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Can also be used to help wean patients from Versed drips Chloral Hydrate (25-75mg/kg max dose 2gm/day) • Class: sedative hypnotic • Half-life: around 8 hours • Metabolism: by liver to trichloroethanol (active metabolite) then excreted in urine • Dosing Frequency: Q6hours to Qday • Precautions: Trichloroethanol is carcinogenic in mice discount 20 mg tamoxifen otc, prolonged usage may put patient at risk discount 20mg tamoxifen visa. No preservatives in solution so at high risk for infection unless aseptic technique is adhered to purchase tamoxifen 20mg with mastercard, particularly for prolonged drips. Also used overnight prior to extubation on patients who have had prolonged sedation to allow decreasing other sedatives, rapid wean prior to extubation. Prolonged administration can produce prolonged muscle weakness after stoppage • Uses: as a paralytic in patients who need prolonged mechanical ventilation with significant lung disease, those with significant pulmonary hypertension, Pancuronium (Pavulon) (0. Can improve urine output in patients whose renal function is not responding to high dose loop diuretics. Antiarrhythmic Agents Adenosine (Adenocard) (50mcg/kg initial dose, then increase by 50 for each subsequent dose) • Class: endogenous nucleoside • Half-Life: <10 seconds • Metabolism: rapidly taken up by erythrocytes and vascular endothelial cells, becomes part of body pool of nucleosides • Dosing Frequency: repeat doses can be given as early as 2 minutes after initial dose • Administration: should be given in most central venous access site as rapidly as possible. Central venous access is preferred but not essential • Precautions: may produce a short-lasting first, second or third degree av block. It is used • exclusively in supraventricular tachycardia to convert to sinus rhythm. At high doses (10-20mcg/kg/min) alpha effects more prevalent • Use: good first line to improve cardiac output when used in mid-range • Risk: high doses may cause vasoconstiction. Long term use downregulates catecholamine receptors, decreasing effect, also increases myocardial oxygen demand Drugs to Improve Cardiac Output and cause Vasodilation Milrinone (0. May cause reflex tachycardia due to vasodilation • Use: afterload reduction, additional inotropic support when catecholamines already in use. Drugs to increase systemic vascular resistance (increase afterload) Norepinephrine (Levophed) (initial dose 0. The goal in any patient is for this ratio to approach 1, so there is equal blood flow to the lungs and body. In patients who have all of their pulmonary blood flow supplied by a shunt from the aorta (i. Sat (pulm venous) = as we usually cannot measure this we assume that, with healthy lungs the blood will be fully oxygenated, i. Qp 80%-60% = 20 = 1 Qs 100-%-80% 20 Oxygen Content (CxO2) (for any sample of blood) CxO2 = 1. It is essential to get comfortable with the idea of titrating drugs to effect--there is no “dose”. A dose of morphine that wouldn’t touch a narcotic-tolerant oncology patient could cause life-threatening respiratory depression in an adolescent with a broken arm. Onset of action--t1/2 reflects initial distribution from blood to highly perfused tissues. Volume of distribution--relates the amount of drug in the body to the concentration of drug in the blood or plasma--the fluid volume that would be needed to account for all the drug in the body. Small Vd implies that the drug is retained within the vascular compartment, large Vd implies distribution through the body of sequestration in certain tissues. Clearance--The ability of the body to eliminate a drug, expressed as a volume of blood cleared of drug per unit time. Bioavailability--the percent of the dose reaching the systemic circulation as unchanges drug following administration by any route. In addition to their analgesic properties, narcotics decrease responsiveness to external stimulation and reduce the level of consciousness. Nevertheless, the sedative properties of narcotics are inferior to those of the benzodiazepines, and amnesia following narcotic administration is incomplete. Depending on the drug you can see decreased ventilatory rate or tidal volume (thus, the rate may be ok, but the tidal volume may be inadequate). Pruritis--Several of the opioids cause itching, and there is significant inter-patient variability in susceptibility. Dependence is treated with gradual withdrawal of the drug, either using the initial drug, or converting to methadone for convenient dosing. Treatment of withdrawal can be difficult if the patient has been receiving narcotics for prolonged periods.

This ‘shifts’ the oxyhaemoglobin tems and ventilators and deliver it via a pipeline dissociation curve to the left tamoxifen 20mg without a prescription, increasing the af- system to the external atmosphere order tamoxifen 20mg without prescription. Hypocapnia will widely used is an active system in which a low neg- induce vasoconstriction in many organs tamoxifen 20 mg generic, includ- ative pressure is applied to the expiratory valve 46 Anaesthesia Chapter 2 A C B Figure 2. The use of such systems does not eliminate the problem of pollution; it merely shifts Measurement and monitoring are closely linked it from one site to another. A measuring instrument ics, particularly nitrous oxide, are potent destroy- becomes a monitor when it is capable of delivering 47 Chapter 2 Anaesthesia A B Figure 2. During anaesthesia, both the • anaesthetic technique used; patient and the equipment being used are moni- • present and previous health of the patient; tored, the complexity of which depends upon a va- • equipment available and the anaesthetist’s riety of factors including: ability to use it; 48 Anaesthesia Chapter 2 Monitoring is not without its own potential hazards: faulty equipment may endanger the pa- tient, for example from electrocution secondary to faulty earthing; the anaesthetist may act on faulty data, instituting inappropriate treatment; or the patient may be harmed by the complications of the technique to establish invasive monitoring, for ex- ample pneumothorax following central line inser- tion. Ultimately, too many monitors may distract the anaesthetist from recognizing problems occur- ring in other areas. Finally, additional equipment will be required in • preferences of the anaesthetist; certain cases, to monitor, for example: • any research being undertaken. Monitoring should commence before the induction of anaesthesia and continue until the This is easily applied and gives information on patient has recovered from the effects of anaes- heart rate and rhythm, and may warn of the pres- thesia, and the information generated should be ence of ischaemia and acute disturbances of certain recorded in the patient’s notes. It can be tors supplement clinical observation; there is no monitored using three leads applied to the right substitute for the presence of a trained and experi- shoulder (red), the left shoulder (yellow) and the enced anaesthetist throughout the entire operative left lower chest (green), to give a tracing equivalent procedure. The pulse oximeter therefore This is the most common method of obtaining the gives information about both the circulatory and patient’s blood pressure during anaesthesia and respiratory systems and has the advantages of: surgery. A pneumatic cuff with a width that is 40% • providing continuous monitoring of oxygena- of the arm circumference must be used and the inter- tion at tissue level; nal inflatable bladder should encircle at least half • being unaffected by skin pigmentation; the arm. If the cuff is too small, the blood pressure • portability (mains or battery powered); will be overestimated, and if it is too large it will be • being non-invasive. Auscultation of the Korotkoff Despite this, there a number of important limita- sounds is difficult in the operating theatre and au- tions of this device: tomated devices (Fig. An • There is failure to realize the severity of hypoxia; electrical pump inflates the cuff, which then un- dergoes controlled deflation. A microprocessor- controlled pressure transducer detects variations in cuff pressure resulting from transmitted arterial pulsations. Initial pulsations represent systolic blood pressure and peak amplitude of the pulsa- tions equates to mean arterial pressure. The frequency at which blood pressure is estimated can be set along with values for blood pressure, outside which an alarm sounds. Such devices cannot measure pressure continually and become increasingly inaccurate at extremes of pressure and in patients with an arrhythmia. Hypoventilation can be compensated for by increasing the inspired oxygen concentration to maintain oxygen saturation. A single device embolus), the gap between arterial and end-tidal can be calibrated for all of the commonly used carbon dioxide increases (end-tidal falls), mainly inhalational anaesthetics. The gap also increases monitors are integrated and displayed on a single in patients with chest disease due to poor mixing screen (Fig. Urine Temperature output needs to be measured at least hourly, aim- During anaesthesia the patient’s temperature is ing for a flow of approximately 1mL/kg/h. The most com- to produce urine indicates that renal blood flow is monly used device is a thermistor, the resistance of inadequate, as well as the flow to the other vital which is temperature dependent. Catheterization also placed in the oesophagus (cardiac temperature) or eliminates bladder distension or incontinence. An infrared tympanic membrane thermome- This is measured by inserting a catheter via a cen- ter can be used intermittently, but the external tral vein, usually the internal jugular or subclavian, auditory canal must be clear. Most patients’ core so that its tip lies at the junction of the superior temperature falls during anaesthesia as a result of vena cava and right atrium. It is then connected via exposure to a cold environment, evaporation of a fluid-filled tube to a transducer that converts the fluids from body cavities, the administration of pressure signal to an electrical signal. This is then cold intravenous fluids and breathing dry, cold amplified and displayed as both a waveform and anaesthetic gases.

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Daily prophylaxis during an influenza season reduces infection rates by 50–90 % (Dawkins 1968 buy tamoxifen 20mg otc, Dolin 1982 trusted 20mg tamoxifen, Clover 1986) purchase 20mg tamoxifen mastercard. In one study, rimantadine was ineffective in pro- tecting household members from influenza A infection (Hayden 1989). In addition, amantadine has a wide range of toxicity which may be in part attributable to the anticholinergic effects of the drug. The same frequency of side effects was found when the drug was tested in young healthy volunteers over a four-week period. Among 44 individuals, side effects (dizziness, nervousness, and insomnia) were well tolerated by most subjects, but 6 volunteers discontinued amantadine because of marked complaints. When studied in 450 volunteers during an outbreak of influenza A, the prophylactic effects of rimantadine and amantadine were comparable. Influ- enza-like illness occurred in 14 % of the rimantadine group and in 9 % of the amantadine group (Dolin 1982). Withdrawal from the study because of central nervous system side effects was more frequent in the amantadine (13 %) than in the rimantadine group (6 %). The potential for drug interactions is greater for amantadine, especially when co- administered with central nervous system stimulants. Agents with anticholinergic properties may potentiate the anticholinergic-like side effects of amantadine. Point mutations in the M gene lead to amino acid changes in the transmembrane region of the M2 protein and may confer high-level resistance to amantadine. The genetic basis for resistance appears to be single amino acid substitutions at positions 26, 27, 30, 31 or 34 in the transmembrane portion of the M2 ion channel (Hay 1985). In an avian model, they were also genetically stable, showing no reversion to the wild- type after six passages in birds over a period of greater than 20 days (Bean 1989). Such strains may develop in up to one third of patients treated with amantadine or rimantadine; in immunocompromised individuals the percentage may even be higher (Englund 1998). Drug-resistant influenza A virus (H3N2) can be obtained from rimantadine-treated children and adults as early as 2 days after starting treat- ment (Hayden 1991). Some H5N1 strains which have been associated with human 174 Treatment and Prophylaxis disease in Southeast Asia are resistant against amantadine and rimantadine (Peiris 2004, Le 2005), while isolates from strains circulating in Indonesia and, more re- cently, in China, Mongolia, Russia, Turkey and Romania are amantadine sensitive (Hayden 2005). Some authors have suggested that the use of amantadine and rimantadine should be gen- erally discouraged (Jefferson 2006). Indications for the Use of M2 Inhibitors Comparative studies indicate that rimantadine is tolerated better than amantadine at equivalent doses (Stephenson 2001). Treatment of “Classic” Human Influenza In uncomplicated cases, bed rest with adequate hydration is the treatment of choice for most adolescents and young adult patients. However, salicylates must be avoided in children of 18 years or younger because of the association of salicylate use and Reye’s syndrome. Ideally, the choice of the drug should be guided by Gram staining and culture of respiratory specimens. In daily practice, however, the aetiology cannot always be determined, and so treatment is empirical, using antibacterial drugs ef- fective against the most common pathogens in these circumstances (most impor- tantly S. In more severe cases, supportive treatment includes fluid and electrolyte control, and finally supplemental oxygen, intubation, and assisted ventilation. Treatment of “Classic” Human Influenza 175 Antiviral Treatment Oseltamivir is indicated for the treatment of uncomplicated acute illness due to in- fluenza infection in patients aged 1 year and older, who have been symptomatic for no more than 2 days. The recommended duration of treatment with oseltamivir is 5 days (but may be longer in severe H5N1 infection). Zanamivir is indicated for the treatment of uncomplicated acute illness due to influ- enza infection in patients aged 7 years and older and who have been symptomatic for no more than 2 days. Rimantadine and amantadine are ineffective against the influenza B virus and are, therefore, indicated for prophylaxis and treatment of illness caused by influenza A virus only.

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The difference between motives and emotions are as follows: Emotions are usually aroused by external stimuli and that emotional expression is directed toward the stimuli in the environment that arouses it buy tamoxifen 20mg cheap. Motives on the other hand purchase 20 mg tamoxifen fast delivery, are more often aroused by internal stimuli and naturally directed towards certain objects in the environment buy discount tamoxifen 20mg. Most of the motivated behaviour has some affective or emotional accompaniment although we may be too pre occupied in our striving towards goal. The bodily effects of pain, hunger, fear and rage have all the emotions of characteristically, negative polarity. The sympathetic system is responsible for the following changes: 1) Blood pressure and heart rate increases. Nerve impulses with sympathetic system, which reach adrenal glands located on the top of the kidneys, trigger the secretion of hormones. Theories of emotion: James theory or emotion proposes the following sequences of events in emotional state. The major objection to James Lang theory came from Cannon who pointed out 1) That changes do not seem to differ very much from one emotional state to another. James Langes Theory Perception of Activation of Feed back to brain emotion Visceral and from bodily producing skeletal responses produce stimulus responses experience of emotion Canon theory Messages to cortex produce experience Perception of Stimulus processed by of emotion emotion Thalamus, which producing simultaneously send stimulus messages to the cortex and other parts of the body Messages from thalamus activates visceral and skeletal responses Emotion when sufficiently intense can seriously impair the process that control organized behavior. Motion pictures and recording of children’s cries indicate that the infants’ response to stimuli designated to arouse emotion are very diffuse and lacking in organization. Emotional shocks and hurts suffered by individuals at an early age can handicap them as long as they live. Children sooner or later acquire the capacity for experiencing negative emotions such as anger, fear, and also sorrow or grief to an intense degree. This capacity develops, before the child is mature enough to use language, to formulate his experience in words. These improvements in the young child’s ability to respond in specific ways to situations that arouse him, parallel the development of his mental and motor abilities. As the child’s intellectual and motor capacity matures, he acquires large variety of means and forms of expression such as overt and direct to more graded covert and indirect. If a person may mask intense feeling of anger tat occurs when someone hunts his pride very sharply and then still harboring his anger may explode on another occasions because of a very trivial affront. The most important factors in a child’s emotional development and the affection that he receives from his parents, peer group and society. The more genuine the parents love for the child, the, more the child tends to feel free to love other people. All physiological healthy nurses are likely to feel some affection for patients in their charge or with whom they have a chance to associate even though the children are not their own. Their un­ loved person may suffer in connection with the development of positive attitudes and concepts concern­ ing his own worth. This personality is not fixed state but dynamic totality, which is continuously changing due to interaction with the environment. Definition of personality: In the words of Munn, it is characteristic integration of an individual’s structure. In the words of Gorden Allport, “personality is the dynamic organization within the individual of those psychophysical systems, that determine his unique adjustment to his environment” The personality is the organization of the internal and external activities. Personality is the total quality of behavior, attitudes, interests, capacities, aptitudes and behavior patterns, which are manifested in his relation with the environment. However as a person genetic inheritance interacts with and is shaped by environmental factors, the emerges a self structure that becomes an important influence in shapijgn further development and behavior. A trait is an enduring and consistent characteristic of a person that is observed in a wide variety of situations. In fact All port and Odbert have listed 17,593 words in English, which are adjectives standing for personality traits. Norman listed 5 terms extroversion, agreeableness, consciousness, and emotional stability and culture.

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