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If Lente insulins) a liquid; the liquid must be rotated or shaken not remixed discount phenergan 25 mg, the liquid vehicle is given rather than before measuring a dose cheap phenergan 25mg visa. Dermatologic Creams, Lotions, Ointments Topically to skin • Most are formulated for minimal absorption Formulations vary with intended uses and are not through skin and local effects at the site of appli- interchangeable. Solutions and Powders for • Oral inhalations are used mainly for asthma; nasal Several research studies indicate that patients often Oral or Nasal Inhalation, sprays for nasal allergies (allergic rhinitis) do not use MDIs correctly and sometimes are in- Including Metered Dose • Effective with less systemic effect than oral drugs correctly taught by health care providers. Correct Inhalers (MDIs) • Deliver a specified dose per inhalation use is essential to obtaining therapeutic effects and avoiding adverse effects. Eye Solutions and Ointments • Should be sterile Can be systemically absorbed and cause systemic • Most are packaged in small amounts, to be used adverse effects by a single patient Throat Lozenges • Used for cough and sore throat Ear Solutions • Used mainly for ear infections (continued) 34 SECTION 1 INTRODUCTION TO DRUG THERAPY TABLE 3–2 Drug Dosage Forms (continued) Dosage Forms and Their Routes of Administration Characteristics Considerations/Precautions Vaginal Creams and • Formulated for insertion into the vagina Suppositories • Commonly used to treat vaginal infections Rectal Suppositories • Formulated for insertion into the rectum Effects somewhat unpredictable because absorption and Enemas • Suppositories may be used to administer seda- is erratic tives, analgesics, laxatives • Medicated enemas are used to treat inflammatory bowel diseases (eg, ulcerative colitis) PO, oral; GI, gastrointestinal; IV, intravenous; IM, intramuscular; SC, subcutaneous. CALCULATING DRUG DOSAGES animal tests (ie, the amount of drug required to produce a particular response). For ex- When calculating drug doses, the importance of accuracy ample, concentrations of insulin and heparin are both ex- cannot be overemphasized. Accuracy requires basic skills in pressed in units, but there is no relation between a unit of mathematics, knowledge of common units of measurement, insulin and a unit of heparin. These drugs are usually ordered and methods of using data in performing calculations. Milliequivalents express the ionic ac- The most commonly used system of measurement is the met- tivity of a drug. Drugs such as potassium chloride are ordered ric system, in which the meter is used for linear measure, the and labeled in the number of milliequivalents per dose, tablet, gram for weight, and the liter for volume. The apothecary system, now obsolete and rarely used, has units called grains, minims, drams, ounces, pounds, pints, Mathematical Calculations and quarts. The household system, with units of drops, tea- spoons, tablespoons, and cups, is infrequently used in health Most drug orders and labels are expressed in metric units of care agencies but may be used at home. If the amount specified in the order is the same alent measurements within and among these systems. Equiv- as that on the drug label, no calculations are required, and alents are approximate. For example, if A few drugs are ordered and measured in terms of units the order reads ibuprofen 400 mg PO and the drug label or milliequivalents (mEq). Units express biologic activity in reads ibuprofen 400 mg per tablet, it is clear that one tablet is to be given. What happens if the order calls for a 400-mg dose and 200-mg tablets are available? The question is, How many TABLE 3–3 Equivalents 200-mg tablets are needed to give a dose of 400 mg? This is a simple example that also can be 1 mL = 1 cc = 15 or 16 minims = 15 or 16 drops used to illustrate mathematical calculations. This problem 4 or 5 mL = 1 fluid dram = 1 tsp can be solved by several acceptable methods; the following 60 or 65 mg = 1 gr 30 or 32 mg = 1/2 gr formula is presented because of its relative simplicity for stu- 30 g = 30 mL = 1 oz = 2 tbsp dents lacking a more familiar method. V = unit (one tablet, here) CHAPTER 3 ADMINISTERING MEDICATIONS 35 400 mg X ablett 3. Order: 4 mg IV = Label: 10 mg/mL 200 mg 1 tablet Cross multiply: 4 mg X mL = 200X = 400 10 mg 1 mL 10X = 4 400 X = = 2 tablets 200 4 X = = 04. The desired or ordered dose and the available or label dose 10,000X = 5000 must be in the same units of measurement. Using the equiva- 5000 lents (ie, 1 g = 1000 mg) listed in Table 3–2, an equation can X = = 05. Each has advantages, disadvan- tages, indications for use, and specific techniques of admin- The same procedure and formula can be used to calculate istration (Table 3–4). The term parenteral refers to any route portions of tablets or dosages of liquids. These are illustrated other than gastrointestinal (enteral), but is commonly used to in the following problems: indicate SC, IM, and IV injections. General char- Label: 50-mg tablet acteristics are described below; specific considerations for the intravenous route are described in Box 3–2. Order: 25 mg IM containers with rubber stoppers through which a sterile needle Label: 50 mg in 1 cc can be inserted for withdrawing medication. Single-dose vials usually do not contain a preservative and must be discarded 25 mg X cc after a dose is withdrawn; multiple-dose vials contain a preser- = 50 mg 1 cc vative and may be reused if aseptic technique is maintained.

Other e¤orts in the United States buy 25mg phenergan, Germany buy generic phenergan 25 mg on line, and Japan are building on the basic idea of stimulating retinal cells with a small number of electrodes on a microelectronic chip. In the past, another approach has been to bypass the retina altogether and stim- ulate the visual cortex of the brain. In this approach, an array with penetrating microelectrodes is positioned against the visual cortex. This involves invasive brain 18 Dean Scribner and colleagues surgery through the cranium. There are two major advantages of the cortical stimulation approach (Normann, 1999). First, the skull is a stable stimulation site and will protect the electronics and the electrode array. The retinotopic mapping on the cortical surface is poorly understood, so patterned stimulation may not pro- duce patterned perception. Furthermore, it is unclear what visual perceptions will be evoked by stimulation of cortical neurons. Also, the complex topography of the cor- tical anatomy makes it a di‰cult site for implantation. Other groups are attempting to develop retinal prostheses that will cause visual perception by electrical stimulation of the healthy inner layers of the retina in patients who su¤er from diseases such as retinitis pigmentosa and age-related mac- ular degeneration. Progress in the field of neural prosthetics has converged with advances in retinal surgery to enable the development of an implantable retinal pros- thesis. Initial experiments with intraocular stimulation were performed by de Juan and Humayun several years ago (Humayun et al. Since that time, several re- search groups have begun the development of retinal prostheses (Zrenner et al. Their approaches can be clas- sified according to where their device will be positioned—on the retinal surface (epi- retinal) or in the subretinal space (subretinal). Epiretinal implantation has the advantage of leaving the retina intact by placing the implant in the vitreous cavity, a naturally existing and fluid-filled space. Studies at John Hopkins University Hospital have demonstrated that this position for an array is biocompatible (Majji et al. Other groups are examining this approach as well (Eckmiller, 1997; Rizzo and Wyatt, 1997). The basic concept that has been described in the past is to mount a miniature video camera (e. The video signal and power of the output would be processed by a data processor, and the information transferred to intraocular electronics by either an 820-nm wavelength laser (Rizzo and Wyatt, 1997) or radio- frequency transmission from an external metal coil to an intraocular coil (Troyk and Schwan, 1992; Heetderks, 1988). The power and data transmitted from the laser or the coil would be converted to electrical current on a stimulating chip that would then control the distribution of current to the epiretinal electrode array. A later section of this chapter discusses a means of naturally imaging light onto an epiretinal prosthesis. Subretinal implantation of a retinal prosthesis is being developed by Zrenner (Zrenner et al. This approach essentially replaces the diseased photoreceptors with a microelectronic stimulator device. However, the sur- gical implantation requires detaching the retina, and the location of the device may be disruptive to the health of the retina (Zrenner et al. The histology of the retina after long-term implantation of a device showed a decline in the densities of inner nuclear and ganglion cell layers (Peyman, et al. These issues are being examined in recently announced phase I clinical trials of a subretinal implantation by Chow and col- leagues in Chicago. A disadvantage of this approach is that it is not applicable to patients with AMD because the retina is no longer transparent. Another approach to a retinal prosthesis was proposed by Yagi at the Kyushu Institute of Technology, Japan (Yagi and Hayashida, 1999; Yagi and Watanabe, 1998). This device would be an integrated circuit and include both electronic and cellular components. The neurons on the device would extend their axons to the central nervous system and thus create a natural device/CNS interface.