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By L. Gunock. University of Saint Thomas, Saint Paul.

Ventricular dysrhythmias or con- attain the most therapeutic effects and the fewest adverse vulsions may be the first sign of toxicity discount trandate 100mg on-line. Larger doses of bronchodilators and corticosteroids effects rarely occur at serum drug levels below 20 mcg/ (inhaled order 100mg trandate visa, systemic, or both) are usually required to relieve mL. Overdoses with sustained-release preparations may the symptoms of acute, severe bronchoconstriction or status cause a dramatic increase in serum drug concentrations asthmaticus. Then, doses should be reduced to the smallest much later (12 hours or longer) than the immediate- effective amounts for long-term control. Early treatment helps but does not Dosage of theophylline preparations should be based prevent these delayed increases in serum drug levels. In these patients, Blood for serum levels should be drawn 1 to 2 hours after precautions to prevent aspiration are needed, especially immediate-release dosage forms and about 4 hours after in children. In addition, children and cigarette drug ingestion, gastric lavage may be helpful if unable smokers usually need higher doses to maintain therapeutic to induce vomiting or vomiting is contraindicated. Ad- blood levels because they metabolize theophylline rapidly, ministration of activated charcoal and a cathartic is also and clients with liver disease, congestive heart failure, recommended, especially for overdoses of sustained- chronic pulmonary disease, or acute viral infections usually release formulations. For obese clients, theophylline dosage the airway, giving oxygen, injecting IV diazepam (0. Toxicity of Antiasthmatic Drugs These drugs seem relatively devoid of serious toxicity. There have been few reports of toxicity in humans and Signs and symptoms of overdose and toxicity are probably little clinical experience in managing it. If toxicity oc- most likely to occur when clients with acute or chronic curs, general supportive and symptomatic treatment is bronchoconstrictive disorders overuse bronchodilators in indicated. Adrenal insufficiency is most likely to occur with sys- temic or high doses of inhaled corticosteroids. Dose-related Gwen, a 7th grader, comes to the health center at the middle school in moderate respiratory distress. Her respiratory rate is inhibition of growth has been reported in short and inter- 36 and you hear audible wheezing without a stethoscope. Her in- mediate studies but long-term studies have found few, if any, halers (albuterol and Vanceril) are kept in the health center for decreases in expected adult height. Gwen has not been in to use have not been associated with significant decreases in bone her inhalers for the last week. Bone growth should be monitored might be important to assist Gwen in long-term management of closely in children taking corticosteroids. The risk of high doses is especially great in children with other allergic conditions that require topical Use in Children corticosteroid drugs. The risk can be decreased by using the lowest effective dose, administration techniques that mini- The American Academy of Pediatrics endorses the clinical mize swallowed drug, and other antiasthmatic drugs to re- practice guidelines established by the National Asthma duce corticosteroid dose. In gen- Leukotriene modifiers have not been extensively studied eral, antiasthmatic medications are used in children and in children and adolescents. With montelukast, the 10-mg adolescents for the same indications as for adults. With film-coated tablet is recommended for adolescents 15 years adrenergic bronchodilators, recommendations for use vary of age and older and a 4-mg chewable tablet is recommended according to route of administration, age of the child, and for children 2 to 5 years of age. However, even infants and young zafirlukast in children younger than 12 years have not been children can be treated effectively with aerosolized or neb- established. In addition, some oral drugs can be given to Cromolyn aerosol solution may be used in children 5 years children as young as 2 years and most can be given to chil- of age and older, and nebulizer solution is used with children dren 6 to 12 years of age. Nedocromil is not established as safe and With theophylline, use in children should be closely effective in children younger than 12 years of age. In children younger than 6 months, especially premature infants and neonates, drug elimination may be Use in Older Adults prolonged because of immature liver function. Except for pre- term infants with apnea, theophylline preparations are not Older adults often have chronic pulmonary disorders for which recommended for use in this age group. Children 6 months bronchodilators and antiasthmatic medications are used. As to 16 years of age, approximately, metabolize theophylline with other populations, administering the medications by in- more rapidly than younger or older clients. Thus, they may halation and giving the lowest effective dose decrease adverse need higher doses than adults in proportion to size and effects. If the child is obese, the dosage should be calculated excessive cardiac and CNS stimulation.

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The child had had enuresis since infancy and had used many formulas without success buy trandate 100 mg online. The patient had enuresis 1-2 times per night buy cheap trandate 100 mg online, frequent, short urination during the day that looked like rice-washing water, devitalized appetite, bright white facial complexion, fatigued essence spirit, lack of strength when moving about, a pale tongue with thin, white fur, and a slow, deep, forceless pulse. Based on these findings, her TCM pattern was discriminated as lower origin vacuity cold and spleen qi vacuity weakness and the treatment principles were to warm the kidneys and secure and contain, fortify the spleen and boost the qi. Tuina consisted of rubbing the following points for two minutes each: Dan Tian (CV 4-6), Guan Yuan (CV 4), Qi Hai (CV 6), San Yin Jiao (Sp 6), and Gui Wei (GV 1). Then the pushing method was used on the following areas: Shen Shui (Kidney Water), 200 times with supplementation method, Xiao Chang (Small Intestine), 100 times with draining method, and Pi Tu (Spleen Earth), 200 times with supplementation method. After three treatments, the little girl would respond when the parents called her to wake to urinate, and her daytime urination was not as frequent and was less in amount. After continuing for seven treatments, her appetite had returned to normal and her enuresis was cured. Combined therapies Case 26:26 This patient was a six year-old male whose initial visit occurred on June 23, 1994. The child had enuresis at least one time per night and as many as 2-3 times per night. Other signs and symptoms included a bright white facial complexion, an emaciated, weak body, cold limbs, frequent, long, clear urination, a pale tongue with thin, white fur, and a deep, slow, forceless pulse. Therefore, the diagnosis was enuresis due to kidney qi insufficiency and lower origin vacuity cold. The treat- ment principles were to warm and supplement the kidney qi and secure and astringe the lower origin. First Shen Jing (Kidney Channel) was massaged with supplementation method. Then Dan Representative Case Histories 201 Tian (CV 4-6) and Gui Wei (GV 1) were kneaded 100 times each. One treatment was given per day, and seven times equaled one course of therapy. After massaging the child, moxa was used with the warming method on the acupoints Guan Yuan (CV 4) and San Yin Jiao (Sp 6). Each day, this treatment was given one time, and seven times also equaled one course of treatment. After applying this treatment one time, the child slept more peacefully and had no enuresis. After continuing to use this method one time a day for one week, the enuresis was eliminated and all other symptoms improved. Case 27:27 The patient in this case was an eight year-old female whose initial visit took place on June 12, 1995. This child had suffered from enuresis for many years, and, typically, her urination was frequent but scanty. The enuresis was accompanied by a white facial complexion, an emaciated body, fatigued spirit, lack of strength, scanty appetite, and sloppy stools. Her tongue was pale with thin, white fur, and her pulse was moderate (or slightly slow) and fine. Therefore, the treatment principles were to supple- ment and warm the lungs and spleen and secure and astringe the lower origin. Before doing anything else, Pi Jing (Spleen Channel) and Fei Jing (Lung Channel) were massaged with supplementation method. This treatment was given once per day, and seven times equaled one course of treatment. After massaging the fore- going points, moxa was used with warming method on the acu- points Guan Yuan (CV 4) and Zu San Li (St 36). Each point was stim- ulated for five minutes, and each day the treatment was given one time.

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The urinary Increased photosensitivity is a common side effect discount 100 mg trandate with amex, and tract is normally sterile except for the lower third of the clients should be warned to take precautions against sun- urethra purchase trandate 100 mg mastercard. Introduction of any bacteria into the bladder may burn while on these drugs. With in- than 2 months of age (except for treatment of congenital dwelling catheters, bacteria colonize the bladder and toxoplasmosis), and people who have had hypersensitivity produce infection within 2 to 3 weeks, even with metic- reactions to them or to chemically related drugs (eg, thi- ulous care. Sulfasalazine • When indwelling catheters must be used, measures to (Azulfidine) is contraindicated in people who are allergic decrease UTI include using a closed drainage system; to salicylates and people with intestinal or urinary tract keeping the perineal area clean; forcing fluids, if not con- obstruction. CHAPTER 36 TETRACYCLINES, SULFONAMIDES, AND URINARY AGENTS 543 levels (12 to 15 mg/100 mL) more rapidly. The amount traindicated, to maintain a dilute urine; and removing the is usually twice the maintenance dose. Urine pH is important in drug therapy with sulfonamides and irrigate the catheter unless obstruction is suspected. With sulfonamide therapy, alkaline urine increases • Force fluids in anyone with a UTI unless contraindicated. In ad- also increases the rate of sulfonamide excretion and dition, emptying the bladder frequently allows it to refill the concentration of sulfonamide in the urine. This decreases the bacterial popu- urine can be alkalinized by giving sodium bicarbon- lation of the bladder. Alkalinization is not needed with sulfisoxazole • Teach women to cleanse themselves from the urethral area (because the drug is highly soluble) or sulfonamides toward the rectum after voiding or defecating to avoid used to treat intestinal infections or burn wounds contamination of the urethral area with bacteria from the (because there is little systemic absorption). With mandelamine therapy, urine pH must be acidic helps cleanse the lower urethra and prevent UTI. At a higher pH, Evaluation mandelamine does not hydrolyze to formaldehyde, the antibacterial component. Urine can be acidified • Observe for improvement in signs of the infection for by concomitant administration of ascorbic acid. Urine cultures and sensitivity tests are indicated in sus- • Interview and observe for adverse drug effects. The best results are obtained with drug therapy indi- cated by the microorganisms isolated from each client. Culture and susceptibility studies are needed before Tetracyclines should not be used in children younger than tetracycline therapy is started because many strains of 8 years of age because of their effects on teeth and bones. In organisms are either resistant or vary greatly in drug sus- teeth, the drugs interfere with enamel development and may ceptibility. Cross-sensitivity and cross-resistance are cause a permanent yellow, gray, or brown discoloration. The oral route of administration is usually effective and tissue and may interfere with bone growth. Intravenous (IV) therapy is used when oral Systemic sulfonamides are contraindicated during late administration is contraindicated or for initial treat- pregnancy, lactation, and in children younger than 2 months. Tetracyclines decompose with age, exposure to light, tal transfer, in breast milk, or by direct administration, the and extreme heat and humidity. Because the break- drug displaces bilirubin from binding sites on albumin. As a down products may be toxic, it is important to store result, bilirubin may accumulate in the bloodstream (hyper- bilirubinemia) and central nervous system (kernicterus) and these drugs correctly. Few data are available regarding the effects of long-term or recurrent use of sulfamethoxazole in chil- Sulfonamides and Urinary Antiseptics dren younger than 6 years of age with chronic renal disease. With systemically absorbed sulfonamides, an initial prim (Bactrim, Septra), although trimethoprim has not been loading dose may be given to produce therapeutic blood established as safe and effective in children younger than 12 years of age. Some clinicians recommend that asymptomatic bacteriuria be treated in children younger than 5 years of age to decrease How Can You Avoid This Medication Error? Trimethoprim-sulfamethoxazole (Bactrim) DS bid is ordered for a client after urologic surgery. He takes no medications and reports an allergy to eggs, nuts, sulfa, and morphine.

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