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Transcript of Anesthetics
Surgical Pharmacology and AnesthesiaSurgical Pharmacology and Anesthesia
Commonly Used Drugs in SurgeryCommonly Used Drugs in Surgery
CLASSIFICATION DRUGS
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
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 Thrombin
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
Indigo carmine
Brilliant green
Gentian violet
Contrast Media Iohexol
Vasovist MRI contrast
Diatrizoate meglumine
Tissue Stains Lugol’s iodine solution
Monsel’s 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 patient’s 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 pain-
free 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 patient’s 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 patient’s 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 patient’s 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 blood–brain 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 knee–chest 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 patient’s 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 AgentsCommonly used General Anesthetic Agents
GENERIC NAME TRADE NAME ADMINISTRATION CHARACTERISTICS USES
Nitrous oxide None Inhalation Inorganic nonvolatile
gas; slight potency;
pleasant, fruitlike
odor; nonirritating;
nonflammable but
supports
combustion; poor
muscle relaxation
Rapid induction
and recovery;
short procedures
when muscle
relaxation
unimportant;
adjunct to potent
agents. Should be
mixed with 30%
oxgwn to prevent
hypoxia.
Halothane Fluothane Inhalation Halogenated volatile
liquid; potent;
pleasant odor;
nonirritating;
cardiovascular and
respiratory
depressant;
incomplete muscle
relaxation;
potentially toxic to
Rapid induction;
wide spectrum for
maintenance;
depth of anesthesia
easily altered;
rapid reversal.
Rarely used.
liver
Enflurane Ethrane Inhalation Halogenated ether;
potent; some muscle
relaxation;
respiratory
depressant
Rapid induction
and recovery; wide
spectrum for
maintenance.
Rarely used.
Desflurane Suprane Inhalation Halogenated liquid
with low solubility;
desflurane has faster
uptake by inhalation
and elimination
Not used for
induction in
children. Can be
used for
maintenance in
adults and
children.
Sevoflurane Ultane Inhalation Volatile liquid form,
nonflammable and
nonexplosive; noted
for its rapid
induction and rapid
emergence qualities
Used for adults and
children. Rapid
elimination.
Isoflurane Forane Inhalation Halogenated methyl
ether; potent; muscle
relaxant; profound
respiratory
depressant;
metabolized in liver
Rapid induction
and recovery with
minimal
aftereffects; wide
spectrum for
maintenance.
Thiopental Pentothal Intravenous Barbiturate; potent; Rapid induction
sodium sodium short acting with
cumulative effect;
rapid uptake by
circulatory system;
no muscle relaxation;
respiratory
depressant
and recovery;
short procedures
when muscle
relaxation not
needed; basal
anesthetic.
Methohexital Brevital Intravenous Barbiturate; potent;
circulatory and
respiratory
depressant
Rapid induction;
brief anesthesia
Propofol Diprivan Intravenous Alkylphenol; potent
short-acting
sedative-hypnotic;
cardiovascular
depressant
Rapid induction
and recovery;
short procedures
alone; prolonged
anesthesia in
combination with
inhalation agents
or opioids.
Ketamine Ketaject,
ketalar
Intravenous,
intramuscular
Dissociative drug;
profound amnesia
and analgesia; may
cause psychological
problems during
emergence
Rapid induction;
short procedures
when muscle
relaxation not
needed; children
and young adults
Fentanyl Sublimaze Intravenous Opioid; potent High-dose narcotic
narcotic; metabolizes
slowly; respiratory
depressant
anesthesia in
combination with
oxygen
Sufentanil Sufenta Intravenous Opioid; potent
narcotic; respiratory
depressant
Premedication;
high-dose narcotic
anesthesia in
combination with
oxygen
Fentanyl and
droperidol
Innovar Intravenous Combination
narcotic and
tranquilizer; potent;
long acting
Neuroleptanalgesia
Diazepam Valium Intravenous,
intramuscular
Benzodiazepine;
tranquilizer;
produces amnesia;
sedation, and muscle
relaxation
Premedication;
awake intubation;
induction
Midazolam Versed Intravenous,
intramuscular
Benzodiazepine;
sedative; short-
acting amnesic;
central nervous
system and
respiratory
depressant
Premedication;
conscious
sedation; induction
in children
Local and Regional Anesthetic AgentsLocal and Regional Anesthetic Agents
GENERIC NAME TRADE NAME
USES CONCENTRATION
DURATION MAXIMUM DOSAGE
AMINO AMIDES
Bupivacaine Marcaine;
Sensorcain
e
Local
infiltration*;
Regional block*;
Surgical epidural
0.25% -
0.50%
2 to 3 400 mg
Dibucaine Nupercain
e;
Percaine;
Cinchocain
e
Local
infiltration;
Peripheral
nerves
0.05% - 0.1% 3 to 3½ 30 mg
Etidocaine Duranest Peripheral
nerves; epidural
0.5% - 1% 2 to 3 500 mg
Lidocaine Xylocaine;
Lignocaine
Topical;
Infiltration*;
Peripheral
nerves*;
Nerve block*;
Spinal; Epidural
2% - 4%
0.5%
1% - 2%
½ to 2 200 mg or 4
mg/kg;
500 mg or 7
mg/kg when
mixed with
vasoconstrict
or
Mepivacaine Carbocain
e
Infiltration;
Peripheral
nerves;
Epidural
0.5% - 1%
1% - 2%
½ to 2 500 mg
Prilocaine Citanest Infiltration;
Peripheral
1% - 2% ½ to 2½ 600 mg
nerves;
Regional block;
Epidural
2% - 3%
Ropivacaine Naropin Infiltration;
Field block;
Nerve block;
Epidural;
Postoperative
pain and
management;
not used for Bier
block
0.2%
0.5%
0.75%
1%
2½ for
surgical
analgesia; 6
t0 10 for
surgical
nerve block
200 mg for
analgesia; 300
mg for nerve
block
AMINO ESTERS
Chloroprocaine Nesacaine Infiltration*;
Peripheral
nerves*;
Nerve block*;
Epidural;
Topical
0.5%
2%
2%
2% - 3%
¼ to ½ 1000 mg
4% - 10% ½ 200 mg of 4
mg/kg body
weight
Cocaine;
Procaine
Novocain Infiltration;
Peripheral
nerves;
Spinal
0.5%
1% - 2%
¼ to ½ 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.
GeneralAnesthesic
Agents
NITROUS OXIDENitronox, Entonox
Drug classAnesthetic 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 ClassGeneral 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 post-procedural 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 patient’s 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 ClassAnesthetic 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, general—Ketamine 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, adjunct—Ketamine 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; SublimazeDrug 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 4–6 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 10–20 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.
EnfluraneForane
Drug ClassGeneral 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 classesBenzodiazepine
AnxiolyticAntiepileptic
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
2 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 enzymes—LDH, 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.
RegionalAnesthesic
Agents
LIDOCAINE HYDROCHLORIDELocal anesthetic preparations:
Octocaine, Xylocaine HCl (injectable)
Drug classesAntiarrhythmicLocal 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 (single-
dose 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 short-
acting barbiturate (thiopental, thiamylal) readily available in case of seizures.
WARNING: Monitor for malignant hyperthermia (jaw muscle spasm, rigidity); have life-
support 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 6–12
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:
1–5 mcg/mL). Doses > 6–10 mcg/mL are usually toxic.
TETRACAINE HYDROCHLORIDEDrug 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 dose-
related.
Reactions Associated with Spinal Anesthesia Techniques: Central Nervous System: post-
spinal 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 25°C/25°C 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 25°C/25°C.
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 121°C (250°F), 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 HYDROCHORIDEDrug 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 HYDROCHLORIDENovocaineDrug 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 CHLORIDEMivacron
Drug classNon – 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 8.2°C, 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 24-
hour 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.