The following is a list of individuals who would not be candidates for sedation and includes but not limited to: 1. Diabetics- unless blood sugar is well controlled and patient is compliant with dietary and prescription regimens. Type II are typically better candidates as patients with Type I (insulin dependent) typically experience larger fluctuations in blood sugar and need a quicker response to this fluctuation. 2. Liver and kidney diseases. Patients with liver and kidney disorders are usually not great candidates for sedation because their ability to metabolize drugs is altered or compromised. These metabolism deficiencies can lead to patients hypo or hyperresponding to medications and will also shorten or prolong the response to the medications. Patients with these disorders need clearance from their physician prior to sedation. 3. Thyroid and adrenal disorders. Patients with altered responses to stress, altered metabolisms can affect the response to sedation. Patients that are taking steroids on a regular basis can also have adverse reactions because their body is not conditioned for stressful situations. Patients with these disorders or anything else endocrine in origin should consult their dentist and physician for any proposed sedation treatment. 4. Pregnancy- Patients who are pregnant are not good candidates due to the teratogenic properties of sedation medications but also due to the altered metabolic demands of a fetus on a mother's body. If absolutely necessary, the 2nd trimester is the best choice but I would prefer to defer sedation or any unnecessary dental treatment until after pregnancy. 5. Medications/recreational drugs- Patients that take mind altering medications such as antidepressants and anti-anxiety medications can also respond very erratically or not at all to sedation medications. Patients typically don't respond as well because the body has been conditioned to process mind altering medications that fall along the same categories of sedative medications. Recreational drugs is a huge contraindication as the response is totally unpredictable and could be potentially life threatening. 6. Respiratory- This is the biggest and most frequent complication I run into. Factors such as Asthma, COPD, sleep apnea, sickle cell disease, bronchitis, sinus infections, etc. All sedation medications have some sort of respiratory depressing effects that control a person's breathing. Sedation medications can severely hamper the body's ability to maintain normal breathing and furthermore should be taken with caution. An example of someone who is not always a good candidate is someone that snores on a regular basis as this is already an indication of someone who may be developing respirator
Midazolam Benzodiapine alprazolam Contraindicated with opoid medication
Iv injec tion is fast acting than orally medicine. Sedation depends age & pychologoical condition. But in oldage tab. Zolpidem is most safest drug for sleep.
trazodone (Rx) ADULT Dosage Forms & Strengths tablet 50mg 100mg 150mg 300mg tablet, extended-release 150mg 300mg PEDIATRIC Dosage Forms & Strengths tablet 50mg 100mg 150mg 300mg tablet, extended-release 150mg 300mg GERIATRIC Depression Immediate release: 25-50 mgPO qHS; increase dose by 25-50 mg every three days if inpatient or every week if oupatient not to exceed 75-150 mg/day Extended release: Experience limited; use 150 mg PO HS initially; may increase by increments of 75 mg/day q3Days; not to exceed 375 mg/day
Angioedema Zolpidem should be avoided in those with a hypersensitivity to zolpidem or any ingredient in the product. Reactions including anaphylaxis or angioedema may occur with sedative-hypnotics, and may become evident as early as the initial dose. Patients should be instructed on the appropriate action in the event of an allergic reaction. Treatment with zolpidem should not be reinitiated in patients who experience angioedema after administration of the drug. Behavioral changes, depression, suicidal ideation Because sleep disturbances may be the presenting manifestation of a physical and/or psychiatric disorder, symptomatic treatment of insomnia or sleep disorders with zolpidem should be initiated only after a careful evaluation of the patient. The failure of the sleep disturbance to remit after 7 to 10 days of treatment may indicate the presence of a primary psychiatric and/or medical illness that should be evaluated. Worsening of insomnia or the emergence of new thinking or behavior abnormalities may be the consequence of an unrecognized psychiatric or physical disorder. Such findings have emerged during the course of treatment with sedative/hypnotic drugs, including zolpidem. Because some adverse effects of zolpidem appear to be dose-related, it is important to use the lowest possible effective dose. A variety of abnormal thinking and behavioral changes have been reported to occur in association with the use of sedative/hypnotics, including zolpidem. Some of these changes included decreased inhibition (e.g., aggressiveness and extroversion that seemed out of character), bizarre behavior, agitation and depersonalization. Visual and auditory hallucinations have been reported. Amnesia and other neuropsychiatric symptoms may occur unpredictably. In primarily depressed patients, worsening of depression, including suicidal thoughts and actions (suicidal ideation, including completed suicides), has been reported in association with the use of sedative/hypnotics. Intentional overdosage is more common in patients with depression; therefore, the least amount of drug that is feasible should be prescribed for the patient at any one time. The emergence of any new behavioral sign or symptom of concern requires careful and immediate evaluation. Coadministration with other CNS depressants, complex sleep-related behaviors, driving or operating machinery, drug-induced complex sleep-related behaviors, ethanol ingestion, females Sedative-hypnotics can cause complex sleep-related behaviors such as phone calls, sexual activity, preparing and eating food, or driving while not fully awake and in some cases having no memory of the event. These behaviors appear to be more frequent with nonbenzodiazepine benzodiazepine-receptor agonists (NBRAs), such as zolpidem, than other sedative-hypnotics and may occur with or without the concomitant use of alcohol or other CNS depressants. Although rare, serious injuries or death have occurred; therefore, zolpidem and other NBRAs are contraindicated in patients with a history of drug-induced complex sleep-related behaviors. Patients should be informed of the risks before receiving any medication from this class, including instructions to discontinue the medication if they experience a sleep-related episode and to contact their health care provider immediately. Health care professionals and patients are encouraged to report adverse events or side effects related to the use of NBRAs to the FDA MedWatch Safety Information and Adverse Event Reporting Program. Because zolpidem has a rapid onset of action and causes CNS depressant activity, zolpidem products indicated for insomnia due to difficulty with sleep initiation should only be administered immediately before retiring and with at least 7 to 8 hours remaining before the planned time of waking. Zolpidem products indicated for difficulty returning to sleep after middle-of-the-night awakenings should only be taken while the patient is in bed and has at least 4 hours of bedtime remaining before the planned time of waking. Vehicle drivers and machine operators should be warned that hypnotics, such as zolpidem, have a possible risk of adverse reactions including drowsiness, prolonged reaction time, dizziness, sleepiness, blurred/double vision, reduced alertness and impaired driving, even the day after use. Patients should be instructed to avoid driving or operating machinery or performing other tasks requiring mental alertness for at least 8 hours after taking immediate-release formulations, and patients receiving the extended-release formulation should be alerted about the potential impact on such activities the full day after use. Patients receiving zolpidem for middle-of-the-night awakenings should wait for at least 4 hours after dosing and until they feel fully awake before driving or engaging in other activities requiring full mental alertness. Because zolpidem can cause drowsiness and a decreased level of consciousness, there is a higher risk of falls, particularly in the elderly, with the potential for subsequent severe injuries. Zolpidem use has been associated with severe injuries such as hip fractures and intracranial hemorrhage. Due to gender differences in the elimination of zolpidem, a lower initial dose is recommended in adult females (women). Plasma levels of zolpidem in some patients, particularly women, may be high enough the morning after use to impair activities requiring mental alertness, such as driving. The risk for next-morning impairment is higher if zolpidem products are taken without adherence to the proper hours for sleep recommended following use or if a higher than the recommended dose is taken. Risks for impairment are also increased during coadministration with other CNS depressants with zolpidem or with use of drugs that increase the blood levels of zolpidem. Concurrent alcohol or CNS depressant use increases the risk for CNS depression, impairment, and other additive effects. Patients taking zolpidem should avoid ethanol ingestion. Lower initial dosages of zolpidem should be considered in patients taking other CNS-depressant therapies. Anterograde amnesia may be particularly evident at zolpidem doses above 10 mg/day. Abrupt discontinuation, alcoholism, substance abuse Immediate-release zolpidem is recommended for use in the short-term treatment of insomnia. No such recommendation exists in the package labeling for extended-release zolpidem, although cautious use is prudent when prescribing any hypnotic. Problems associated with abrupt discontinuation of hypnotic drugs are more likely to occur following chronic therapy. There is no reliable data documenting the occurrence of withdrawal symptoms following discontinuation of zolpidem, but evidence of fatigue, nausea/vomiting, flushing, lightheadedness, inconsolable crying, stomach cramps, panic attack, nervousness, and abdominal discomfort may constitute a withdrawal syndrome. Rare postmarketing reports of abuse, dependence, and withdrawal have been received. Withdrawal of some hypnotics also precipitates a rebound insomnia. If therapy is continued for more than 2 weeks the possibility of a withdrawal syndrome should be considered and abrupt discontinuation of therapy avoided. The possibility of physical and psychological dependence to zolpidem requires close monitoring. Zolpidem should be used cautiously in patients with a history of alcoholism or substance abuse. Encephalopathy, hepatic disease Zolpidem should be administered cautiously to patients with hepatic disease because the elimination half-life of the drug can be prolonged, with possible resultant toxicity. Patients with hepatic insufficiency do not clear zolpidem as rapidly as patients with normal hepatic function. Patients with mild to moderate hepatic disease (e.g., Child Pugh class A or B) should receive a lower initial dosage (i.e., 5 mg/day). Avoid zolpidem use in patients with severe hepatic impairment (e.g., Child Pugh class C) since the drug may contribute to encephalopathy. Gamma-aminobutyric acid (GABA) agonists, such as zolpidem, have been associated with the development of hepatic encephalopathy in patients with hepatic insufficiency. Chronic obstructive pulmonary disease (COPD), myasthenia gravis, pulmonary disease, respiratory depression, sleep apnea Postmarketing reports indicate that respiratory insufficiency or oxygen desaturation may occur in some patients treated with zolpidem, mostly in patients with pre-existing pulmonary disease. Zolpidem should be used with caution in patients with pre-existing respiratory depression, such as severe chronic obstructive pulmonary disease (COPD), sleep apnea, or myasthenia gravis to avoid the risk of depressing ventilatory function. Labor, neonates, obstetric delivery, pregnancy Available data from observational studies, birth registries, and case reports on the use of zolpidem during human pregnancy have not reported a clear association with the drug and major birth defects. Zolpidem crosses the placenta and may produce respiratory depression and sedation in neonates with in utero exposure during the later stages of pregnancy; there are a limited number of exposed neonatal cases of moderate to severe respiratory depression requiring aspiration, artificial ventilation, or intratracheal intubation. The majority of neonates recovered within hours to a few weeks after birth once treated. Neonatal flaccidity has also been reported in infants born to mothers who have received sedatives during pregnancy. Newborns who have been exposed to zolpidem during pregnancy and labor should be monitored for signs of sedation and respiratory depression and managed accordingly. Withdrawal symptoms may also be possible during the postnatal period. Zolpidem has no established use during labor or obstetric delivery. Breast-feeding The developmental and health benefits of breast-feeding should be assessed along with the mother's clinical need for zolpidem and potential adverse effects on the breastfed infant from zolpidem or any underlying maternal condition. Zolpidem is excreted into breast milk, and there are reports of excess sedation in babies exposed to zolpidem through breast milk; therefore, it is recommended to monitor the breast-fed infant for excess sedation, hypotonia, and respiratory depression. Alternatively, a lactating woman may consider interrupting breast-feeding and pumping and discarding breast milk during treatment and for 23 hours (about 5 half-lives) after zolpidem administration to minimize infant drug exposure. In one small study of lactating women (n = 5) who received a single 20 mg dose of zolpidem on postpartum day 3 or 4, the mean milk to maternal plasma concentration ratio was 0.13 (range, 0.11 to 0.18) three hours after drug administration. The amount of zolpidem measured in the breast milk samples represented 0.004% to 0.019% of the maternal administered dose. No detectable zolpidem was measured in subsequent milk samples taken at 13 and 16 hours after the dose. Breast-feeding was discontinued for 24 hours after drug administration; therefore, infant exposure was not assessed. The transfer of zaleplon, an alternative sedative, into breast milk has also been assessed; however, the effects of zaleplon exposure on the breast-feeding infant have not been formally evaluated. Children, infants The safety and efficacy of zolpidem in pediatric patients have not been established and the drug cannot be recommended for use in children, adolescents or infants. Studies of zolpidem in pediatric patients have not suggested efficacy of the drug over placebo, and, adverse events were frequent. Results of a controlled 8-week study for the treatment of insomnia in 201 children aged 6 to 17 years with attention-deficit hyperactivity disorder (ADHD) indicated that zolpidem was not effective compared to placebo. One or more adverse events was experienced in 62.5% of pediatric patients treated with zolpidem (dizziness [23.5%], headaches [23.5%], and hallucinations [7.4%]). Geriatric Debilitated and/or geriatric patients are more sensitive to the effects of zolpidem. The impairment of cognitive and motor function may be more marked in the elderly and a lower initial dosage of zolpidem is recommended with close monitoring. Because zolpidem can cause drowsiness and a decreased level of consciousness, there is a higher risk of falls, particularly in the elderly, with the potential for subsequent severe injuries. Elderly patients who receive greater than 5 mg/day of zolpidem immediate-release or greater than 6.25 mg/day of zolpidem extended-release may especially be at risk for falls or mental status changes. When zolpidem is discontinued, there may be a period of rebound insomnia if higher doses are used. During studies evaluating sleep after zolpidem was discontinued, geriatric patients reported impaired sleep on the first post-treatment night after using doses above 5 mg/day. No objective evidence of rebound insomnia was observed at recommended doses.According to the Beers Criteria, zolpidem is considered a potentially inappropriate medication (PIM) in geriatric patients and use should be avoided. Nonbenzodiazepine, benzodiazepine-receptor agonists (NBRAs) such as zolpidem may produce adverse effects similar to benzodiazepines such as falls, fractures, and delirium in older adults. There are increased emergency department visits, hospitalizations, and motor vehicle crashes, as well as minimal improvement in sleep latency and duration in older adults with the use of NBRAs. Avoid NBRA use in geriatric patients with dementia/cognitive impairment (adverse CNS effects) or delirium/high risk of delirium (new-onset or worsening delirium). Avoid use of an NBRA in elderly patients with a history of falls or fractures, unless safer alternatives are not available since NBRAs can produce ataxia, impaired psychomotor function, syncope, and additional falls. If an NBRA must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures and implement other strategies to reduce fall risk. The federal Omnibus Budget Reconciliation Act (OBRA) regulates medication use in residents of long-term care facilities (LTCFs). According to the OBRA guidelines, evaluate factors that potentially cause insomnia before initiating a sedative (e.g., sleep environment, inadequate physical activity, provision of care disruptions, caffeine or medications, pain, and discomfort, or other underlying conditions that cause insomnia). Most cases of insomnia are associated with other underlying conditions. Non-pharmacologic interventions and maximized treatment of underlying conditions (if applicable) are expected to be addressed. Precede or accompany the initiation of a sleep induction or maintenance medication with other interventions to improve sleep. Use all sleep medications per approved product labeling. The use of sedating medications for individuals with diagnosed sleep apnea requires careful assessment, documented clinical rationale, and close monitoring. Exceptions to the OBRA provisions include: single-dose sedative use for a dental or medical procedure or short-term sedative use during initiation of treatment for depression, pain, or another comorbid condition until symptoms improve or the underlying cause can be identified and effectively treated. OBRA provides dosing guidance for most sedatives, including zolpidem. When a drug is being used to induce sleep or treat a sleep disorder, the facility should attempt periodic tapering of the medication or provide documentation of medical necessity per the OBRA guidelines.
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70 yrs old presented with dyspnea bilateral pedal edema raised jvp Known case of asthma on inhalers Total count 18000 Bp160/90 Treated as acute asthma Ecg shows p pulmonale Tdy out put is decreased to 500ml ???Sepsis/rvf/ccf// Plz comment on xray !!!Dr. Vinayak Hiremath1 Like32 Answers
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32yr/male, c/o occasional discomfort in the sternal regional ( chest tightness and breathing difficulty) . this episode lasts for half to one hour.c/o lightheadedness ( last for nearly an hour). c/o epigastric discomfort +.c/o sweating.C/o indigestion and belching (severe ) for past 1 month.No c/o vomting/nausea/ chest pain / headache.No c/o fever. His CBG , Blood pressure were normal at the time of incidence. he is known smoker but stopped for 3 months.His CBC ,ECG, THYROID PROFILE , CHEST X RAY WERE NORMAL.On examination CVS, RS WERE NORMAL. Bowel and bladder habits were normal.per abd-soft and BS +. the above complaints relieved by antacids and for PPI. eventhough he is on antacids he is still have the same problem . Now patient is on HP KIT BD for 10 days,Tab.nexito 10mg half HS for 5 days,tab. ativan 1mg hs for 10 days. tab. Revotril 0.5 mg half tablet twice a day for 10 days,tab.domstal BD for 20 days. he has been admitted in private hospital and treated there for 3 days and discharged with above medications .Again patient is having the similar complaint from today early morning. all his vitals were stable .kindly suggest me how to proceed further and what all are the medications to be added or any other investigation that we need to do for this patient. what suggestions can we give to the patient.I am posting all the investigations that done to the patient till date.kindly interpret the patient PFT. only rearrangement in LFT.Dr. Gokul Raj2 Likes19 Answers