perceived as two objects. Distal - Situated away from the center of the body, or from the point of origin; specifically applied to the extremity or distant part of a limb or organ. Dysarthria - A disturbance of speech and language due to emotional stress, to brain injury, or to paralysis, incoordination, or spasticity of the muscles used for speaking. Dysphagia, dysphagy - Difficulty in swallowing. Dysphonia - Altered voice production.

Dyspnea - Shortness of breath, a subjective difficulty or distress in breathing, usually associated with disease of the heart or lungs; occurs normally during intense physical exertion or at high altitude. Ecchymosis - A purplish patch caused by extravasation of blood into the skin, differing from petechiae only in size (larger than 3 mm diameter). Eczema - Generic term for inflammatory conditions of the skin, particularly with vesiculation in the acute stage, typically erythematous, edematous, papular, and crusting; followed often by lichenification and scaling and occasionally by duskiness of the erythema and, infrequently, hyperpigmentation; often accompanied by sensations of itching and burning. Edema - An accumulation of an excessive amount of watery fluid in cells, tissues, or serous cavities. Enanthem, enanthema - A mucous membrane eruption, especially one occurring in connection with one of the exanthemas. Encephalitis, pl. encephalitides - Inflammation of the brain. Endotoxemia - Presence in the blood of endotoxins. Endotracheal intubation - Passage of a tube through the nose or mouth into the trachea for maintenance of the airway during anesthesia or for maintenance of an imperiled airway. Enterotoxin - A cytotoxin specific for the cells of the intestinal mucosa. Epistaxis - Profuse bleeding from the nose. Epizootic - 1. Denoting a temporal pattern of disease occurrence in an animal population in which the disease occurs with a frequency clearly in excess of the expected frequency in that population during a given time interval. 2. An outbreak (epidemic) of disease in an animal population; often with the implication that it may also affect human populations. Erythema - Redness of the skin due to capillary dilatation.

Erythema multiforme - An acute eruption of macules, papules, or subdermal vesicles presenting a multiform appearance, the characteristic lesion being the target or iris lesion over the dorsal aspect of the hands and forearms; its origin may be allergic, seasonal, or from drug sensitivity, and the eruption, although usually self-limited (e.g., multiforme minor), may be recurrent or may run a severe course, sometimes with fatal termination (e.g., multiforme major or Stevens-Johnson syndrome). Erythrocyte - A mature red blood cell. Erythropoiesis - The formation of red blood cells. Exanthema - A skin eruption occurring as a symptom of an acute viral or coccal disease, as in scarlet fever or measles. Extracellular -Outside the cells. Extraocular - Adjacent to but outside the eyeball. Fasciculation - Involuntary contractions, or twitchings, of groups (fasciculi) of muscle fibers, a coarser form of muscular contraction than fibrillation. Febrile - Denoting or relating to fever. Fomite - Objects, such as clothing, towels, and utensils that possibly harbor a disease agent and are capable of transmitting it. Formalin - A 37% aqueous solution of formaldehyde. Fulminant hepatitis - Severe, rapidly progressive loss of hepatic function due to viral infection or other cause of inflammatory destruction of liver tissue. Generalized vaccinia - Secondary lesions of the skin following vaccination which may occur in subjects with previously healthy skin but are more common in the case of traumatized skin, especially in the case of eczema (eczema vaccinatum). In the latter instance, generalized vaccinia may result from mere contact with a vaccinated person. Secondary vaccinial lesions may also occur following transfer of virus from the vaccination to another site by means of the fingers (autoinnoculation).

Glanders - A chronic debilitating disease of horses and other equids, as well as some members of the cat family, caused by Pseudomonas mallei; it is transmissible to humans. It attacks the mucous membranes of the nostrils of the horse, producing an increased and vitiated secretion and discharge of mucus, and enlargement and induration of the glands of the lower jaw. Granulocytopenia -Less than the normal number of granular leukocytes in the blood. Guarnieri bodies - Intracytoplasmic acidophilic inclusion body's observed in epithelial cells in variola (smallpox) and vaccinia infections, and which include aggregations of Paschen body's or virus particles. Hemagglutination - The agglutination of red blood cells; may be immune as a result of specific antibody either for red blood cell antigens per se or other antigens which coat the red blood cells, or may be nonimmune as in hemagglutination caused by viruses or other microbes. Hemagglutinin - A substance, antibody or other, that causes hemagglutination. Hematemesis - Vomiting of blood. Hemopoietic - Pertaining to or related to the formation of blood cells. Hematuria - Any condition in which the urine contains blood or red blood cells. Hemodynamic - Relating to the physical aspects of the blood circulation. Hemolysis -Alteration, dissolution, or destruction of red blood cells in such a manner that hemoglobin is liberated into the medium in which the cells are suspended, e.g., by specific complement-fixing antibodies, toxins, various chemical agents, tonicity, alteration of temperature. Hemolytic Uremic Syndrome - Hemolytic anemia and thrombocytopenia occurring with acute renal failure. Hemoptysis - The spitting of blood derived from the lungs or bronchial tubes as a result of pulmonary or bronchial hemorrhage.

Hepatic - Relating to the liver. Heterologous - 1. Pertaining to cytologic or histologic elements occurring where they are not normally found. 2. Derived from an animal of a different species, as the serum of a horse is heterologous for a rabbit. Hyperemia - The presence of an increased amount of blood in a part or organ. Hyperesthesia - Abnormal acuteness of sensitivity to touch, pain, or other sensory stimuli. Hypotension - Subnormal arterial blood pressure. Hypovolemia - A decreased amount of blood in the body. Hypoxemia - Subnormal oxygenation of arterial blood, short of anoxia. Idiopathic - Denoting a disease of unknown cause. Immunoassay - Detection and assay of substances by serological (immunological) methods; in most applications the substance in question serves as antigen, both in antibody production and in measurement of antibody by the test substance. In vitro - In an artificial environment, referring to a process or reaction occurring therein, as in a test tube or culture media. In vivo - In the living body, referring to a process or reaction occurring therein. Induration - 1. The process of becoming extremely firm or hard, or having such physical features. 2. A focus or region of indurated tissue. Inguinal - Relating to the groin. Inoculation - Introduction into the body of the causative organism of a disease. Leukopenia - The antithesis of leukocytosis; any situation in which the total number of leukocytes in the circulating blood is less than normal, the lower limit of which is generally regarded as 4000-5000 per cu mm. Lumbosacral - Relating to the lumbar vertebrae and the sacrum. Lumen, pl. lumina - The space in the interior of a tubular structure, such as an artery or

the intestine. Lymphadenopathy - Any disease process affecting a lymph node or lymph nodes. Lymphopenia - A reduction, relative or absolute, in the number of lymphocytes in the circulating blood. Macula, pl. maculae - 1. A small spot, perceptibly different in color from the surrounding tissue. 2. A small, discolored patch or spot on the skin, neither elevated above nor depressed below the skin's surface. Mediastinitis - Inflammation of the cellular tissue of the mediastinum. Mediastinum - The median partition of the thoracic cavity, covered by the mediastinal pleura and containing all the thoracic viscera and structures except the lungs. Megakaryocyte - A large cell with a polyploid nucleus that is usually multilobed; megakaryocytes are normally present in bone marrow, not in the circulating blood, and give rise to blood platelets. Melena - Passage of dark-colored, tarry stools, due to the presence of blood altered by the intestinal juices. Meningism - A condition in which the symptoms simulate a meningitis, but in which no actual inflammation of these membranes is present. Meningococcemia - Presence of meningococci (N. meningitidis) in the circulating blood. Meninges - Any membrane; specifically, one of the membranous coverings of the brain and spinal cord. Microcyst - A tiny cyst, frequently of such dimensions that a magnifying lens or microscope is required for observation. Microscopy - Investigation of minute objects by means of a microscope. Moribund - Dying; at the point of death. Mucocutaneous - Relating to mucous membrane and skin; denoting the line of junction of the two at the nasal, oral, vaginal, and anal orifices.

Myalgia - Muscular pain. Mydriasis - Dilation of the pupil. Narcosis - General and nonspecific reversible depression of neuronal excitability, produced by a number of physical and chemical agents, usually resulting in stupor rather than in anesthesia. Necrosis - Pathologic death of one or more cells, or of a portion of tissue or organ, resulting from irreversible damage. Nephropathia epidemica - A generally benign form of epidemic hemorrhagic fever reported in Scandinavia. Neutrophilia - An increase of neutrophilic leukocytes in blood or tissues; also frequently used synonymously with leukocytosis, inasmuch as the latter is generally the result of an increased number of neutrophilic granulocytes in the circulating blood (or in the tissues, or both). Nosocomial - Denoting a new disorder (not the patient's original condition) associated with being treated in a hospital, such as a hospital-acquired infection. Oliguria - Scanty urine production. Oropharynx - The portion of the pharynx that lies posterior to the mouth; it is continuous above with the nasopharynx via the pharyngeal isthmus and below with the laryngopharynx. Osteomyelitis - Inflammation of the bone marrow and adjacent bone. Pancytopenia - Pronounced reduction in the number of erythrocytes, all types of white blood cells, and the blood platelets in the circulating blood. Pandemic - Denoting a disease affecting or attacking the population of an extensive region, country, continent; extensively epidemic. Papule - A small, circumscribed, solid elevation on the skin. Parasitemia -The presence of parasites in the circulating blood; used especially with

reference to malarial and other protozoan forms, and microfilariae. Passive immunity - Providing temporary protection from disease through the administration of exogenously produced antibody (i.e., transplacental transmission of antibodies to the fetus or the injection of immune globulin for specific preventive purposes). PCR - see below for polymerase chain reaction. Percutaneous - Denoting the passage of substances through unbroken skin, for example, by needle puncture, including introduction of wires and catheters. Perivascular - Surrounding a blood or lymph vessel. Petechia, pl. petechiae - Minute hemorrhagic spots, of pinpoint to pinhead size, in the skin, which are not blanched by pressure. Pharyngeal - Relating to the pharynx. Pharyngitis - Inflammation of the mucous membrane and underlying parts of the pharynx. Phosgene - Carbonyl chloride; a colorless liquid below 8.2C, but an extremely poisonous gas at ordinary temperatures; it is an insidious gas, since it is not immediately irritating, even when fatal concentrations are inhaled. Photophobia - Morbid dread and avoidance of light. Photosensitivity, or pain in the eyes with exposure to light, can be a cause. Pleurisy - Inflammation of the pleura. Polymerase chain reaction - An in vitro method for enzymatically synthesizing and amplifying defined sequences of DNA in molecular biology. Can be used for improving DNA-based diagnostic procedures for identifying unknown BW agents. Polymorphonuclear - Having nuclei of varied forms; denoting a variety of leukocyte. Polyuria - Excessive excretion of urine. Presynaptic - Pertaining to the area on the proximal side of a synaptic cleft.

Prophylaxis, pl. prophylaxes - Prevention of disease or of a process that can lead to disease. Prostration - A marked loss of strength, as in exhaustion. Proteinuria - Presence of urinary protein in concentrations greater than 0.3 g in a 24hour urine collection or in concentrations greater than 1 g/l in a random urine collection on two or more occasions at least 6 hours apart; specimens must be clean, voided midstream, or obtained by catheterization. Pruritus - Syn: itching. Ptosis, pl. ptoses - In reference to the eyes, drooping of the eyelids. Pulmonary edema -Edema of the lungs. Pyrogenic - Causing fever. Retinitis - Inflammation of the retina. Retrosternal - Posterior to the sternum. Rhinorrhea - A discharge from the nasal mucous membrane. Sarin - A nerve poison which is a very potent irreversible cholinesterase inhibitor and a more toxic nerve gas than tabun or soman. Scarification -The making of a number of superficial incisions in the skin. It is the technique used to administer tularemia and smallpox vaccines. Septic shock - 1. shock associated with sepsis, usually associated with abdominal and pelvic infection complicating trauma or operations; 2. shock associated with septicemia caused by Gram-negative bacteria. Sequela, pl. sequelae - A condition following as a consequence of a disease. Shigellosis - Bacillary dysentery caused by bacteria of the genus Shigella, often occurring in epidemic patterns. Soman - An extremely potent cholinesterase inhibitor, similar to sarin and tabun. Sterile abscess - An abscess whose contents are not caused by pyogenic bacteria.

Stridor - A high-pitched, noisy respiration, like the blowing of the wind; a sign of respiratory obstruction, especially in the trachea or larynx. Superantigen - An antigen that interacts with the T cell receptor in a domain outside of the antigen recognition site. This type of interaction induces the activation of larger numbers of T cells compared to antigens that are presented in the antigen recognition site. Superinfection - A new infection in addition to one already present. Tachycardia - Rapid beating of the heart, conventionally applied to rates over 100 per minute. Teratogenicity -The property or capability of producing fetal malformation. Thrombocytopenia - A condition in which there is an abnormally small number of platelets in the circulating blood. Toxoid - A modified bacterial toxin that has been rendered nontoxic (commonly with formaldehyde) but retains the ability to stimulate the formation of antitoxins (antibodies) and thus producing an active immunity. Examples include Botulinum, tetanus, and diphtheria toxoids. Tracheitis - Inflammation of the lining membrane of the trachea. Urticaria - An eruption of itching wheals, usually of systemic origin; it may be due to a state of hypersensitivity to foods or drugs, foci of infection, physical agents (heat, cold, light, friction), or psychic stimuli. Vaccine - A suspension of attenuated live or killed microorganisms (bacteria, viruses, or rickettsiae), or fractions thereof, administered to induce immunity and thereby prevent infectious disease. Vaccinia - An infection, primarily local and limited to the site of inoculation, induced in man by inoculation with the vaccinia (coxpox) virus in order to confer resistance to smallpox (variola). On about the third day after vaccination, papules form at the site of

inoculation which become transformed into umbilicated vesicles and later pustules; they then dry up, and the scab falls off on about the 21st day, leaving a pitted scar; in some cases there are more or less marked constitutional disturbances. Varicella - An acute contagious disease, usually occurring in children, caused by the varicella-zoster virus, a member of the family Herpesviridae, and marked by a sparse eruption of papules, which become vesicles and then pustules, like that of smallpox although less severe and varying in stages, usually with mild constitutional symptoms; incubation period is about 14 to 17 days. Syn: chickenpox Variola - Syn: smallpox. Variolation - The historical practice of inducing immunity against smallpox by scratching the skin with the purulency from smallpox skin pustules. The first inoculation for smallpox is said to have been done in China about 1022 B.C. Viremia - The presence of virus in the bloodstream. Virion - The complete virus particle that is structurally intact and infectious. Zoonosis - An infection or infestation shared in nature by humans and other animals that are the normal or usual host; a disease of humans acquired from an animal source.