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Certain general anesthetics can sensitize the myocardium to stimulation by dopamine and other catecholamines buy generic nolvadex line menopause 29 years old, thereby increasing the risk for dysrhythmias buy nolvadex 10 mg visa menstrual cramps 6 days before period. Dobutamine • Receptor specificity: beta1 • Chemical classification: catecholamine Actions and Uses At therapeutic doses cheap nolvadex 10mg women's health issues discharge, dobutamine causes selective activation of beta -adrenergic1 receptors purchase nolvadex discount women's health clinic uk. Concurrent use of tricyclic antidepressants may cause a moderate increase in the cardiovascular effects. Certain general anesthetics can sensitize the myocardium to stimulation by dobutamine, thereby increasing the risk for dysrhythmias. Phenylephrine • Receptor specificity: alpha1 • Chemical classification: noncatecholamine Phenylephrine [Neo-Synephrine, others] is a selective alpha agonist. The1 drug can be administered locally to reduce nasal congestion and parenterally to elevate blood pressure. Also, phenylephrine can be coadministered with local anesthetics to delay anesthetic absorption. Albuterol • Receptor specificity: beta2 • Chemical classification: noncatecholamine Therapeutic Uses Asthma Albuterol [Proventil, Ventolin, VoSpire, others] can reduce airway resistance in asthma by causing beta -mediated bronchodilation. Because albuterol is2 relatively selective for beta receptors, it produces much less activation of2 cardiac beta receptors than does isoproterenol. As a result, albuterol and other1 beta -selective agents have replaced isoproterenol for therapy of asthma. Accordingly, patients should be warned not to exceed2 recommended doses because doing so may cause undesired cardiac stimulation. If dosage is excessive, albuterol can cause tachycardia by activating beta receptors1 in the heart. Ephedrine • Receptor specificity: alpha, alpha, beta, beta1 2 1 2 • Chemical classification: noncatecholamine Ephedrine is referred to as a mixed-acting drug because it activates adrenergic receptors by direct and indirect mechanisms. Owing to the development of more selective adrenergic agonists, uses for ephedrine are limited. By promoting beta2-mediated bronchodilation, ephedrine can benefit patients with asthma. By activating a combination of alpha and beta receptors, ephedrine can improve hemodynamic status in patients with shock. Because ephedrine activates the same receptors as epinephrine, both drugs share the same adverse effects: hypertension, dysrhythmias, angina, and hyperglycemia. All of the drugs presented here are also discussed in chapters that address specific applications (Table 13. Other uses include control of superficial bleeding, delay of local anesthetic absorption, and management of cardiac arrest. Identifying High-Risk Patients Epinephrine must be used with great caution in patients with hyperthyroidism, cardiac dysrhythmias, organic heart disease, or hypertension. Administration Considerations The concentration of epinephrine solutions varies according to the route of administration (see Table 13. To avoid serious injury, check solution strength to ensure that the concentration is appropriate for the intended route. By stimulating the heart, epinephrine can cause anginal pain, tachycardia, and dysrhythmias. By activating alpha receptors on blood vessels, epinephrine can cause intense1 vasoconstriction, which can result in severe hypertension. If extravasation occurs, infiltrate the region with phentolamine to minimize injury. When combined with certain general anesthetics, epinephrine can induce cardiac dysrhythmias. Baseline Data Full assessment of cardiac, hemodynamic, and renal status is needed. Identifying High-Risk Patients Dopamine is contraindicated for patients with tachydysrhythmias or ventricular fibrillation. Caution is also needed in patients with angina pectoris and in those receiving tricyclic antidepressants or general anesthetics. Administration Considerations Administer by continuous infusion, employing an infusion pump to control flow rate. If extravasation occurs, stop the infusion immediately and infiltrate the region with an alpha-adrenergic antagonist (e. Ongoing Monitoring and Interventions Evaluating Therapeutic Effects Monitor cardiovascular status continuously. By stimulating the heart, dopamine may cause anginal pain, tachycardia, or dysrhythmias. Baseline Data Full assessment of cardiac, renal, and hemodynamic status is needed. Caution is also needed in patients with angina pectoris and in those receiving tricyclic antidepressants or general anesthetics. Minimizing Adverse Effects Major adverse effects are tachycardia and dysrhythmias. When combined with certain general anesthetics, dobutamine can cause cardiac dysrhythmias. With one exception, all of the adrenergic antagonists produce reversible (competitive) blockade. Unlike many adrenergic agonists, which act at alpha- and beta-adrenergic receptors, most adrenergic antagonists are more selective. As a result, the adrenergic antagonists can be neatly divided into two major groups (Table 14. We begin by discussing the therapeutic and adverse effects that can result from alpha- and beta-adrenergic blockade, after which we discuss the individual drugs that produce receptor blockade. It is much easier to understand responses to the adrenergic drugs if you first understand the responses to activation of adrenergic receptors. Alpha-Adrenergic Antagonists Therapeutic and Adverse Responses to Alpha Blockade In this section we discuss the beneficial and adverse responses that can result from blockade of alpha-adrenergic receptors. Therapeutic Applications of Alpha Blockade Most clinically useful responses to alpha-adrenergic antagonists result from blockade of alpha receptors on blood vessels. Blockade of alpha receptors in the eyes and blockade of alpha receptors have1 2 no recognized therapeutic applications. Essential Hypertension Hypertension (high blood pressure) can be treated with a variety of drugs, including the alpha-adrenergic antagonists. Alpha antagonists lower blood pressure by causing vasodilation by blocking alpha receptors on arterioles and1 veins. Dilation of veins lowers arterial pressure by an indirect process: in response to venous dilation, return of blood to the heart decreases, thereby decreasing cardiac output, which in turn reduces arterial pressure. The role of alpha-adrenergic blockers in essential hypertension is discussed further in Chapter 39. Reversal of Toxicity From Alpha Agonists1 Overdose with an alpha-adrenergic agonist (e. When this occurs, blood pressure can be lowered by reversing the vasoconstriction with an alpha-blocking agent.

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Age discount generic nolvadex uk breast cancer bras, severity of pneumonia cheap nolvadex amex womens health center of advocate christ medical center tinley park il, co-morbidities buy discount nolvadex 20 mg online womens health ri, and the nature of the infectious agent can all affect the rate of resolution buy 10mg nolvadex free shipping menstruation yahoo. Overall, 6–15% of hospitalized patients do not respond to initial antibiotic treatment. It is important to recognize non-responders so they can be reassessed and appropriate therapeutic changes made. Patients may fail to respond to treatment for a number of reasons: • Resistant bacterial pathogen—rates vary from area to area and close liaison with a local microbiologist is important. Patients may be infected with bacteria such as Pseudomonas aeuriginosa, with innate resistance to some first-line antibiotics. Neoplasms Neoplasms may be mistaken for pneumonic change (most typically broncho-alveolar cell lung cancers) and may also coexist with it if they cause endobronchial obstruction leading to pneumonia. Inflammatory disorders Inflammatory disorders can cause symptoms similar to pneumonia. Eosinophilic lung disease There is a spectrum of eosinophilic lung disease, including eosinophilic pneumonia, where the lung infiltrate is due to eosinophils. Globally, para- sites are the major aetiological factor and these diseases are rare in the developed world. Eosinophilic pneumonia can also occur due to drug hypersensitivity and inhaled antigens. Pulmonary infiltrates are also seen in Churg Strauss syndrome, which may occur in the context of an established diagnosis of asthma and is characterized by peripheral blood eosinophilia and systemic vasculitis. Diagnosis rests on a combination of the clinical picture, chest radiograph findings, laboratory tests, and, in some cases, bronchiolar lavage and lung biopsy. Most eosinophilic lung disease responds to steroids, but it is important to look for and treat specific parasitic infections and drug reactions. It is a recognized complication of a large number of agents, including amiodarone, disease-modifying agents used in rheumatoid arthritis such as leflunomide, and biological agents such as rituximab. A careful drug history is important, although symptoms may lag behind the start of a new drug regime. It has a rapid onset with fever, cough, and shortness of breath being the most common symptoms. There is an equal gender distribution with most patients being over the age of 40. Mortality is over 60%, with only a minority of patients surviving more than 6 months. An approach to the non-responding patient Review history In patients failing to respond history and presentation should be reviewed. Review microbiology Initial microbiological studies should be pursued, if they were collected. Further evaluation is aimed at detecting complications and obtaining microbiological information. Ensure the patient is receiving appropriate treatment at the appropriate doses for organisms identified or suspected. Bronchoscopy may reveal evidence of non-infectious aetiologies such as diffuse alveolar haemorrhage, acute eosinophilic pneumonia, or neoplasm. Low pH or turbid appearance of pleural fluid are immediately suggestive of an empyema. All empyemas need draining as well as prolonged antibiotic treatment, including cover for anaerobes. The quoted mortality of surgical lung biopsy is around 6%, and a careful risk–benefit analysis needs to be made. Aspiration pneumonia Microaspiration is a phenomenon that occurs in many healthy individuals, often without clinical sequelae. Aspiration refers to the aspiration of large volumes of exogenous or endogenous substances into the lower airway. Predisposing factors include: • Reduced conscious level • Neurological disease, particularly with dysphagia • Gastrointestinal conditions, reflux, motility disorders • Medical procedures—endotracheal intubation, occasionally bronchoscopy, upper gastrointestinal endoscopy • Protracted vomiting, large volume nasogastric feeding • Prolonged periods in the recumbent position. Aspiration can cause airway obstruction, chemical pneumonitis, and bacterial infection. It is essen- tial to remove the obstruction using suction for fluids and a rigid or fibre optic bronchoscope for particles. Chemical pneumonitis Chemical pneumonitis occurs following the aspiration or inhalation of substances toxic to the lungs, normally acid stomach contents. Steroid treatment has been shown not to be of value and may increase the incidence of Gram-negative infection. Bacterial infection Bacterial pneumonia following aspiration may be a secondary infection following airway obstruction or chemical pneumonitis, or it may be a primary event following aspiration of fluid-containing bacteria (especially anaerobes) that are resident in the stomach and upper airways. Metronidazole should not be used alone as it is associated with a significant rate of treatment failure as a sole agent. Pneumonia in the immunocompromised host The immunocompromised host presents a number of challenges. Particularly in patients who have undergone chemotherapy or radiation treatment for malignancy, a number of non-infectious disease processes may also occur: • Radiation-induced pneumonitis • Drug reactions • Progression of the primary disease. These patients are also at increased risk of non-infectious disease, including Kaposi’s, lung cancer, lymphoma, and emphysema. In immunocompromised patients chest radiograph changes may be subtle or even non-existent due to immune suppression. Microbiological samples and sometimes biopsies for histopathological staining are needed. Transbronchial and lung biopsy improve the diagnostic yield further but carry a risk of morbidity and mortality (see above). It is reported to affect 7–9% of all intubated patients and is discussed in b Complications of ventilation, p 244, and b The microbiology laboratory, p 49. Multidrug-resistant pathogens are a concern and are seen more frequently with: • Antimicrobial therapy in the preceding 90 days • Current hospitalization of 5 days or more • High frequency of antibiotic resistance in the community or in the specific hospital unit • Significant previous healthcare contact • Nursing home residents • Immunosuppression. Diseases related to pregnancy can present as, or be complicated by, respiratory failure, and previously unknown underlying respiratory or cardiac disease can manifest for the first time during pregnancy. These changes reduce maternal respiratory reserve and will exacerbate any pre-existing respiratory disease. Respiratory changes Physiological changes in the respiratory system start in the first trimester of pregnancy and are hormonally mediated. These changes are necessary to accommodate the growing uterus upwards into the abdomen, meet increased maternal oxygen requirements (i15–20%), and facilitate foetal gas exchange. Alterations in respiratory rate and arterial blood gases From the first trimester progesterone stimulates the respiratory centre, resulting in hyperventilation (see Table 6.