HIEM New pre-anesthetic drug allows patient to forego recall but remain awake Surgical Team magazine reported the use of a pre-anesthetic drug that enables the patient to have no recall of the operating room, but yet allows him to remain "awake" during surgery. Tests involving lorazepam, a mild sedative and anti-anxiety drug used outside of the United States but not yet approved here for routine usage, were described by Dr. David V. Heisterkamp, assistant professor, and Dr. Peter J. Cohen, department chairman of anesthesia, both from the University of Colorado Medical School in Denver. According to these men, lorazepam appears to have amnesic properties that far surpass those of other drugs which block recall for only a few minutes. AORN formulates standards of practice Standards of practice in operating room nursing have been developed through a collaborative effort by the Association of Operating Room Nurses (AORN) and the American Nurses' Association. These new standards, reports AORN magazine, are based on ANA's standards of practice but have been structured to apply specifically to operating room nursing. APHA supports direct fee.for.service payments in nursing care The American Public Health Association (APHA) has given its support to various Congressional bills that would enable nurse practitioners to be paid by insurers for patient care covered by Medicare or Medicaid. RN magazine reported that the APHA endorses direct fee-for-service payment for nursing care by all third-party payers. February/1975 AANA participates in ANA invitational accreditation conferences The American Association of Nurse Anesthetists has participated in two invitational conferences on accreditation sponsored by the American Nurses' Association (ANA) Commission on Nursing Education. Representing the AANA were Ruth P. Satterfield, CRNA, and Ira P. Gunn, MLN, CRNA, both of whom serve as AANA educational consultants. The conferences brought together approximately 25 persons knowledgeable in the area of accreditation. One conference was held in Denver, the other in New Orleans. Each examined the feasibility of accrediting formal nursing programs. ASA forms committee to define the anesthesia health care team The American Society of Anesthesiologists (ASA) announced the formation of a committee to define and set standards for the anesthesia health care team. In other news, the ASA has sent letters to physician directors of both schools and departments of anesthesiology in which nurse anesthesia training occurs to determine the feasibility of forming an "Association of Physician Faculty of Anesthesia Care Team Schools". This group plans to consider the future role of the nurse anesthetist and the role of the physician in accreditation, examination, and certification of non-physician anesthesia personnel. 15 aak ah Axesav Anet 0 nsh af a Vitri th .M aly hyrxzieH~)hep anitShtmycm inuto an Iths lct reovr roo infcn ersatefcso Sr cicltr fucto redce potprtve50iberdcd moo atviy a nac h rr Sfe onroi nleis fnroi uha eeii opieslaeadpnaoie VstrlIM isaceof feto et n an edmipie.Ivlnay icudn nbcuei emrec.ijcal0nleicrqie reprtr Vital~~~~ sinSr mndddoae usalywthhghrtanrco rreiain a spyial o mstc11I1o1yusdanlesc, ptbewt n cnb tre or nd onvlsinshasbee reored, mid wth hemin he am Pfyie. Alone, ~ ~ ~ ora*najntfr*s ~ ihijcal 0* ~ ~ analgesics, aiu eom eddds 0h Vi s aril IL.M. (hydroxyzine HC1) 100 mg./2 ml., 50 mg./ml. and 25 mg./ml. ® Vials and Isojects Calm Before Anesthesia... In Recovery AMR" Brief Summary VISTARIL* (hydroxyzline hydrochloride) Intramusoular Solution For Intramuscular Use Only Contraindications: Hypersensitivity to hydroxyzine. The solution for Intramuscular use must not be Injected subcutaneously, Intra-arterially, or Intravenously. Hydroxyzine, when administered to the pregnant mouse, rat, and rabbit, Induced fetal abnormalities in the rat at doses substantially above the human therapeutic range. Clinical data In human beings are Inadequate. Until adequate data are available to establish safety in early pregnancy, hydroxyzine is contraindicated during this period. Precautions: Hydroxyzlne may potentiate the action of centralnervous system depressantssuch as narcoticsand barbiturates.In conjunctive use, dosage for these drugs should be decreased as much as 50%. Because drowsiness may occur, patients should be cautioned against driving a car or operating dangerous machinery. The usual precautions for Intramuscular Injection should be followed; soft-tissue reactions have rarely been reported when proper technique has been used. Hydroxyzlne intramuscular solution should be injected well within the body of a relatively large muscle. In adults, the preferred sites are the upper outer quadrant of the buttock (i.e., gluteus maximus), or the midlateral thigh. Inchildren, preferably the mid-lateral muscle of the thigh. In Infants and small children, the upper outer quadrant of the gluteal region should only be used when necessary, as in burn patients, in orde to minimize the possibility of damage to the sciatic nerve. The deltoid area should be used only If well developed, such as in certain adults an older children, and only with caution to avoid radial nerve Injury. Injections should not be maces Inthe lower and middle thirds of the upper arm. Aspiration Is necessary to help avoid Intravascular Injection Adverse Reactions: Drowsiness may occur; if so, It Is usually transitory and may disappear In a few days of continued therapy or upon dosage reduction. Dryness of the mouth may occur with higher doses. Involuntary motor activity, Including rare instances of tremor and convulsions, has been reported, usually with higher than recommended dosage. Supply: Vistaril (hydroxyzine HCI) Intramuscular Solution: 25 mg./ml.10 ml. vial; 50 mg./ml.-2 ml. and 10 ml. vial; Isoject*, 25 mg./ml. and 50 mg./mI., 1 ml. fill; 100 mg./2 ml., 2 ml. fill. Military Depot: NSN 6505-00-052-1367 (50 mg./mI., 10 ml. vial) VA Depot: NSN 6505-00-052-1367B (50 mg./ml., 10 ml. vial) More detailed professional Information available on request. ® LABORATORIES DIVISION PFIZER INC. a "p II .g~ gI ...with an expanded selection of options in machines, components and agents. Anesthesia Machines Anesthesia Ventilator Four machines In a variety of customized models. All with individually calibrated, easy-to-read flowmeters. Finely machined silver-seated needle valves with adjustable stops. Precision gas flows. And a variety of accessories to customize each model to meet your specific professional requirements. Accurate delivery of anesthesia vapor. Both the popular VERNITROL Vaporizer and Sidearm version have separate flow control valves and flowmeters for accuracy in low flow ranges. Use with all popular halogenated agents. Absorbers ander Evacuators OHIO durable absorbers are capable of handling both disposable pre-packs or twin canister packs of Sodasorb. v New fluldically controlled Anesthesia Ventilator. Fluidically controlled means fewer moving parts, greater reliability, less maintenance. A precise method of ventilating your patient during surgery. Patient circuit is easily removable without tools for sterilization. Integral gas evacuation system. Integral low pressure alarm. Unit mounts easily on all anesthesia machines. Or on its own four wheel stand. Protect OR personnel from anesthetic gas pollution with an OHIO Gas Evacuator. Dependable. Simple to operate. Easily adaptable to most anesthesia machines now in use. Efficiently removes gases from the OR providing a safer environment for you and your staff. "Trademark of Dewey and Almy, Division of W R Grace and Co. Whether you're designing a new system or upgrading your present one, OHIO* offers the largest selection of machines and accessories, incorporating new technology for better patient care and OR staff safety. Disposable Anesthesia Accessories wr C>.. OHIO Disposable Anesthesia Circuits fit Into today's asepsis procedures. Exclusive and highly effective bacteria retentive filter is an integral part of the OHIO Circuit. Lightweight and flexible tubing. Built-in swivel "Y". Latex rubber bag and three sizes of masks. Disposable endotracheal tubes, cuffed and uncuffed. Oral airways - six popular sizes. Disposable filter now available separately. Monitors and other Accessories VORTEX" Respiration Monitor measures ventilatory output Instantly, accurately. Measures tidal volumes continuously. Or totalizes them so that minute volumes may be obtained. The VORTEX monitor head fits easily intn thp breathing circuit of any ventilator or anesthesia machine. Oxygen Monitor. For continuous monitoring of Oz concentrations administered through gas machines. Audio and visual alarms. Laryngoscopes. Five hookon blade styles in four sizes. Three interchangeable handle sizes, one rechargeable. Plus full complement of endotracheal accessories. Inhalation Agents and Gases ETHRANE (enflurane) and FLUOROMAR" (fluroxene) are two OHIO anesthetic agents presently available. Ohio is also a leading producer of high purity medical gases, such as oxygen, nitrous oxide, carbon dioxide, helium and compressed air. Moreover, if you need a special blend of laboratory type gases, ask us. We're capable of mixing and blending to your precise specifications. Ohio Medical Products And to complete your needs. Standing behind every Ohio product Is our unique nationwide service organization. Depend on over 70 factory trained Ohio servicemen and six service centers in the USA and Canada to keep your anesthesia system equipment performing. Ohio offers everything from liquid 02 stations, gas manifolds, pumps and compressors, to DIAMOND" II outlets, ceiling gas and IV tracks and retractable or rigid ceiling columns. Plus MULTIWALL* Modular Panels for RR, ICU, CCU, RCU and general patient rooms. Call upon our Planning Service Department. New Critical Care Ventilator. Allows patient triggering when PEEP level is used and automatically adjusts when PEEP level is changed. Has a wider range of flow and pressures (250 Ipm). And a complete electronic alarms system check. One of three models available. Send for our Anesthesia Systems Catalogs Send me additional information - DM5000 Anesthesia Machine (Form No 9905) Model 4000 Anesthesia Machine (Form No 525) Model 2000 Anesthesia Machine (Form No 2993) UNITROL*Anesthesia Machine (Form No 9906) Vaporizers, Absorbers, etc (Form No. 1754) Fluidically Controlled Anesthesia Ventilator(Form No 8140) Sodasorb Data Sheet (Form No 1890) Gas Evacuator (Form No 547) Disposable Anesthesia Circuits and Masks (Form No 1852) Disposable Anesthesia Filter (Form No 553) Disposable Anesthesia Endotracheal Tubes (Form No. 2604) Disposable Anesthesia Airways (Form No 2610) Rubber Goods and Endotracheal Accessories (Form No 1755) VORTEX Respiration Monitor (Form No 589) Oxygen Monitor (Form No 380) ETHRANE (enflurane) (Form No 373) FLUOROMAR (fluroxene) (Form No 1890) Medical Gases (Folio No 21) Specialty Gases (Form No 2564) Primary Piping Systems (Folio No 50) Modular Walls, etc (Folio No 70) Critical Care Ventilator (Form No 627) Model 550 Ventilator Series (Form No 527) Neonatal Ventilator (Form No 347) Have my OHIO Representative phone me for an appointment Ohio Medical Products AIc0® Box 1319, 3030 Airco Drive, Department JAANA, Madison, Wis. 53701 Name Address City State Zip PAVULON Pancuronium Bromide the unique nondepolarizing muscle relaxant * At least 5x more potent than d-tubocurarine chloride * Ganglionic blockade does not occur * Minimal cardiovascular effects * amine release rarely occurs PAVU LON Pancuronium Bromide THIS DRUG SHOULD ONLY BE ADMINISTERED BY ADEQUATELY TRAINED INDIVIDUALS FAMILIAR WITH ITS ACTIONS, CHARACTERISTICS, AND HAZARDS. DESCRIPTION: Pavulon (pancuronium bromide) is the aminosteroid 2 beta, 16 beta-dipiperidine-5 alpha-androstane-3 alpha, 17-beta-diol diacetate dimethobromide. It has the following structural formula: r . CHCOO OOC.CH, 1 H ACTIONS: Pavulon is a non-depolarizing neuromuscular blocking agent possessing all of the characteristic pharmacological actions of this class of drugs (curariform) on the myoneural junction. Pavulon is approximately 5 times as potent as d-tubocurarine chloride. The onset and duration of action of Pavulon is dose dependent. With the administration of 0.04 mg per kg. the onset of action, as measured by a peripheral nerve stimulator, is usually within 45 seconds, and its peak effect is usually within 4V/2minutes; recovery to 90% of control twitch height usually takes place in less than one hour. Larger doses, more suitable for endotracheal intubation, such as 0.08 mg. per kg. of Pavulon have an onset of action of about 30 seconds, and a peak effect within 3 minutes. Supplemental incremental doses of Pavulon, following the initial dose, slightly increase the magnitude of blockade, and significantly increase the duration of the blockade. Pavulon has little effect upon the circulatory system. The most frequently reported observation is a slight rise in pulse rate. Human histamine assays, and clinical observations, as well as in vivo guinea pig testing, and in vitro mast cell testing, indicate that histamine release rarely, if ever, occurs. Pavulon is antagonized by acetylcholine, anticholinesterases, and potassium ion Its action is increased by inhalational anesthetics such as halothane, diethyl ether, and methoxyflurane, as well as quinine, magnesium salts, hypokalemia, some carcinomas, and certain antibiotics such as neomycin, streptomycin, kanamycin, and bacitracin. The action of Pavulon may be altered by dehydration, electrolyte imbalance, acid-base imbalance, renal disease, and concomitant administration of other neuromuscular agents. Pavulon has no known effect on consciousness, the pain threshold, or cerebration. INDICATIONS: Pavulon is indicated as an adjunct to anesthesia to induce skeletal muscle relaxation. It may also be employed to facilitate the management of patients undergoing mechanical ventilation. CONTRAINDICATIONS: Pavulon is contraindicated in patients known to be hypersensitive to the drug or to the bromide ion. WARNINGS: PAVULON SHOULD BE ADMINISTERED IN CAREFULLY ADJUSTED DOSAGE BY OR UNDER THE SUPERVISION OF EXPERIENCED CLINICIANS, WHO ARE FAMILIAR WITH ITS ACTIONS AND THE POSSIBLE COMPLICATIONS THAT MIGHT OCCUR FOLLOWING ITS USE. THE DRUG SHOULD NOT BE ADMINISTERED UNLESS FACILITIES FOR INTUBATION, ARTIFICIAL RESPIRATION, OXYGEN THERAPY, AND REVERSAL AGENTS ARE IMMEDIATELY AVAILABLE. THE CLINICIAN MUST BE PREPARED TO ASSIST OR CONTROL RESPIRATION. In patients who are known to have myasthenia gravis small doses of Pavulon may have profound effects. A peripheral nerve stimulator is especially valuable in assessing the effects of Pavulon in such patients. USAGE IN PREGNANCY: The safe use of pancuronium bromide has not been established with respect to the possible adverse effects upon fetal development Therefore, it should not be used in women of childbearing potential and particularly during early pregnancy unless in the judgment of the physician the potential benefits outweigh the unknown hazards There are insufficient data to support safe use of Pavulon in obstetrics, so such use is not recommended. PRECAUTIONS: Although Pavulon has been used successfully in many patients with pre-existing pulmonary, hepatic, or renal disease, caution should be exercised in these situations. This is particularly true of renal disease since a major portion of administered Pavulon is excreted unchanged in the urine. ADVERSE REACTIONS: Neuromuscular: The most frequently noted adverse reactions consist primarily of an extension of the drug's pharmacological actions beyond the time period needed for surgery and anesthesia. This may vary from skeletal muscle weakness to profound and prolonged skeletal muscle relaxation resulting in respiratory insufficiency or apnea. Inadequate reversal of the neuromuscular blockade by anticholinesterase agents has also been observed with Pavulon (pancuronium bromide) as with all curariform drugs. These adverse reactions are managed by manual or mechanical ventilation until recovery is judged adequate. Cardiovascular: A slight increase in pulse rate is frequently noted Gastrointestinal: Salivation is sometimes noted during very light anesthesia, especially if no anticholinergic premedication is used Skin: An occasional transient rash is noted accompanying the use of Pavulon. Respiratory: One case of wheezing, responding to deepening of the inhalational anesthetic, has been reported. DRUG INTERACTION: The intensity of blockade and duration of action of Pavulon is increased in patients receiving potent volatile inhalational anesthetics such as halothane, diethyl ether, enflurane, and methoxyflurane. No increase in intensity of blockade or duration of action of Pavulon is noted from the use of thiobarbiturates, narcotic analgesics, nitrous oxide, or droperidol. Prior administration of succinylcholine, such as that used for endotracheal intubation, enhances the relaxant effect of Pavulon and the duration of action. If succinylcholine is used before Pavulon, the administration of Pavulon should be delayed until the succinylcholine shows signs of wearing off. DOSAGE AND ADMINISTRATION: Pavulon should be administered only by or under the supervision of experienced clinicians DOSAGE MUST BE INDIVIDUALIZED IN EACH CASE. The dosage information which follows has been denved from dose-response studies based on body weight and is intended to serve as a guide only Since potent inhalational agents or prior administration of succinylcholine enhance the intensity of blockade and duration of Pavulon (see DRUG INTERACTION), these factors should be taken into consideration in selection of initial and incremental dosage. In adults the initial intravenous dosage range is 0.04 to 0.1 mg. per kg. Later incremental doses starting at 0.01 mg per kg may be used. These increments slightly increase the magnitude of the blockade, and significantly increase the duration of blockade, because a significant number of myoneural junctions are still blocked when there is clinical need for more drug If Pavulon is used to provide skeletal muscle relaxation for endotracheal intubation, doses of 0.06 to 0 1 mg per kg are recommended. Conditions satisfactory for intubation are usually present within 2 to 3 minutes. The ability of the anesthetist to intubate with Pavulon (pancuronium bromide) improves with experience Dosage in Children; Dose-response studies in children indicate that, with the exception of neonates, dosage requirements are the same as for adults. Neonates are especially sensitive to nondepolarizing neuromuscular blocking agents, such as Pavulon, during the first month of life. It is recommended that a test dose of 0.02 mg. per kg. be given first in this group to measure responsiveness MANAGEMENT OF PROLONGED NEUROMUSCULAR BLOCKADE: Residual neuromuscular blockade beyond the time period needed for surgery and anesthesia may occur with Pavulon as with other neuromuscular blockers. This may be manifested by skeletal muscle weakness, decreased respiratory reserve, low tidal volume or apnea A peripheral nerve stimulator may be used to assess the degree of residual neuromuscular blockade Under such circumstances the primary treatment is manual or mechanical ventilation and maintenance of a patent airway until complete recovery of normal respiration is assured. Regonol, (pyridostigmine bromide) or neostigmine, in conjunction with atropine, will usually antagonize the skeletal muscle relaxant action of Pavulon. These should be accompanied by or preceded by injection of atropine sulfate to minimize the incidence of cholinergic side effects, notably excessive secretions and bradycardia. Satisfactory reversal can be judged by adequacy of skeletal muscle tone, and by adequacy of respiration. A peripheral nerve stimulator may also be used to monitor restoration of twitch height Failure of prompt reversal (within 30 minutes) may occur in the presence of extreme debilitation, carcinomatosis, and with concomitant use of certain broad spectrum antibiotics, or anesthetic agents and adjuncts which enhance neuromuscular blockade or cause respiratory depression of their own Under such circumstances the management is the same as that of prolonged neuromuscular blockade; ventilation must be supported by artificial means until the patient has resumed control of his respiration Prior to the use of reversal agents, reference to the specific package insert of the reversal agents should be made. CAUTION: Federal law prohibits dispensing without prescription. HOW SUPPLIED: 2 ml ampuls-2 mg./ml -box of 25 5 ml. ampuls-2 mg /ml. -box of 25 10 ml multiple dose vials-1 mg./ml -box of 25 ORGANON INC. * WEST ORANGE, N.J. 07052 4' Dioxide. RAC A s Revsena -- Stre MCAMS ID"@ MAS. 02140 City, State, ZIp . , ,. In your hands... anesthesia systems of Air Products and Foregger are synonymous with quality anesthesia gases and equipment. Together they form a versatile system that recognizes today's individualized techniques. Plus, built-in flexibility for tomorrow's needs. Precision flexibility in an anesthesia system is no accident. Ours is the result of decades of research and development and proven performance in thousands of hospitals and teaching institutions around the world. today built for tomorrow. From quality-checked anesthesia gases and premium-engineered central piping systems, right down to the smallest positioning strap on a face mask, we pursue a basic objective- to build modular anesthesia systems whose components will perform with excellence, over a wide range of applications and methods. From our hands to yours . . . finely-crafted anesthesia systems of today that are built for tomorrow. We'd like to tell you more. Con- tact your sales representative or Foregger dealer. Or write to Air Products and Chemicals, Inc., Medical Products Division, P.O. Box 538, Allentown, Pa. 18105. (A a) y lyr 4 FrSL'- , r y - , f r l", lh r: ~ vr he r{ t .' , ; v.M.5 i 1rte,'.{" y' y+ k 'y Xf t r -11 n~ h j+ S " ., kr y( ',( Y .; F S? ! . r s 'f'r r 9 2 r ' n-iSk,5r a=air : r " Urt Ile' o 1 x t .Y,,. ; h - Y r " 1rr 7 y Offers a firm gripping surface for easy handling and attachment to administration sets. Has rigid markings and a clearly defined meniscus for accurate determination of fluid level. Stores upright, with easy-to-read labels for quick, sure identification. Provides vacuum for sterility assurance, ease in adding medicaments. Is safe from accidental puncture. Allows accurate visual check for particulates. Has a record of proven reliability in the hospital, proven compatibility with virtually all IV solutions and additives. Provides safety and convenience you can depend on. Only glass is acceptable for Cutter's SaftisystemT IV System. Because it's clearly better. Saftisystemi IV System Cutter Medical A Division of Cutter Laboratories, Inc.,Berkeley, Ca 94710