Neutrophil.PPT ....

Neutropenia is a blood disorder that can affect anyone. Some Neutropenia is a blood disorder that can affect anyone. Some

people are born with it. It can happen after a viral infection. In some people are born with it. It can happen after a viral infection. In some

cases the cause can be a side effect of a drug, or exposure to cases the cause can be a side effect of a drug, or exposure to

certain poisons. People can get certain poisons. People can get neutropenianeutropenia when treated for when treated for

cancer with chemotherapy drugs. Sometimes it happens for no cancer with chemotherapy drugs. Sometimes it happens for no

known reason.known reason.

Blood is made up of billions of cells. There are many different types Blood is made up of billions of cells. There are many different types

of blood cells, but most of the time you hear about two kinds - red of blood cells, but most of the time you hear about two kinds - red

cells and white cells. There are more red cells than any other type of cells and white cells. There are more red cells than any other type of

blood cell. They are very important as they carry oxygen from your blood cell. They are very important as they carry oxygen from your

lungs to all parts of your body. White blood cells are just as lungs to all parts of your body. White blood cells are just as

important, but for a very different reason. One of their jobs is to important, but for a very different reason. One of their jobs is to

protect you from infection. protect you from infection.

There are several kinds of white cells. Each has a special function. There are several kinds of white cells. Each has a special function. The most common ones are:The most common ones are:

NeutrophilsNeutrophils (pronounced NEW TROH FILS), which surround and (pronounced NEW TROH FILS), which surround and destroy bacteria in your body; anddestroy bacteria in your body; and

Lymphocytes Lymphocytes (pronounced LIM FOH SITES), which are the key part (pronounced LIM FOH SITES), which are the key part of your body’s immune system, and defend against viruses.of your body’s immune system, and defend against viruses.

A third kind of blood cell, the platelet, helps your blood to clot.A third kind of blood cell, the platelet, helps your blood to clot.

Normal neutrophil function depends on the integration of chemotaxis, Normal neutrophil function depends on the integration of chemotaxis,

phagocytosis, degranulation and oxidative metabolism. As congenital and phagocytosis, degranulation and oxidative metabolism. As congenital and

acquired neutrophil abnormalities increase the risk of infection, frequently acquired neutrophil abnormalities increase the risk of infection, frequently

with no other diagnostic features, diagnosis depends upon specialist with no other diagnostic features, diagnosis depends upon specialist

laboratory investigations. Techniques for quantitative evaluation of the laboratory investigations. Techniques for quantitative evaluation of the

principal neutrophil functions are discussed, and a preliminary screening principal neutrophil functions are discussed, and a preliminary screening

programme for neutrophil abnormalities proposed.programme for neutrophil abnormalities proposed.

What is neutrophil? What is neutrophil? is a type of white blood cell in the granulocytic series, formed by is a type of white blood cell in the granulocytic series, formed by

myelopoietic tissue of the bone marrow (sometimes also in extramedullary myelopoietic tissue of the bone marrow (sometimes also in extramedullary

sites), and released into the circulating blood, where they normally sites), and released into the circulating blood, where they normally

represent 54–65% of the total number of leukocytes. represent 54–65% of the total number of leukocytes.

-A type of white blood cell (WBC) filled with microscopic sacs (granules) A type of white blood cell (WBC) filled with microscopic sacs (granules)

containing enzymes that digest bacteria and other microorganisms. This containing enzymes that digest bacteria and other microorganisms. This

process is known as process is known as phagocytosisphagocytosis..

-Neutrophils respond to infection and attack bacteria and other foreign Neutrophils respond to infection and attack bacteria and other foreign

invaders directly.invaders directly.

- Any cell or tissue that manifests no special affinity for acid or basic dyes, - Any cell or tissue that manifests no special affinity for acid or basic dyes,

the cytoplasm stains approximately equally with either type of dye.the cytoplasm stains approximately equally with either type of dye.

Neutrophils are the first type of immune cell to respond to and Neutrophils are the first type of immune cell to respond to and

arrive at the site of infection, often within an hour. They will arrive at the site of infection, often within an hour. They will

respond to infection inside the body, but also on the surface, as in respond to infection inside the body, but also on the surface, as in

the case of skin infections.the case of skin infections.

Pus, which is one visible sign of a skin infection, contains mainly Pus, which is one visible sign of a skin infection, contains mainly

dead neutrophils, bacteria, and cells. Pus can form internally, as dead neutrophils, bacteria, and cells. Pus can form internally, as

well.well.

The results of a common blood test, called an The results of a common blood test, called an absolute absolute

neutrophil count (ANC),neutrophil count (ANC), are routinely checked during cancer are routinely checked during cancer

treatment to determine how the immune system is responding to treatment to determine how the immune system is responding to

treatment. When ANC is low, this is called treatment. When ANC is low, this is called neutropenia.neutropenia...

If ANC drops below about 500 cells per microliter, the If ANC drops below about 500 cells per microliter, the

risk of infection increases and your doctor may prescribe risk of infection increases and your doctor may prescribe

medications to bring ANC back into a normal range and medications to bring ANC back into a normal range and

temporarily offer antibiotics to prevent serious infections.temporarily offer antibiotics to prevent serious infections.

Neutrophils are part of the innate immune system, Neutrophils are part of the innate immune system,

which means that they can "non-specifically" destroy any which means that they can "non-specifically" destroy any

invaders that they encounter in the body, such as bacteria invaders that they encounter in the body, such as bacteria

and parasites. Non-specifically means that neutrophils do not and parasites. Non-specifically means that neutrophils do not

have to recognize the invader specifically, but instead simply have to recognize the invader specifically, but instead simply

recognize the invader as something that should not be recognize the invader as something that should not be

present in the body and should be destroyed.present in the body and should be destroyed.

The measurement of how severe a Neutropenia The measurement of how severe a Neutropenia

case is will depend on a person's neutrophil count. case is will depend on a person's neutrophil count.

Normal neutrophil levels in adults fall between Normal neutrophil levels in adults fall between

1,500 to 7,000 neutrophils per mm3. Children under 1,500 to 7,000 neutrophils per mm3. Children under

7 years of age may have a lower neutrophil count. 7 years of age may have a lower neutrophil count.

Patients with mild Neutropenia will have an Patients with mild Neutropenia will have an

absolute neutrophil count (ANC) of below 1,500 per absolute neutrophil count (ANC) of below 1,500 per

mm3, moderate cases have an ANC of between 500 mm3, moderate cases have an ANC of between 500

to 1,000 per mm3, while the ANC of severe to 1,000 per mm3, while the ANC of severe

Neutropenia falls below the 500 per mm3 level. Neutropenia falls below the 500 per mm3 level.

Females have a higher risk for Females have a higher risk for

Neutropenia, as are elderly adults. A Neutropenia, as are elderly adults. A

person with severe Neutopenia will person with severe Neutopenia will

need immediate medical attention, as need immediate medical attention, as

there is a greater potential for several there is a greater potential for several

types of infection to develop, such as types of infection to develop, such as

bacterial, fungal or viral, or all three at bacterial, fungal or viral, or all three at

once combined. once combined.

Is the development of Is the development of fever, often with other signs of , often with other signs of infection, in a patient with , in a patient with

neutropenia, an abnormally low number of , an abnormally low number of neutrophil granulocytes (a type of (a type of

white blood cell) in the blood.) in the blood.

Mouth ulcers are sores or open Mouth ulcers are sores or open lesions in the mouth.lesions in the mouth.

To diagnose Neutropenia, the doctor may order a To diagnose Neutropenia, the doctor may order a complete blood count to to

determine the number of neutrophils in the blood. Sometimes, to make a determine the number of neutrophils in the blood. Sometimes, to make a

precise diagnosis especially if the doctor suspects other serious illnesses, a precise diagnosis especially if the doctor suspects other serious illnesses, a

bone marrow aspiration or bone marrow aspiration or biopsy may be necessary. may be necessary.

In a In a bone marrow biopsy, the doctor will use a needle to take a sample of , the doctor will use a needle to take a sample of

the patient's bone marrow and examine it under a microscope. The doctor the patient's bone marrow and examine it under a microscope. The doctor

will be looking for impaired neutrophil production, or if there has been will be looking for impaired neutrophil production, or if there has been

excessive use or destruction of these cells. This test will show if there are excessive use or destruction of these cells. This test will show if there are

any signs of an intrinsic defect in the marrow, Congenital Neutropenia, any signs of an intrinsic defect in the marrow, Congenital Neutropenia,

maturation arrest, a maturation arrest, a fungal infection, a lack of Vitamin B12 or a folate , a lack of Vitamin B12 or a folate

deficiency in the body. There may be other diseases present, as well, like deficiency in the body. There may be other diseases present, as well, like

leukemia, , tuberculosis, and other cancers. , and other cancers.

When the patient exhibits a form of Neutropenic fever, When the patient exhibits a form of Neutropenic fever,

laboratory tests like blood cultures, urinalysis, Sputum Gram laboratory tests like blood cultures, urinalysis, Sputum Gram

stain and culture, and measuring the serum Vitamin B12 and stain and culture, and measuring the serum Vitamin B12 and

RBC folate levels may be recommended. RBC folate levels may be recommended.

For patients already afflicted with an infection, taking For patients already afflicted with an infection, taking

radiograph images of the posterio-anterior and lateral chests radiograph images of the posterio-anterior and lateral chests

may be required to check for any signs of may be required to check for any signs of pneumonia..

o round of antibioticsround of antibiotics

o sargramostin (Leukine, Prokin), a blood growth factor that acts to stimulate sargramostin (Leukine, Prokin), a blood growth factor that acts to stimulate

the production of white blood cellsthe production of white blood cells.(Patients who have acquired .(Patients who have acquired

Neutropenia through chemotherapy for cancer treatments) Neutropenia through chemotherapy for cancer treatments)

o B-complex vitamins and B-complex vitamins and folic acid supplements supplements,(For patients who have ,(For patients who have

acquired Neutropenia due to a nutritional deficiency or a poor diet)acquired Neutropenia due to a nutritional deficiency or a poor diet)

o spleen removal for patients who incur repeat infections because of Felty's spleen removal for patients who incur repeat infections because of Felty's

syndromesyndrome

o stool softeners to remedy constipationstool softeners to remedy constipation

omedicated ointments and creams for infected wounds and abrasions;medicated ointments and creams for infected wounds and abrasions;

o colony-stimulating growth factors to induce white blood cell productioncolony-stimulating growth factors to induce white blood cell production

o corticosteroid treatment for Neutropenia caused by an autoimmune reactioncorticosteroid treatment for Neutropenia caused by an autoimmune reaction

oAntithymocyte globulin to treat symptoms of aplastic Antithymocyte globulin to treat symptoms of aplastic anemia,,

o bone marrow or stem cell transplant to treat more severe cases of bone marrow or stem cell transplant to treat more severe cases of

Neutropenia like leukemia or aplastic anemia. Neutropenia like leukemia or aplastic anemia.

People diagnosed with Neutropenia should avoid getting an infection People diagnosed with Neutropenia should avoid getting an infection

by observing proper hygiene, keeping clean surroundings, and by observing proper hygiene, keeping clean surroundings, and

avoiding crowded public places where they may be exposed to a avoiding crowded public places where they may be exposed to a

whole range of germs, viruses and bacteria. They should also avoid whole range of germs, viruses and bacteria. They should also avoid

exposing themselves to other people who are sick to prevent any exposing themselves to other people who are sick to prevent any

contamination. contamination.

Other ways of preventing infection while neutropenic include Other ways of preventing infection while neutropenic include

wearing sunscreen, taking proper care of wearing sunscreen, taking proper care of teeth and gums, avoiding and gums, avoiding

contact sports which may cause cuts or injuries, avoiding the use of contact sports which may cause cuts or injuries, avoiding the use of

rectal suppositories, tampons, and even sexual intercourse. rectal suppositories, tampons, and even sexual intercourse.

There is an excellent prognosis for Neutropenia. Patients' recovery will depend on There is an excellent prognosis for Neutropenia. Patients' recovery will depend on

how severe the complications are. Usually, only 21% of patients incur serious how severe the complications are. Usually, only 21% of patients incur serious

complications, and recovery is even faster if the disease is diagnosed and treated complications, and recovery is even faster if the disease is diagnosed and treated

immediately. In cancer patients suffering from Neutropenia due to chemotherapy immediately. In cancer patients suffering from Neutropenia due to chemotherapy

treatments, the mortality rate is 4 to 30%. treatments, the mortality rate is 4 to 30%.

Scientists at the Northwest Scientists at the Northwest Hepatitis C Resource Center working on Neutropenia Resource Center working on Neutropenia

Prevention have recently found that using an alternative treatment combination of Prevention have recently found that using an alternative treatment combination of

ribavirin, pegylated interferon, erthropoietin and ganulocyte colony-stimulating factor ribavirin, pegylated interferon, erthropoietin and ganulocyte colony-stimulating factor

can control anemia and Neutropenia during anti-hepatitis C therapy. can control anemia and Neutropenia during anti-hepatitis C therapy.

The use of acupuncture is another alternative therapy undertaken by the NESA The use of acupuncture is another alternative therapy undertaken by the NESA

Acupuncture Research Collaborative to reduce Neutropenia brought about by Acupuncture Research Collaborative to reduce Neutropenia brought about by

chemotherapy treatments in women diagnosed with gynecological disorders like chemotherapy treatments in women diagnosed with gynecological disorders like

ovarian cancer.ovarian cancer.

Severe chronic neutropenia can exist from Severe chronic neutropenia can exist from birth (congenital neutropenia) or cn occur birth (congenital neutropenia) or cn occur an any time through life (acquired an any time through life (acquired neutropenia). It may develop by itself or as neutropenia). It may develop by itself or as an accompanying symptom of a different an accompanying symptom of a different underlying disease. The following list gives underlying disease. The following list gives you examples of the different types of you examples of the different types of chronic neutropenias.chronic neutropenias.

The following list gives you examples of The following list gives you examples of the different types of chronic the different types of chronic neutropenias.neutropenias.

Neutropenias present at birth: Neutropenias present at birth: • Severe congenital neutropenia (Kostmann syndrome)• Cyclic neutropenia

Metabolic diseases associated with neutropenia Metabolic diseases associated with neutropenia • Shwachman-Diamond syndrome• Glycogen-storage disease type 1b

Neutropenias that are acquired during life Neutropenias that are acquired during life • Idiopathic neutropenia• Autoimmune neutropeniaAutoimmune neutropenia

InfectionInfectionImmunologic diseasesImmunologic diseases

Human immunodeficiency virusHuman immunodeficiency virusParvovirusParvovirusHepatitis virusesHepatitis virusesMalariaMalariaIsoimmune neonatal NeutropeniaIsoimmune neonatal NeutropeniaAutoimmune NeutropeniaAutoimmune NeutropeniaFelty's syndromeFelty's syndromeRheumatoid arthritisRheumatoid arthritisSjogren's syndromeSjogren's syndromeSystemic lupus erythematosusSystemic lupus erythematosus

Drug Induced NeutropeniaDrug Induced Neutropenia

Hematologic diseasesHematologic diseases Congenital Neutropenia or Congenital Neutropenia or Kostmann's syndromeKostmann's syndromeCyclic NeutropeniaCyclic NeutropeniaChildhood idiopathic NeutropeniaChildhood idiopathic NeutropeniaAdult idiopathic NeutropeniaAdult idiopathic NeutropeniaShwachman's syndromeShwachman's syndromeMyelokathexis syndromeMyelokathexis syndromeCongenital immunologic deficiency Congenital immunologic deficiency syndromessyndromesAplastic anemiaAplastic anemiaMyelodysplastic syndromesMyelodysplastic syndromes

This grave and unpredictable disorder is characterized by severe Neutropenia This grave and unpredictable disorder is characterized by severe Neutropenia

caused by an idiosyncratic reaction reaction to a drug that results in either caused by an idiosyncratic reaction reaction to a drug that results in either

direct suppression or immune destruction of neutrophils or myeloid direct suppression or immune destruction of neutrophils or myeloid

precursors. Historically, women and older individuals experience these precursors. Historically, women and older individuals experience these

reactions more commonly than men and younger patients. In addition, genetic reactions more commonly than men and younger patients. In addition, genetic

factors appear to influence a particular individual's tendency to develop this factors appear to influence a particular individual's tendency to develop this

type of reaction. Typically, Neutropenia becomes evident 1 - 2 weeks following type of reaction. Typically, Neutropenia becomes evident 1 - 2 weeks following

an initial exposure to a drug, or swiftly following a recent re-exposure to any an initial exposure to a drug, or swiftly following a recent re-exposure to any

offending agent. Treatment consists of rapid withdrawal of any drug suspected offending agent. Treatment consists of rapid withdrawal of any drug suspected

of causing the idiosyncratic reaction. Unfortunately, therapy with of causing the idiosyncratic reaction. Unfortunately, therapy with

cortcosteroids has not shown significant efficacy. A partial list of drugs that cortcosteroids has not shown significant efficacy. A partial list of drugs that

have been associated with drug-induced Neutropenia is provided in Table 2.have been associated with drug-induced Neutropenia is provided in Table 2.

AntibioticsAntibiotics Antithyroid AgentsAntithyroid Agents

ChloramphenicolChloramphenicol PropythiouracilPropythiouracil

PenicillinPenicillin TranquilizersTranquilizers

SulfonamidesSulfonamides ChlorpromazineChlorpromazine

Analgesics/antiinflammatory Analgesics/antiinflammatory agentsagents PhenothiazinesPhenothiazines

AspirinAspirin AntirheumaticsAntirheumatics

AcetaminophenAcetaminophen GoldGold

PhenylbutazonePhenylbutazone LevamisoleLevamisole

SedativesSedatives PenicillaminePenicillamine

BarbituatesBarbituates   

BenzodiazepinesBenzodiazepines   

What is Neupogen?What is Neupogen?

Neupogen (filgrastim) is a drug given to chemotherapy Neupogen (filgrastim) is a drug given to chemotherapy

patients who have patients who have neutropenianeutropenia (low (low neutrophilneutrophil count). An count). An

injection of Neupogen stimulates white blood cell production. injection of Neupogen stimulates white blood cell production.

It is a clear liquid that is usually given as a shot (injection).It is a clear liquid that is usually given as a shot (injection).

Use For Breast Cancer:Use For Breast Cancer:

Chemotherapy for breast cancer affects all the rapidly dividing Chemotherapy for breast cancer affects all the rapidly dividing

cells in your body, including bone marrow cells, which produce cells in your body, including bone marrow cells, which produce

white and red blood cells and platelets. Fewer bone marrow white and red blood cells and platelets. Fewer bone marrow

cells means less blood cells overall. If your cells means less blood cells overall. If your CBCCBC shows that your shows that your

neutrophil count is low, you may be neutrophil count is low, you may be neutropenicneutropenic. Injections of . Injections of

Neupogen can boost production of your neutrophils, a special Neupogen can boost production of your neutrophils, a special

type of white blood cell that helps your body fight infection.type of white blood cell that helps your body fight infection.

How Neupogen Works:How Neupogen Works:

Usually, your body produces a protein that stimulates Usually, your body produces a protein that stimulates

the production of neutrophils. But during chemo for the production of neutrophils. But during chemo for

breast cancer, your body may not make enough of this breast cancer, your body may not make enough of this

protein. Your CBC may reveal that your neutrophil blood protein. Your CBC may reveal that your neutrophil blood

counts are low, and that you are neutropenic. Neupogen counts are low, and that you are neutropenic. Neupogen

injections will boost production of your neutrophils. You injections will boost production of your neutrophils. You

may feel aches and some bone pain while this drug is may feel aches and some bone pain while this drug is

working, but it may help to imagine your immune working, but it may help to imagine your immune

system rebuilding itself and becoming stronger at system rebuilding itself and becoming stronger at

protecting your health.protecting your health.

How Neupogen is Given:How Neupogen is Given:

You will have injections of Neupogen once daily, until You will have injections of Neupogen once daily, until

your white blood cell counts return to normal levels. your white blood cell counts return to normal levels.

When properly given, these injections will not hurt. When properly given, these injections will not hurt.

This drug can also be given through an intravenous This drug can also be given through an intravenous

infusion (IV).infusion (IV).

Some Common Side Effects of Neupogen:Some Common Side Effects of Neupogen:

Not everyone has side effects from Neupogen, Not everyone has side effects from Neupogen,

but here are the most common: but here are the most common:

Bone pain Bone pain

Fever Fever

Self-Care Tips: Self-Care Tips:

Soak in a warm bath to help reduce bone pain.Soak in a warm bath to help reduce bone pain.

Take Tylenol (acetaminophen) to help lower mild Take Tylenol (acetaminophen) to help lower mild

fever and reduce pain.fever and reduce pain.

Call Your Doctor if You Have These Call Your Doctor if You Have These Symptoms:Symptoms:

unusual fatigue and lethargy unusual fatigue and lethargy

chest pain chest pain

heart palpitationsheart palpitations

mouth soresmouth sores

Urgent Symptoms include:Urgent Symptoms include:

allergic reaction (hives; problems breathing; allergic reaction (hives; problems breathing;

swelling of face, lips, tongue or throat; rash swelling of face, lips, tongue or throat; rash

spreading over your body) spreading over your body)

abdominal pain abdominal pain

shoulder painshoulder pain

AntibioticsAntibioticsChloramphenicol - Pentamycetin Chloramphenicol - Pentamycetin

SulfonamidesSulfonamides

PRESCRIBED FOR:PRESCRIBED FOR: PTU is used to manage hyperthyroidism PTU is used to manage hyperthyroidism

associated with Graves' disease in patients who did not tolerate associated with Graves' disease in patients who did not tolerate

methimazole, and are not able to receive surgery or radioactive methimazole, and are not able to receive surgery or radioactive

iodine therapy. It also is used to decrease symptoms of iodine therapy. It also is used to decrease symptoms of

hyperthyroidism in preparation for surgical removal of the thyroid hyperthyroidism in preparation for surgical removal of the thyroid

gland or before radioactive iodine therapy in patients who did not gland or before radioactive iodine therapy in patients who did not

tolerated methimazole.tolerated methimazole.

DRUG INTERACTION DRUG INTERACTION :: PTU may increase the effect of oral blood PTU may increase the effect of oral blood

thinners, for example warfarin (Coumadin). Therefore, warfarin dose thinners, for example warfarin (Coumadin). Therefore, warfarin dose

changes and monitoring for the effects of warfarin on blood clotting changes and monitoring for the effects of warfarin on blood clotting

are necessary.are necessary.

Antithyroid Agents Antithyroid Agents PropythiouracilPropythiouracil

SIDE EFFECTS:SIDE EFFECTS:

The most common side effects are related to the skin and include rash, The most common side effects are related to the skin and include rash,

itching, hives, abnormal hair loss, and skin pigmentation. Other itching, hives, abnormal hair loss, and skin pigmentation. Other

common side effects are swelling, nausea, vomiting, heartburn, loss of common side effects are swelling, nausea, vomiting, heartburn, loss of

taste, joint or muscle aches, numbness and headache. Less common taste, joint or muscle aches, numbness and headache. Less common

but serious side effects have occurred with PTU therapy. A decrease of but serious side effects have occurred with PTU therapy. A decrease of

white blood cells in the blood (agranulocytosis) may occur. Symptoms white blood cells in the blood (agranulocytosis) may occur. Symptoms

and signs of agranulocytosis include infectious lesions of the throat, and signs of agranulocytosis include infectious lesions of the throat,

the gastrointestinal tract, and skin with an overall feeling of illness and the gastrointestinal tract, and skin with an overall feeling of illness and

fever. fever.

A decrease in blood platelets (thrombocytopenia) also may occur. A decrease in blood platelets (thrombocytopenia) also may occur.

Since platelets are important for the clotting of blood, Since platelets are important for the clotting of blood,

thrombocytopenia may lead to excessive bleeding. Severe liver injury thrombocytopenia may lead to excessive bleeding. Severe liver injury

and acute liver failure, in some cases fatal, have been associated with and acute liver failure, in some cases fatal, have been associated with

PTU. Some adults and pediatric patients required liver transplantation. PTU. Some adults and pediatric patients required liver transplantation.

Tranquilizers Tranquilizers ChlorpromazineChlorpromazine

ActionAction

Unknown.May block postsynaptic dopamine receptors in brain and depress areas Unknown.May block postsynaptic dopamine receptors in brain and depress areas

involved in wakefulness and emesis. Also possesses anticholinergic, involved in wakefulness and emesis. Also possesses anticholinergic,

antihistaminic, and adrenergicblocking properties.antihistaminic, and adrenergicblocking properties.

IndicationsIndications

➣➣Acute schizophrenia or maniaAcute schizophrenia or mania

Preoperative sedationPreoperative sedation

Adults: 25 to 50 mg P.O. 2 to 3 hours before surgery, or 12.5 to 25 mg I.M. 1 to 2 Adults: 25 to 50 mg P.O. 2 to 3 hours before surgery, or 12.5 to 25 mg I.M. 1 to 2

hours before surgeryhours before surgery

Children ages 6 months to 12 years: 0.55 mg/kg P.O. (15 mg/m2) 2 to 3 hours Children ages 6 months to 12 years: 0.55 mg/kg P.O. (15 mg/m2) 2 to 3 hours

before surgery, or 0.55 mg/kgbefore surgery, or 0.55 mg/kg

I.M. 1 to 2 hours before surgeryI.M. 1 to 2 hours before surgery

Drug-behaviors. Drug-behaviors. Alcohol use: increased CNS depressionAlcohol use: increased CNS depressionSun exposure: increased risk of photosensitivitySun exposure: increased risk of photosensitivityPatient monitoringPatient monitoring● Monitor blood pressure closely during I.V. infusion.● Monitor blood pressure closely during I.V. infusion.

Stay alert for signs and symptoms of neuroleptic malignant syndrome Stay alert for signs and symptoms of neuroleptic malignant syndrome (hyperpyrexia,muscle rigidity, altered mental status, irregular pulse or (hyperpyrexia,muscle rigidity, altered mental status, irregular pulse or blood pressure, tachycardia, diaphoresis, and arrhythmias). Stop drug blood pressure, tachycardia, diaphoresis, and arrhythmias). Stop drug immediately if these occur.immediately if these occur.

● Assess for extrapyramidal symptoms.● Assess for extrapyramidal symptoms.

Patient teachingPatient teaching● Tell patient to take capsules or tablets with a full glass of water, with or ● Tell patient to take capsules or tablets with a full glass of water, with or without food.without food.

● Instruct patient not to crush sustained-release capsules.● Instruct patient not to crush sustained-release capsules.

● Tell patient to mix oral concentrate in juice, soda, applesauce, or ● Tell patient to mix oral concentrate in juice, soda, applesauce, or pudding.pudding.

● Caution patient to avoid driving and other hazardous activities until he ● Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration and alertness.knows how drug affects concentration and alertness.

● As appropriate, review all other significant and life-threatening adverse ● As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, reactions and interactions, especially those related to the drugs, tests, herbs, and behaviors mentioned above.herbs, and behaviors mentioned above.

PHENOTHIAZINESPHENOTHIAZINESUSES:USES: This medication is used to treat mental/emotional conditions. It is also used to treat This medication is used to treat mental/emotional conditions. It is also used to treat

nausea and vomiting and may be used for other conditions as determined by your doctor.nausea and vomiting and may be used for other conditions as determined by your doctor.

SIDE EFFECTS:SIDE EFFECTS: Constipation, drowsiness, vision changes or dry mouth may occur. If any of Constipation, drowsiness, vision changes or dry mouth may occur. If any of

these effects persist or worsen, notify your doctor. This medication may cause dizziness and these effects persist or worsen, notify your doctor. This medication may cause dizziness and

lightheadedness. To minimize these effects, get up slowly when rising from a seated or lying lightheadedness. To minimize these effects, get up slowly when rising from a seated or lying

position. Unlikely to occur but report promptly: restlessness, muscle stiffness, weakness, position. Unlikely to occur but report promptly: restlessness, muscle stiffness, weakness,

difficulty speaking, loss of balance, mask- like facial expression, trembling or shaking, difficulty speaking, loss of balance, mask- like facial expression, trembling or shaking,

dizziness, lip smacking or other uncontrollable movements, difficulty urinating, skin dizziness, lip smacking or other uncontrollable movements, difficulty urinating, skin

rash/discoloration. Very unlikely to occur but report promptly: sore throat, unusual rash/discoloration. Very unlikely to occur but report promptly: sore throat, unusual

bleeding/bruising, stomach pain, yellowing of eyes/skin, dark urine, hot dry skin, vomiting. bleeding/bruising, stomach pain, yellowing of eyes/skin, dark urine, hot dry skin, vomiting.

Though very unlikely to occur, notify your doctor immediately if you experience any of the Though very unlikely to occur, notify your doctor immediately if you experience any of the

following effects: severe muscle stiffness, confusion, fever, seizures, irregular/fast heartbeat, following effects: severe muscle stiffness, confusion, fever, seizures, irregular/fast heartbeat,

increased sweating, prolonged/painful erection. In the unlikely event you have an allergic increased sweating, prolonged/painful erection. In the unlikely event you have an allergic

reaction to this drug, seek immediate medical attention. Symptoms of an allergic reaction reaction to this drug, seek immediate medical attention. Symptoms of an allergic reaction

include: rash, itching, swelling, dizziness, trouble breathing. If you notice other effects not include: rash, itching, swelling, dizziness, trouble breathing. If you notice other effects not

listed above, contact your doctor or pharmacist.listed above, contact your doctor or pharmacist.

Analgesics/antiinflammatory Analgesics/antiinflammatory agentsagents

Acetylsalicylic Acid (Aspirin) - Aspergum Acetylsalicylic Acid (Aspirin) - Aspergum

Pharmacologic class:Pharmacologic class:Non-steroidal anti-inflammatory drug (NSAID)Non-steroidal anti-inflammatory drug (NSAID)

Therapeutic class:Therapeutic class: Nonopioid analgesic, antipyretic, Nonopioid analgesic, antipyretic, antiplatelet drugantiplatelet drugPregnancy risk category C (with full dose in third trimester: D)Pregnancy risk category C (with full dose in third trimester: D)

ActionAction- Reduces pain and inflammation by inhibiting prostaglandin - Reduces pain and inflammation by inhibiting prostaglandin production.production.- Fever reduction mechanism unknown; may be linked to - Fever reduction mechanism unknown; may be linked to decrease in endogenous pyrogens in hypothalamus resulting decrease in endogenous pyrogens in hypothalamus resulting from prostaglandin inhibition.from prostaglandin inhibition.- Exerts antiplatelet effect by inhibiting synthesis of - Exerts antiplatelet effect by inhibiting synthesis of prostacyclin and thromboxane A2.prostacyclin and thromboxane A2.

Adverse reactionsAdverse reactionshearing losshearing lossnauseanauseavomitingvomitingGI bleedingGI bleedingthrombocytopeniathrombocytopeniahyponatremiahyponatremiahypokalemia,hypokalemia,hypoglycemiahypoglycemiawheezingwheezingrashrashhypersensitihypersensitivity reactionsvity reactions

Patient monitoringPatient monitoringWatch for signs and symptoms of hypersensitivity and other adverse reactions, especially Watch for signs and symptoms of hypersensitivity and other adverse reactions, especially bleeding tendency.bleeding tendency.

● Stay alert for signs and symptoms of acute toxicity, such as diplopia, ECG abnormalities, ● Stay alert for signs and symptoms of acute toxicity, such as diplopia, ECG abnormalities, generalized seizures, hallucinations, hyperthermia, oliguria, acute renal failure, incoherent generalized seizures, hallucinations, hyperthermia, oliguria, acute renal failure, incoherent speech, irritability, restlessness, tremor, vertigo, confusion, disorientation, mania, lethargy, speech, irritability, restlessness, tremor, vertigo, confusion, disorientation, mania, lethargy, laryngeal edema, anaphylaxis, and coma.laryngeal edema, anaphylaxis, and coma.

●Monitor elderly patients carefully because they’re at greater risk for salicylate toxicity.●Monitor elderly patients carefully because they’re at greater risk for salicylate toxicity.

● With prolonged therapy, frequently assess hemoglobin, hematocrit, International ● With prolonged therapy, frequently assess hemoglobin, hematocrit, International Normalized Ratio, and kidney function test results.Normalized Ratio, and kidney function test results.

● Check salicylate blood levels frequently.● Check salicylate blood levels frequently.

● Evaluate patient for signs and symptoms of ototoxicity (hearing loss, tinnitus, ataxia, and ● Evaluate patient for signs and symptoms of ototoxicity (hearing loss, tinnitus, ataxia, and vertigo).vertigo).

Acetaminophen (N-acetyl-p-Acetaminophen (N-acetyl-p-aminophenol) aminophenol)

Drug classesDrug classes: : Antipyretic Analgesic (nonopioid) Antipyretic Analgesic (nonopioid)

Therapeutic actions:Therapeutic actions:

Antipyretic: Reduces fever by acting directly on the hypothalamic heat-regulating Antipyretic: Reduces fever by acting directly on the hypothalamic heat-regulating

center to cause vasodilation and sweating, which helps dissipate heat. center to cause vasodilation and sweating, which helps dissipate heat.

Analgesic: Site and mechanism of action unclearAnalgesic: Site and mechanism of action unclear..

Indications:Indications:

Analgesic-antipyretic in patients with aspirin allergy, hemostatic disturbances, Analgesic-antipyretic in patients with aspirin allergy, hemostatic disturbances,

bleeding diatheses, upper GI disease, gouty arthritis Arthritis and rheumatic bleeding diatheses, upper GI disease, gouty arthritis Arthritis and rheumatic

disorders involving musculoskeletal pain (but lacks clinically significant disorders involving musculoskeletal pain (but lacks clinically significant

antirheumatic and anti-inflammatory effects) Common cold, flu, other viral and antirheumatic and anti-inflammatory effects) Common cold, flu, other viral and

bacterial infections with pain and fever Unlabeled use: Prophylactic for children bacterial infections with pain and fever Unlabeled use: Prophylactic for children

receiving DPT vaccination to reduce incidence of fever and painreceiving DPT vaccination to reduce incidence of fever and pain

Nursing responsibilities.Nursing responsibilities.•Do not exceed the recommended dosage. Do not exceed the recommended dosage.

•Consult physician if needed for children < 3 yr; if needed for longer than 10 Consult physician if needed for children < 3 yr; if needed for longer than 10

days; if continued fever, severe or recurrent pain occurs (possible serious days; if continued fever, severe or recurrent pain occurs (possible serious

illness). illness).

•Avoid using multiple preparations containing acetaminophen. Avoid using multiple preparations containing acetaminophen.

•Carefully check all OTC products. Carefully check all OTC products.

•Give drug with food if GI upset occurs.Give drug with food if GI upset occurs.

• Discontinue drug if hypersensitivity reactions occur. Discontinue drug if hypersensitivity reactions occur.

•Treatment of overdose: Monitor serum levels regularly, N-acetylcysteine should Treatment of overdose: Monitor serum levels regularly, N-acetylcysteine should

be available as a specific antidote; basic life support measures may be be available as a specific antidote; basic life support measures may be

necessary.necessary.