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Theactiveearsur- plate and result in cerebrospinal fluid leakage and/or olfactory geon discount meclizine online amex treatment table, who uses a systematic anatomic approach to find buy meclizine online pills medications excessive sweating, isolate order meclizine 25mg amex medicine the 1975, nerve injury buy meclizine 25mg with visa 86 treatment ideas practical strategies. At its cephalic border, the osseous septum and protect the nerve, is more likely to perform a safe and eﬀec- attaches to the frontal bone and its posterior free edge forms tive operation. There is an active thought process involved, in the midline partition of the nasal choanae. Similarly, Anteriorly and caudally, the septum is cartilaginous, formally in nasal surgery, the surgeon must thoughtfully approach the sep- termed the “quadrangular cartilage. Dorsally, the paired, shieldlike upper lateral Ebers Papyrus describes initial attempts by Egyptians in cartilages are fused in the midline to the dorsal edge of the 114 Management of Naso-septal L-strut Deformities cartilaginous septum. The septum and the upper lateral carti- internal airway must be assessed to diagnose and localize the lages are fused early in embryonic development and form a sin- deformities needing correction. Caudally, the lower lateral carti- geon may formulate a surgical plan and select the appropriate lages have an intimate relationship with the caudal edge of the techniques. The intercrural ligament, also termed “the ligamentous In the normal nose, the orientation, size, and shape of the sling,” binds the medial aspect of the lateral crura, the intermedi- upper lateral cartilages and lower lateral cartilages form the ate crura, and the medial crura to each other. In certain cases of variant anatomy, however, the cartilagi- Incorporating the perichondrium into the flap will ensure nous septum does become externally conspicuous. In these sit- greater vascular supply to the flaps and will result in a biome- uations, the dorso-caudal L-strut is in a position or shape that chanically stronger flap less likely to result in septal perforation. The most common examples are This is supported by cadaver studies in which stress tests on the noses in which lateral deviation of the septum results in an out- constituent layers of human septal lining demonstrated that the wardly crooked or twisted nose. Other examples are the col- perichondrial layer imparted most of the mechanical strength. In general, the upper lat- The cartilaginous nasal septum serves two structural roles in eral cartilages and middle vault parallel the dorsal deviations of supporting the nose: a cantilever and a supporting beam. Like a the cartilaginous septum, the cartilaginous domes and nasal tip cantilever, the upper cartilaginous vault projects as a beam, follow deflections of the anterior septal angle, the medial crura supported cephalically through the thick fibrous attachment of and columella parallel the caudal septal margin, and the colum- the upper lateral cartilages and dorsocephalic septum to the ellar base (medial crural footplates) mirrors the posterior septal nasal bones and osseous septum. In the collapsed nose, the upper lateral and/or lower lat- support depends on the length and thickness of the nasal eral cartilages are pulled downward into an under-projected bones. Thus the adage “where the the osseous vault and the upper cartilaginous vault with the septum goes, so goes the nose” is applicable for the crooked or dorsal edge of the septum forms the basis of dorsal support for collapsed nose. Disruption of these connections greatly weakens the lateral cartilages form the external contour of the nose. However, by virtue of the intimate relationship of the septum The quadrangular cartilage also supports the dorsum and tip to the upper and lower lateral cartilages, the septal deformities of the nose from beneath much as a support wall holds up a roof. Because the quadrangular cartilage is inherently made to determine their etiology. The most common causes are rigid and sits firmly in an osseous foundation from the nasal spine trauma and previous surgery. In some cases, these types of along the maxillary crest and up the osseous septum to the nasal deformities may be congenital. In the case of saddle nose or col- bones, it provides significant stabilization to the nose. Active nasal buttressing caudal element forms the basis of the L-shaped granulomatous or rheumatic disease, continued cocaine abuse, strut—the most structurally important aspect of the quadran- and other progressive destructive processes of the nasal septum gular cartilage. Compromise to the caudal component may lead to nasal tip ptosis, particularly in the presence of weak 15. Traumatic or iatrogenic injury is most often the Analyses of these types of deformities must be meticulous and cause. On the frontal view, the symmetry and width of ginous septum in cadavers has been shown to result in a signifi- the nose should be assessed. The external nasal contour and the ness at the middle vault, and width again at the tip. Most importantly, tip support should be determined by palpation and noting the degree of resistance and recoil. Lack of support noted by ease of downward compression of the middle nasal vault may indicate complete loss of underlying septal support, which will dictate the method of reconstruction. Severe loss of nasal tip support may indicate total loss of caudal septal support. The three-quar- ters view aids in confirming the assessment made with the aforementioned views. Deviation of the caudal septum may cause canting of the tip, lobule, or columella. Severe caudal septal deformities can result in foreshortening of the nose and loss of the normal columellar/lobular angle. The entire caudal septum should be palpated to localize the deformity (anterior septal angle, midcaudal septum, or posterior septal angle). Dorsal or caudal deviation of the septum may correspond to distorted areas of the middle vault, tip, and nasal base. The internal angle between the septum and upper lateral cartilage is normally 15 degrees. In such cases, inspection may reveal dynamic collapse of the upper lateral car- tilages with inspiration. The non-L-strut sep- tum must be assessed to determine impact on the nasal airway, need for excision or rearrangement, and availability of cartilagi- Fig. Management of is clear that there is insufficient cartilage in the septum to pro- posttraumatic nasal deformities: the crooked nose and the saddle vide adequate grafting material, the surgeon may need to har- nose. In some techniques used to correct common nasal deformities related to cases, the direction of deviation varies at diﬀerent levels of the the L-strut. On the lateral view, the projection of the radix, bony dorsum, cartilaginous dorsum, and nasal tip must be evaluated. However, considerable normal variation of the dorsal line exists depending on ethnic- In some crooked nose deformities, the attachment of the dorsal ity and familial traits of the individual. If a saddle nose deform- septum and upper lateral cartilages to the bony septum and ity is present, the areas of maximum deficiency should be local- nasal bones will allow the middle vault and tip to move into ized along the dorsal line. An attempt should be made to quan- favorable position with bony vault repositioning. In some of these position should be assessed by determining the projection as cases, medial and lateral osteotomies will reposition the oss- compared with the length of the nose. The nasolabial angle is a eous vault and allow the tilted septum to return to the midline, helpful metric to assess nasal tip rotation, though is not reliable bringing the middle vault and nasal tip with it. If the lower two Analysis of these types of deformities must be meticulous and thirds of the nose do not straighten with bony vault correction, methodical. On the frontal view, the symmetry and width of it is likely that the deviations are related to inherent cartilagi- the nose should be assessed. The parallel dorsal lines of the nous deformities of the septum, upper lateral cartilages, or 116 Management of Naso-septal L-strut Deformities lower lateral cartilages or distortion of the relationships Prior to addressing the caudal-septal strut, the remaining between these structures.
With Klinefelter syndrome discount meclizine 25 mg fast delivery medicine video, testosterone replacement allows for more normal adolescent male development generic 25 mg meclizine overnight delivery 2d6 medications, although azoospermia is the rule; the breast cancer incidence approaches that of women buy 25mg meclizine free shipping medications you cannot eat grapefruit with. Turner syndrome also includes widely spaced nipples and broad chest purchase cheap meclizine medicine in balance, cubitus valgus (increased carrying angle of arms), edema of the hands and feet in the newborn period, congenital heart disease (coarctation of the aorta or bicuspid aortic valve), horseshoe kidney, short fourth metacarpal and metatarsal, hypothyroidism, and decreased hearing. His mother states that he is extremely tired and has not been acting like himself for the past 2 days. Upon further questioning, you note that despite the patient’s recent increase in appetite, he has lost weight. He has been asking for several glasses of water per day and has had new-onset nocturnal enuresis. His vital signs include a heart rate of 155 beats/min, a respiratory rate of 40 breaths/min, a temperature of 37. On examination, the patient is noted to be taking deep, rapid breaths and his capillary refill is prolonged at 4 seconds. Considerations The patient has a recent history of polyuria, polydipsia, and polyphagia. He pres- ents with signs consistent with dehydration, including increased pulse, decreased blood pressure, and increased capillary refill time. This condition is a medical emergency, and the first step in treatment should include management of Airway, Breathing, and Circulation. Once this initial evaluation is complete, fluid resuscita- tion and insulin administration should begin. Resultant complications include hyper- tonic dehydration, ketonuria, and metabolic disturbances including increased serum anion gap, decreased serum bicarbonate, decreased serum pH. Patients may complain of nausea and vomit- ing, fatigue, and severe abdominal pain at presentation. The history is frequently positive for polyuria and polydipsia, which result from serum glucose concentra- tion exceeding the renal threshold for glucose reabsorption, which leads to osmotic diuresis. Consequently, these patients become dehydrated and will increase their caloric intake, while simultaneously losing weight. Vital signs are often indicative of dehydration, with increased pulse and decreased blood pressure. Respirations are typically rapid and deep (termed Kussmaul respirations) which can eventually lead to fatigue and respi- ratory failure. Patients are classically described as having “fruity breath,” caused by acetone formation. Laboratory work also often reveals hyperkalemia, although total body potassium is invariably low. Hyponatremia is often seen, which is usually dilutional and results from increased serum glucose concentration. The remainder of the calculated fluid deficit should be replaced over the ensuing 48 hours. Intravenous insulin infusion should also be initiated after the initial bolus at a rate of 0. Although the hyperglycemia resolves more quickly than the metabolic acidosis, intravenous insulin therapy is continued until the anion gap has closed. As the patient’s hyperglycemia and metabolic acidosis resolve, intravenous insulin therapy can be discontinued and a transition to subcutaneous insulin can be initiated. Signs and symptoms of cerebral edema include severe headache, sudden deterioration of mental status, bradycardia, hypertension, and incontinence. Diabetes can be considered a secondary cause of immune deficiency (Case 40) and be heralded by oral or vaginal candidiasis. Her serum glucose level is 250 mg/dL, and her urinalysis is posi- tive for 2+ glucose but is otherwise negative. Stop intravenous insulin therapy and allow the patient to begin subcuta- neous insulin administration. This condition is far more common in overweight children, especially those with a family history of the condition. Although each of these conditions alone could be caused by other diagnoses, the constellation is concerning for diabetes mellitus. Up to 75% of newly diagnosed diabetics have a progressive decrease in the daily insulin requirement in the months after their diabetes diagnosis; a few patients temporarily require no insulin. This “honeymoon” period usually lasts a few months, and then an insulin requirement returns. A strict adher- ence to diabetic diet will not increase endogenous insulin production and the disease does not resolve with treatment. Although many patients have hyperkalemia on initial laboratory work due to their acidosis, they are often intracellularly depleted of potassium. Administering a potas- sium binder would further decrease her total-body potassium and could result in cardiac arrhythmias. The patient should not be converted to subcutane- ous insulin until her glucose has normalized, her bicarbonate level is greater than 18 mEq/L, and her serum pH is greater than 7. Because of the risk of causing hypoglycemia with continued insulin therapy, dextrose should be added to her fluids. Intravenous infusion of insulin should continue until acidosis resolves and the anion gap closes. Any child diagnosed with ketoacido- sis who also exhibits signs of neurologic dysfunction should be evaluated for cerebral edema so that treatment can be initiated quickly. She reports that he has added about 15 lb, but she has not noticed a major growth spurt. Further questions reveals that he often snores while sleeping and that he sometimes seems to gasp for air at night. At school, he is hyperactive and is having trouble keeping up his grades, often falling asleep in class. On physical examination, his weight is in the 95th percentile for his age (up from the 75th percentile on his last visit), and his body mass index has increased from 25 to 35. His physical examination is normal other than his oropharynx dem- onstrating bilateral tonsillar hypertrophy. Appropriate weight management is appropriate for all obese children which will further reduce symptoms and a variety of health-related risks. The prevalence has been reported to range between 1% and 5% with the peak preva- lence occurring between the ages of 2 to 8 years and without gender differences. Risk factors for this condition include obesity, anatomical factors (adenotonsillar hypertrophy, retro/micrognathia, tongue size), and increased upper airway collaps- ibility (altered neurological upper airway reflexes, hypotonia, upper airway inflam- mation). Primary snoring happens in individuals who do not have any associated ventilatory problems or sleep disturbances. Nighttime symp- toms include snoring, excessive sweating, restless sleep, mouth breathing, apneas, gasping, labored or paradoxical breathing, and hyperextension of neck during sleep. Daytime symptoms include difficulty concentrating, behavioral and mood prob- lems, morning headaches, excessive daytime sleepiness, and failure to thrive.
Close attention to hydration and potential electrolyte disorders and the immediate correction of any such abnormalities is important in improv ing the underlying medical conditions 25mg meclizine free shipping medicine natural. Reversal of the narcotic overdose buy meclizine in united states online treatment 4s syndrome, which is the source of the respiratory depression and coma buy cheap meclizine 25 mg line medications like gabapentin, is accomplished by giving nalxoxone expeditiously purchase cheap meclizine line medications and pregnancy. This reversal is usually rapid but may be blunted since it was accompanied by alcohol. If acetaminophen levels are elevated, acetyl cysteine should be administered to avoid irreversible hepatic damage. Codeine and oxycodone are not water soluble but acetaminophen is, so abusers fequently dissolve the combined medications in water and filter out the acetaminophen leaving the narcotic compound fee of acetaminophen. If an osmolal gap between measured and calculated osmolality of >10 mOm/g water exists in the presence of a positive gap metabolic acidosis, ethylene glycol and methyl alco hol should be considered as the cause of the coma. She has had 3 seizures within 45 minutes and had decreased sensorium since surgery. If needed, general anesthesia with midazolam or propofol can be used to assist in seizure control. Co nsidertions This 68-year-old patient has undergone an aortic bypass surgery for the repair of an ascending aortic aneurysm. She has been in coma since surgery, and the brain imaging reveals multiple embolic strokes. She has had 3 seizures within 45 minutes each lasting 5 minutes, which is consistent with status epilepticus. The most management important steps are to maintain oxygenation, suction oral secretions to prevent aspiration, and control the seizures. The best immediate treatment includes intravenous benzodiazepines, followed by an antiepileptic such as phenytoin. The fequency of cases in the United States is approximately 150,000 per year, with 55,000 deaths annually. The mortality rate of status epilepticus is high, especially if treatment is not initiated quickly. Approximately 2 million persons in the United States have epilepsy, making the prevalence of this disorder similar to that of type 1 diabetes mellitus. Once the seizures cease, this acidosis rapidly reverses if adequate perfsion returns the skeletal muscle. The use of intrave nous bicarbonate should be avoided except in the most severe cases of acidosis. The patient should not be overly restrained while in an active state of seizure to avoid fractures and dislocations. Subse quent medications should include phenytoin or fosphenytoin in a continuous fashion to maintain therapeutic blood levels. Failure to stop the convulsions with the regimen above requires anes thesia with midazolam or propofol as the next step in management. Figure 31-1 indi cates the approach to a stepwise treatment and the preferred dosages of antiepileptic medications, respectively. Many medications are known to decrease the seizure threshold and cause seizures in otherwise healthy patients. Systemic infections, such as bacterial endocarditis, include vegetations that embolize to the brain which can lead to a seizure. The treatment of seizures related to alcohol involves long-acting benzodiazepines (lorazepam, diazepam, or chlordiazepoxide). Physical examination often reveals geotropic eye movements or eyes moving away fom the examiner, and briskly reactive pupils. The absence of cyanosis and seizure activity that intensifies when the patient is restrained are also consistent with pseudoseizures. Treatment includes removal of the drug, aggressive hydration, and dantrolene therapy. His mother stated that he had taken his moring insulin but had not eaten break fast. She heard noises and saw the patient having a tonic-clonic seizure in his bedroom. The most likely cause for the seizure on this diabetic patient is hypoglyce mia, especially with the omission of breakfast. The use of intramuscular glucagon is indicated and avoids the risk of aspiration when oral glucose is given. If oral glucose must be used, powdered sugar is preferred over liquid forms to prevent aspiration. Once the main resources to stop seizures have been exhausted, general anesthesia with midazolam or propofol must be considered. While in the emergency department, he complains ofa severe headache associated with emesis. The interal capsule is the most common area for strokes in hyper tensive patients. Once intracranial bleeding is identified, all anticoagulation therapies are discontinued. The incidence of stroke varies among countries and increases exponentially with age. In Western societies, 80% of strokes are caused by focal cerebral ischemia due to arterial occlusion, and 20% are caused by hemorrhage. Depending on the duration and severity of the ischemia, the edematous area may be incorporated into the infarct or normal tissue. Mortality is related to the size of the infarct; the risk of death is as low as 2. Treatment leads to a 31% to 50% favorable neurologic or functional outcome at 3 months. Intracranial hemorrhage after thrombolysis is higher in patients with more severe, larger strokes and with older patients. Anticoagulation Ischemic stroke occurs because of a trombus or narrowing of the arteries. Dipyridamole or clopidogrel therapy in the acute phase of ischemic stroke has not been tested in randomized trials. The incidence of ischemic stroke has declined in the middle and elderly age groups but has increased in younger patients, likely due to obesity andhypertension being the contributing factors. The use of unfractionated heparin, low-molecular-weight heparins, heparinoids, thrombin inhibitors, or oral antico agulants in the acute phase of stroke improves functional outcomes. Aggressive management of cardiovascular risk factors including smoking cessation, treatment of hypertension, and initiating statin therapy is also recommended. A number of small molecular weight inhibitors of Factor Xa are currently available and can be delivered orally. Large supratentorial infarcts and space-occupying edema of the brain may lead to transtentorial or uncal herniation, usually between the second and fifth day after the onset of stroke. Intensive care units with these cases have reported early fatality rates of up to 78%.
This is extremely dangerous since a greater amount of t ime will most likely pass before the abrupt ion is diagnosed purchase meclizine 25mg free shipping treatment viral conjunctivitis. Trauma is t he most significant risk fact or for abrupt ion in comparison t o the other answer choices generic meclizine 25 mg on-line symptoms multiple sclerosis. Marijuana meclizine 25mg cheap medicine 93 3109, as opposed to cocaine discount meclizine 25mg without prescription treatment viral meningitis, is not associated wit h abrupt ion since it does not cause maternal hypertension and vasocon- st rict ion like cocaine. A prior cesarean delivery may predispose a pat ient t o placenta previa with an associated accreta in future pregnancies, but neither a prior cesarean delivery nor an accreta is a significant risk factor for abruption. The most significant fetal risk associated with breech presentation is cord prolapse, which can lead to significant oxygen deprivation to the fetus. Cocaine use is strongly associated with the development of placental abrupt ion due t o it s effect on t he vasculat ure (vasospasm). Whereas, the management of placental abrupt ion wit h a live fet us many t imes includes cesarean, wit h a fet al demise, the management focuses on vaginal delivery. She has a history of previous myomectomy and one prior low-transverse cesarean delivery. She was counseled about the risks, benefits, and alternatives of vag in al b irt h aft e r ce sare an, an d e le ct e d a t rial o f lab o r. The placenta does not deliver after 30 minutes, and a manual extraction of the placenta is undertaken. The retained placenta is firmly adherent t o the ut erus wh en t here is an att empt at manual ext ract ion. Co n s i d e r a t i o n s T his patient has had two previous uterine incisions, which increases the risk of placenta accreta. The placenta is noted to be very adherent to the uterus, which is the clinical definition of placenta accreta, although the histopathological diagnosis requires a defect of the decidua basalis layer. The usual management of true placen- tal accreta is hysterectomy since attempts to remove a firmly attached placenta often lead t o t orrent ial h emorrh age and/ or mat ernal exsanguinat ion. Conser vat ive man- agement of placenta accreta, such as removal of as much placenta as possible and packing the uterus, often leads to excess mortality as compared to immediate hys- terectomy. N evertheless, in the rare case of a younger patient who strongly desires more children, this option may be entertained. Antepar- tum bleeding may occur, especially when associated with placenta previa (see also Cases 10 [previa] and 11 [abruption] for more common causes of antepartum hemor- rhage). W ith complete placent a accret a, there may be no antepartum bleeding and only a retained placenta. W it h a ret ained placent a, clinicians will usually att empt a manual ext ract ion of the placent a, in an effort to find a cleavage plane bet ween the placent a and the uterus (N it abuch’s layer). Because the placenta is so firmly adherent, attempts to conserve the uterus, such as leaving the placenta in situ, curettage of the placenta or removing the placenta“piecemeal,” are often unsuccessful, and may lead to torrent ial hemorrhage and maternal exsan- gu in at ion. Recen t r esear ch h as p oin t ed ou the imp or t an ce of a mu lt id isciplin ar y team approach when placenta accreta is known or is suspected prenatally to optimize perinatal outcomes. Placenta accreta should be suspected in circumstances of placenta previa, par- ticularly with a history of a prior cesarean delivery (Table 12– 1). The greater the number of prior cesareans in the face of current placenta previa, the higher the risk of accreta, exponentially. For example, a woman wit h t h ree or mor e pr ior cesarean deliveries and a low-lying anterior placent a suggest ive of partial previa or a known placenta previa has up to a 40% to 50% chance of having placenta accreta. Some practitioners advise performing ultrasound examinations to assess the placental locat ion in t h ose women wh o h ave h ad a prior cesarean delivery. W hen the placent a is anterior or low-lying in posit ion, t h ere is a great er risk of accret a. W hen an ant enat al diagnosis of placent a accret a/ previa is suspected, a planned cesarean hysterectomy should be arranged prior to the onset of labor, preferably. In this instance, the infant is delivered between 34 and 35 weeks (after betamethasone administration, without amniocentesis to ch eck fet al lu n g mat u r it y in dices) wit h out dist u r bin g the t r oph oblast implant at ion site, and t he placent a is left in situ as the hysterectomy is performed immediately aft er delivery of t he infant. P lacen t a accr et a is asso ciat ed wit h a d efect in the m yo m et r ial layer of the uterus. If the patient had gestational diabetes, the risk for placenta accreta would be even higher. The posterior placenta may be associated with less of a risk for accreta than an anterior placenta. Upon cesarean sect ion, bluish tissue densely adherent between the uterus and maternal bladder is noted. A manual extraction of the placenta is attempted and t he placent a seems to be adherent to t he uterus. A hysterec- tomy is contemplated, but the patient refuses due to strongly desiring more ch ild r en. Which of the followin g is the most likely complicat ion aft er this int er vent ion? Which of the following statements is most likely to be cor r ect r egar din g the r isk of placent al accr et a? If the myomectomy incisions are anterior, then she has an increased risk of a placental polyp. Placenta accreta is more common with increasing number of cesareans and placent a previa. T hree prior cesareans with placent a pr evia are associat ed with up to a 50% risk for placent a accreta, in which the decidua basalis layer is defect ive. Nevertheless, the placenta may grow into the myometrium or even through the entire uterus to the serosa. The blue tissue densely adherent between the uterus and bladder is very ch ar act er ist ic of p er cr et a, wh er e the placent a p en et r at es ent ir ely t h r ou gh the myometrium to the serosa and adheres to the bladder. Malignant melanoma can met ast asize t o t he placent a, but this is much less common under these circumstances. T h e b est m an agem en t of p lacen t a accr et a is h yst er ect om y d u e t o the gr eat risk of hemorrhage if the placenta is attempted to be removed. O t h er t h an h emorrh age, the ot h er complicat ion t o be con - cer n ed about is in fect ion. In general, myomectomy incisions on the serosal (outside) surface of the uterus do not predispose to accreta because the endometrium is not disturbed. Placental polyps result from retained products after either a term pregnancy or incomplete abortion, and occur inside the uterus. T herefore, the location of the incisions for a myomectomy will not influence whether or not a patient develops polyps. Placental implantation over a submucosal uterine fibroid may increase the risk of focal accreta.
Fentanyl Fentanyl [Duragesic cheap meclizine 25 mg on line medicine 101, Abstral order meclizine now medicine zocor, Actiq purchase meclizine 25mg overnight delivery medicine x protein powder, Fentora buy generic meclizine 25 mg online medications hard on liver, Onsolis, Lazanda, Subsys] is a strong opioid analgesic with a high milligram potency (about 100 times that of morphine). Eight formulations are available for administration by four different routes: parenteral, transdermal, transmucosal, and intranasal. Depending on the route, fentanyl may be used for surgical analgesia, chronic pain control, and control of breakthrough pain in patients taking other opioids. Fentanyl, regardless of route, has the same adverse effects as other opioids: respiratory depression, sedation, constipation, urinary retention, and nausea. Patients taking these inhibitors should be closely monitored for severe respiratory depression and other signs of toxicity. Transdermal System The fentanyl transdermal system [Duragesic] consists of a fentanyl-containing patch that is applied to the skin of the upper torso. The drug is slowly released from the patch and absorbed through the skin, reaching effective levels in 24 hours. Levels remain steady for another 48 hours, after which the patch should be replaced. If a new patch is not applied, effects will nonetheless persist for several hours, owing to continued absorption of residual fentanyl remaining in the skin. Transdermal fentanyl is indicated only for persistent severe pain in patients who are already opioid tolerant. The patch should not be used in children younger than 2 years or in anyone younger than 18 years who weighs less than 110 pounds. Also, the patch should not be used for postoperative pain, intermittent pain, or pain that responds to a less powerful analgesic. Like other strong opioids, fentanyl overdose poses a risk for fatal respiratory depression. If respiratory depression develops, it may persist for hours after patch removal, owing to continued absorption of fentanyl from the skin. Fentanyl patches are available in five strengths, which deliver fentanyl to the systemic circulation at rates of 12. If a dosage greater than 100 mcg/hour is required, a combination of patches can be applied. As with other long-acting opioids, if breakthrough pain occurs, supplemental dosing with a short-acting opioid is indicated. For most patients, patches can be replaced every 72 hours, although some may require a new patch in 48 hours. Used or damaged patches should be folded in half with the medication side touching and flushed down the toilet. Transmucosal Fentanyl for transmucosal administration is available in four formulations: lozenges on a stick [Actiq], buccal tablets [Fentora], sublingual spray [Subsys], and sublingual tablets [Abstral]. All five products are approved only for breakthrough cancer pain in patients at least 18 years old who are already taking opioids around-the-clock and have developed some degree of tolerance, defined as needing, for 1 week or longer, at least: 60 mg of oral morphine a day, or 30 mg of oral oxycodone a day, or 25 mg of oral oxymorphone a day, or 8 mg of oral hydromorphone a day, or 25 mcg of fentanyl per hour, or an equianalgesic dose of another opioid. Transmucosal fentanyl must not be used for acute pain, postoperative pain, headache, or athletic injuries. Furthermore, it is essential to appreciate that the dose of fentanyl in these formulations is sufficient to kill nontolerant individuals—especially children. Adverse effects of transmucosal fentanyl are like those of other opioid preparations. The most common are dizziness, anxiety, confusion, nausea, vomiting, constipation, dyspnea, weakness, and headache. Because of differences in bioavailability, transmucosal fentanyl products are not interchangeable on a microgram-for-microgram basis. For example, a 100- mcg buccal tablet produces about the same fentanyl blood level as does a 200- mcg lozenge. Accordingly, if a patient switches from one transmucosal product to another, dosage of the new product must be titrated to determine a strength that is safe and effective. To administer the unit, patients place it between the cheek and the lower gum and actively suck it. Analgesia begins in 10 to 15 minutes, peaks in 20 minutes, and persists 1 to 2 hours. If breakthrough pain persists, the patient can take another 200-mcg unit 15 minutes after finishing the first one (i. If the patient needs more than 4 units/day, it may be time to give a higher dose of his or her long-acting opioid. To promote safe and effective use of the Actiq system, the manufacturer provides an Actiq Welcome Kit as well as a Child Safety Kit with the initial drug supply. The kit contains educational materials and safe storage containers for unused, partially used, and completely used units. Buccal Tablets Fentanyl buccal tablets [Fentora] are available in five strengths: 100, 200, 400, 600, and 800 mcg. Patients should place the tablet above a rear molar between the cheek and the gum and let it dissolve in place, usually in 15 to 30 minutes. During each subsequent episode, dosage may be gradually increased, if needed, until an effective dose is established. Sublingual Spray Fentanyl sublingual spray [Subsys] is available in doses of 100, 200, 400, 600, 800, 1200, and 1600 mcg/spray. After the medication is dispensed under the tongue, the spray unit must be disposed of in a disposal bag provided by the manufacturer. If pain is not relieved by 30 minutes after the first dose, one additional dose may be administered. Sublingual Tablets Fentanyl sublingual tablets [Abstral] are available in six strengths: 100, 200, 300, 400, 600, and 800 mcg. Patients should place the tablet on the floor of the mouth directly under the tongue and allow it to dissolve completely. No more than two doses should be used for any pain episode, and patients should wait at least 2 hours before dosing again. With each subsequent episode, the dose should be titrated until a safe and effective dose is identified. Like transmucosal fentanyl, Lazanda is indicated only for breakthrough cancer pain in patients at least 18 years old who are already taking opioids around-the-clock and have developed some degree of tolerance. The spray must not be used for acute pain, postoperative pain, headache, or athletic injuries. Because of differences in bioavailability, Lazanda is not interchangeable with other fentanyl products on a microgram-for-microgram basis. As with the transmucosal products, the dose of fentanyl in Lazanda can be fatal to nontolerant individuals, so the spray must be stored in a secure, child- resistant location. Intranasal fentanyl is supplied in 5-mL bottles that have a metered-dose nasal spray pump. If needed, dosage can be titrated upward at subsequent pain episodes as follows: 200 mcg (100 mcg in each nostril), 400 mcg (400 mcg in 1 nostril), and then 800 mcg (400 mcg in 2 nostrils). If more than 5 days elapse since the last dose, the bottle should be discarded and replaced with a new one.
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