Anesthesia for athletes using performanceenhancing drugs
JOSEPH A. JOYCE, CRNA, BS
Kernersville, North Carolina
Anabolic-androgenicsteroids are used in the
treatment of numerous medical conditions,
including Fank oni's anemia, hypogonadism,
hereditary angioedema,hypopituitarismand
impotence. However, because of their potent
anabolicproperties,athletes began to use
them to enhance body strength, size and
endurance. Despite warningsfrom the
medical and scientific communities of
dangerousside effects such as Wilm's tumor,
hepatocellularcarcinoma, stroke and
myocardial infarction,some athletes continue
to use anabolic steroids.
Among the numerous research
publications, only one case report was found
which related difficulties in anesthesia
administration.This paper presents the
physiologic changes associated with anabolic
steroid ingestion and applies these changes to
the administrationof anesthesia.
Key words: anabolic-androgenic steroids,
enzyme induction, steroids, volume of
distribution.
Historically, the male hormone, testosterone, was
first synthesized in 1935 after its anabolic properties
were recognized.' An anabolic substance is one
which promotes the constructive process by which
cells convert simple substances such as amino acids,
glucose, etc. into more complex substances such as
enzymes, other proteins, fats, etc. Testosterone was
April 1991/ Vol. 59/No. 2
first used to reverse the catabolic process thus stimulating weight gain in patients who were grossly
underweight and those recovering from systemic
illnesses. Anabolic steroids were reportedly administered to German troops during World War II to
enhance their aggressiveness and later to concentration camp survivors to stimulate weight gain. 2
Because of testosterone's potent androgenic
properties, derivatives were developed which attempted to maximize the anabolic properties and at
the same time diminish the androgenic properties
as much as possible. An androgenic substance is one
which stimulates development of male characteristics. In addition to the anabolic properties, these
derivatives are longer lasting, more potent erythropoietic stimulants than the parent compound testosterone. Anabolic steroids are used in the treatment of certain types of aplastic anemia, such as
Fanconi's anemia, as well as the following conditions: hypogonadism, hereditary angioedema, senile and postmenopausal osteoporosis, corticosteroid-induced catabolism, female-to-male sexual reassignment, hypopituitarism and impotence. Table
I lists commonly used anabolic-androgenic steroids along with the recommended dosages for each.
By the 1950s, athletes competing in events
requiring body strength or endurance began to incorporate anabolic steroids into their training regimens to maximize gains in strength, size or endurance over shorter periods of time.' Anabolic steroid
use proliferated over the next 26 years. In 1976, the
International Olympic Committee added anabolic
steroids to the list of banned substances. Also, in
139
Table I
Commonly used anabolic-androgenic steroids
Generic name
Brand name
Recommended dosage
Oral preparations
Testolactone
Teslac®
150 mg PO daily or 100 mg
IM 3 times/week
200 mg PO daily
4-8 mg PO daily
2-30 mg PO daily
5 mg PO daily
Calusterone
Ethylestrenol
Fluoxymesterone
Methandrostenolone
Oxandrolone
Oxymetholone
Methosorb®
Maxibolin®
Halotestin®
Dianabol®(withdrawn from
market by manufacturer, 3/82)
Metardren®
Oreton Methyl®
Anaval®
Anadrol-50®
Stanozolol
Danazol
Winstrol®
Danocrine®
Parenteral preparations
Dromostanolone propionate
Nandrolone deconate
Nandrolone phepropionate
Testosterone cypionate
Testosterone enanthate
Testosterone propionate
Drolban®
Deca-Durabolin®
Durabolin®
Depo-Testosterone®
Delatestryl®
Oreton*
Methandriol
Anabol®
Methyltestosterone
5-15 mg buccal daily
10-50 mg PO daily
5-10 mg PO daily
5-15 mg PO daily
50-100 mg daily (for anemia)
6 mg PO daily
200-800 mg PO daily
100 mg IM3 times/week
50-100 mg IM every 3-4 weeks
25-50 mg IM weekly
100-400 mg IM every 2-4 weeks
100-400 mg IMevery 2-4 weeks
50 mg IM 3 times/week or 300 mg
subcutaneous every 4-6 months
50-100 mg IM 1-2 times/week
IM-intramuscular
PO-per os
Composite listing derived from:
(1) Kibble MW, Ross MB. Adverse effects of anabolic steroids in athletes. Clin Pharm 1987; 6:686-692.
(2) Mellion MB. Anabolic steroids in athletes. Am Fernm
Physician. 1984; 30:113-119.
1986 and 1987, the National Collegiate Athletic Association and the National Football League, respectively, began to test athletes for anabolic use.' Beginning with the 1989 season, the National Football
League penalized players guilty of steroid use. Despite these bans, anabolic steroid use has continued
as evidenced by the disqualification of 15 athletes
from the 1983 Pan American Games and the disqualification of Ben Johnson during the 1988 Seoul
Olympics. A 1988 study by Buckley and associates
showed that an estimated 6.6% of high school senior
males have at some time used or presently are using
anabolic steroids.3
When anabolic steroids were first used by athletes in the 1950s, dosages ingested were predominantly within the medically recommended ranges.
However, the adage, "if one is good, two is better"
began to encroach and seems to have become accepted among these athletes, as well as their coaches.
Athletes, male and female alike, who choose to utilize anabolic steroids as part of their training regimen, currently follow two administration methods.4-6 The first is known as "cycling," where the
140
athlete starts with relatively low doses and steadily
increases the dosages over a period of weeks, followed by gradual decreases in dosages, again over a
period of weeks, to the point of discontinuation."
These "cycles" typically encompass 4 to 18 weeks
and are followed by a period of time, usually 6 to 8
weeks, during which no anabolic steroids are taken.
The second method, employed concurrently, is
known as "stacking."" This method involves ingestion of two or more anabolic steroids during a
"cycle" theoretically to further enhance the much
sought after gains in strength, size or endurance.
Both of these methods of administration result in
the athlete exceeding the medically recommended
dosages by as much as 50- to 150-fold.
Anabolic steroid use has been demonstrated to
affect many body systems. The major cardiovascular effects include secondary polycythemia, hypertension, hypertrophy of the left ventricle, cardiac
muscle lesions and increased cholesterol levels.6
Myocardial infarction and cerebral vascular accident have also been associated with the use of anabolic steroids.10
n
The liver is probably the organ
Journal of the American Association of Nurse Anesthetists
Table II
Adverse side effects
Cardiovascular
Increased low-density lipoprotein
Increased high density lipoprotein (HDL) HDL2, HDL3
Decreased apolipoprotein A-1
Decreased apolipoprotein B
Hypertension
Cardiac muscle lesions
Secondary polycythemia
Decreased erythrocyte sedimentation rate
Decreased platelet aggregation
Left ventricular hypertrophy
Decreased 2,3 diphosphoglycerate
Water retention
Increased serum K+, Na+ and Ca++
Decreased serum K+ (if diuretics used)
Endocrine
Decreased lutenizing hormone
Decreased follicle stimulating hormone
Decreased thyroid stimulating hormone
Decreased adrenocorticotropic hormone
Decreased thyroxine
Decreased triiodothyronine
Decreased free thyroxine
Decreased thyroxine-binding globulin
Decreased protein-bound iodine
Increased serum cortisol
Gynecomastia
Alopecia
Sterility
Impotence
Precocious puberty
Hyperinsulinism
Diminished glucose tolerance
secondary to insulin resistance
Genitourinary
Wilm's tumor
Prostatic hypertrophy
Prostatic adenocarcinoma
Testicular germ cell tumor
Hepatic
Hepatocellular carcinoma
Hepatic angiosarcoma
Intrahepatic cholangiocarcinoma
Cholestasis
Jaundice
Peliosis hepatis
Skeletal
Weakening of tendons
Premature epiphysis closure
Females only
Virilization
Excessive facial hair growth
Hirsutism
Menstrual irregularities
Deepening of voice
Enlarged clitoris
Breast carcinoma
Male-pattern baldness
Decreased breast size
Composite listing from:
(1) Kibble MW, Ross MB. Adverse effects of anabolic steroids in athletes. Clin Pharm. 1987; 6:686-692.
(2) Alen M, and Rahkila P. Anabolic-androgenic steroid effects on endocrinology and lipid metabolism. Sports Med. 1988; 6:327-332.
most affected by anabolic steroids. Among the hepatic problems encountered with anabolic steroid
use are jaundice, cholestasis, peliosis hepatus
(blood-filled lacunae in the liver parenchyma),
hepatocellular carcinoma and intrahepatic cholangiocarcinoma.12 Table II contains a more complete list of adverse effects of anabolic steroid use.
In addition to using anabolic steroids, many athletes use other drugs in an attempt to counteract
some of these adverse side effects. These "associated
drugs" are listed in Table III.
Many of the adverse side effects listed in Table
II are of importance to the anesthetist. Of primary
importance is the possibility of hepatic damage and
dysfunction which would be indicated by elevated
levels of the liver-specific isoenzyme of lactic
dehydrogenase (LDH) and alkaline phosphatase.
Virtually all of the anabolic steroids currently in
use are metabolized by the liver. With continued
April 1991/ Vol. 59/No. 2
Table III
"Associate" drugs commonly used
Sympathomimetics-as stimulants
Beta blockers-to reduce tremors
Human chorionic gonadotropin (Preznyl®)-used to
prevent testicular atrophy and maintain
endogenous testosterone production either
concurrently or immediately after a "cycle."
Diuretics (furosemide, hydrochlorothiazide, etc.)to decrease retention
Thyroglobulin (Proloid")
Composite derived from:
(1) Strauss RH, et al. Side effects of anabolic steroids in
weight-trained men. Physician and
Sports Med. 1983;11:87-96.
(2) Deters T.So you want to take steroids? Muscle
and Fitness. 1989;50:109-110, 230-233.
(3) Brainum J. Growth hormone: Myth vs. fact. Muscle
and Fitness. 1988; 49:161-163, 185-188.
141
use, anabolic steroids can be destructive to the liver.
Oral preparations demonstrate greater hepatic toxicity than parenteral preparations because the oral
agents must pass through the liver twice before
metabolism is complete." Because of this, the anesthetist should be alerted to the possibility of enzyme induction which will result in increased patient requirements. This is especially true for the
athlete just starting or completing a "cycle." In addition, since a large portion of the anesthetist's pharmacologic armament is metabolized by the liver,
one should also be aware of the possibility of prolonged drug actions in such a patient.
Even in medically recommended doses, administration of anabolic steroids results in retention of sodium, potassium, calcium and water. '.
Alen and others have reported significant increases
in fat-free weight at least part of which can only be
attributed to increased water retention. 7 In short,
this results in an increased volume of distribution
of many anesthetic medications. Thus, drug requirements for anesthesia may be increased. Reddy
and associates speculate that the increased volume
of distribution was at least partially responsible for
the resistance to muscle relaxation, with depolarizing and nondepolarizing muscle relaxant drugs,
demonstrated by a patient undergoing abdominal
hysterectomy and bilateral salpingo-oophorectomy
as part of sexual reassignment. These authors also
speculate that increases in the number of acetylcholine receptors resulting from increased muscle mass,
as well as enhanced neuromuscular transmission
from stimulation of adrenocorticotrophic hormone
and corticosteroids' activity, contributed to the observed resistance to muscle relaxation.' 4
Because of the water retention associated with
anabolic steroids, some athletes may use furosemide or some other diuretic to remove the excess
water. Use of furosemide without potassium replacement will result in potassium depletion and
hypokalemia. Hypokalemia and hyperkalemia, at
the extremes, both have profound effects on the
myocardium, for which reason the electrocardiogram (ECG) should be closely monitored.
Because of the erythropoietic stimulation, anabolic steroids cause a secondary polycythemia
which may be further aggravated by the use of diuretics to remove retained water. Polycythemia
alone, or in combination with diuretic-induced dehydration especially, increases the viscosity of the
blood. This, in turn, increases the workload of the
heart, thus increasing the myocardial oxygen requirements. In addition, polycythemia is associated with greater perioperative complications, usually postoperative hemorrhage or thrombosis."
Furthermore, in view of the secondary polycythe-
142
mia and increased workload of the heart, it should
be noted that dehydroepiandrosterone sulfate, a
precursor of androstenedione and testosterone, has
been shown to result in significant decreases in red
cell 2,3-diphosphoglycreate."' This factor shifts the
oxygen-dissociation curve to the left. Because of
this left shift, the cardiac output must increase in
order to maintain adequate tissue oxygenation, thus
the workload of the heart is further increased.
During the preanesthesia interview, every effort should be made to determine whether any
performance-enhancing and/or "associate" drugs
have been used by the athlete either currently or
within the preceeding 8 weeks. Reassure the athlete
that strict confidentiality will be maintained. In any
event, obtaining this information may still be difficult since these athletes are extremely protective
and quiet about this subject. Projecting a nonjudgmental attitude and explaining the importance of
such information to the successful administration
of anesthesia may make obtaining this information
somewhat easier. Although the "community" of athletes using anabolic steroids is relatively small, the
strict "underground" nature of their use warrants
inclusion of this information into the preanesthesia
interview.
In reviewing the patient's laboratory data, particular attention should be paid to the following:
sodium, potassium and calcium concentrations;
cholesterol levels; high-density lipoprotein/low
density lipoprotein (HDL/LDL) ratio; alkaline
phosphatase; liver-specific LDH isoenzyme; aspartate transferase; and alanine transferase; along with
hemoglobin, hematocrit and red blood cell count,
because these values may be elevated and may be
the first indication of the need for a more in-depth
history (Table IV). The ECG, if present, should be
noted for bradycardia, first-degree atrioventricular
delay, wandering atrial pacemaker, Wenckeback
phenomenon, ST-T wave changes and left or right
ventricular hypertrophy, all of which are relatively
common among athletes.
There are no reported contraindications for
spinal or epidural anesthesia for the athletic patient who uses anabolic steroids." If general anesthesia is indicated or desired, one should attempt to
minimize the use of drugs requiring metabolism by
the liver for clearance if hepatic dysfunction is present as indicated by the laboratory data. Induction
with sodium thiopentol is acceptable, keeping in
mind the possibility of enzyme induction and the
larger volume of distribution. Etomidate has been
implicated in suppression of adrenal cortical functioning, which may enhance the effects of prior steroid ingestion and should probably not be used. 1"
Anesthesia can be maintained with a nitrous
Journal of the American Association of Nurse Anesthetists
Table IV
Guidelines for history
Do you have current problems with:
Headache
ENleeding gums
Muscle weakness
SStomach ache after eating
Easily fatigued
fatty foods
Frequent bruises with
Hleart pounding louder and
minor injuries
faster than normal
Bothersome itching
Rlestlessness
especially after bathing
Akpathy
Increased sweating
Irrritability
Blurred vision
D)rowsiness/depression
Nosebleeds that are
difficult to stop
Do you currently take:
Prescribed medicines
Pi'ills or injections to
Over-the-counter medicines
make you bigger
Herbal teas, family
or stronger
remedies, etc.
Males only-Do you have current problems with:
Change in hair
Change in testicle size
growth patterns
Urine stream that is
Breast enlargement
weak or slow
Females only-Do you have current problems with:
Loss of hair on your head
Exceptional voice
Drastic decrease in
change such as
breast tissue
hoarseness, deepening
Drastic increase in
Stopping of menstrual
muscle mass
period
Increased episodes of
dizziness or sleeplessness
Rectal bleeding
Vomiting coffee-ground-like
material
Color change of bowel
movements
Urine color
Painful urination
Frequent urination
Trouble emptying bladder
Return of acne that
had cleared
Change ingenitalia
appearance
Return of acne
Increased hair growth on
your face, chest, arms
or legs
Reprinted with permission from Duncan DJ, Shaw EB. Anabolic steroids:
Implications for the nurse practitioner. Nurse Practitioner 1985;1 0:8-15.
oxide/oxygen)'isoflurane regimen. The muscle relaxant of choice for intubation and intraoperative
relaxation is atracurium since its metabolism is essentially independent of hepatic function.
In conclusion, anabolic steroids occupy a place
in the treatment of various medical conditions.
However, despite proven deleterious and sometimes fatal consequences of their use, many athletes
persist in using them in their training regimens,
usually in megadose fashion. More investigation
and research is needed to understand the full and
long-term effects of anabolic steroid use.
REFERENCES
(1) Bierly JR. Use of anabolic steroids by athletes. Post-grad Med.
1987 ;82 :67-74.
(2) Haupt HA, Rovere (;D. Anabolic steroids: A review of the literature. Am J Sports Med. 1984;12:469-484.
(3) Buckley WE, Yesalis CE, Friedl KE, et al. Estimated prevalence of
anabolic steroid use among male high school seniors. JA MA.
1988;260:3441-3445.
(4) Deters T. So You Want to Take Steroids? Muscle and Fitness.
1989;109-110, 230-233.
(5) Duncan DJ, Shaw EB. Anabolic steroids: Implications for the nurse
practitioner. Nurse Practitioner 1985; 10:8-15.
April 1991/ Vol. 59/No. 2
(6) Kibble MW, Ross MB. Adverse effects of anabolic steroids in athletes. Cin Pharm. 1987 ;6~:686-692.
(7) Ale'n M. Anabolic steroid effects of liver and red cells. 13r].Sports
Med.
1985;l11:15-20.
(8) Lendlers 1W M, 1)e-macker 1)N M, Vos j A, (t al. l)eleterious effects of
anabolic steroids on serum lipoproteins, 1)100( pressure and liver function in amateur body builders. Imt] Sports Med. 1988;9: 19-2:3.
(9) Appxell 11J. Morphological alterations in myocardiurn after ap~plication of anab~olic steroids. Intl./ Sports Med. 1983;4:6i2.
(10) McNutt RA, Ferenchick (;S, Kirlin PC, et al. Acute myocardial
infarction in a 22-year-old world class weight lifter using anabolic steroidis. Am ] Cardiol. 1988;62:16i4.
(11) Frankle MA, Eichberg R, Zachariah SB!. Anabolic androgenic
steroids and a stroke in an athlete: Case report. Arch P/its Med Rehabil
1988;6i9:6i32-633.
(12) ILamb 1). Anabolic steroids in athletes: Hlow well do they work and
how dangcerous are they. Am I Sports
1984;12:31-38.
(13) Stauss Rhi, Wright JE, Finerman (;AM, et al. Side effects of anabolic steroids in weight-trained men. Physician and .SportsMed. 198:1;11:87-96.
Med
(14)
Reddy,.11
Guzman
A, Robalino
J,
et al. Resistance to muscle
relaxants in a patient receiving prolonged testosterone therapy. Anesthesiology. 1989:871-873.
(15) Remes K, Vuopio 11,Jarvinen M, et al. Effects of short-term treatment with an anabolic steroid (methandieone) and dehydroepiandrosterone sulfate on plasma hormones, red cell volume and 2,3-diphosphoglycerate in athletes. Scandif Clin Lab Invest.
(16)
1977;37:577-586.
Solomon S. The athlete. Anesthesiology News. April, 1989:13-23.
ADDITIONAL READING
(1) Ale~n M, Rahkila P, Reinila M, et al. Androgenic-anabolic steroidl
143
effects on serum thyroid, pituitary and steroid hormones in athletes. Am
J Sports Med. 1987;15:357-361.
(2) Alen M, Rahkila P. Anabolic-androgenic steroid effects on endocrinology and lipid metabolism in athletes. Sports Med. 1988;6:327-332.
(3) Cohen JC, Hickman R. Insulin resistance and diminished glucose
tolerance in powerlifters ingesting anabolic steroids. ] Clin Endocrinol
and Metab. 1987;64:960-963.
(4) Creagh, TM, Rubin A, Evans DJ. Hepatic tumors induced by
anabolic steroids in an athlete. J Clin Pathol. 1988;41:441-443.
(5) Edis AJ, Levitt M. Anabolic steroids and colonic cancer. Med J
Australia. 1985;146:426-427.
(6) Mellion MB. Anabolic steroids in athletes. Am Fam Physician.
1984;30:113-119.
(7) Overly WL, Dankoff JA, Wang BK, et al. Androgens and hepatolcellular carcinoma in an athlete. Ann Intern Med. 1984;100:158-159.
(8) Prat J, Gray GF, Stolley PD, et al. Wilm's tumor in an adult associated with androgen abuse. JAMA. 1977;237:2322-2323.
(9) Vinchattle K. Steroids almost killed me. Muscle and Fitness.
1990;51:122-123, 203-204.
(10) Wood TO, Cooke PH, Goodship AE. The effect of exercise and
anabolic steroids on the mechanical properties and crimp morphology
of the rat tendon. Am J Sports Med. 1988;16:153-158.
AUTHOR
Joseph A. Joyce, CRNA, BS, holds a bachelor of science degree in
Chemistry and is a 1989 graduate of the Charleston Area Medical Center
School of Nurse Anesthesia, Charleston, West Virginia. Mr. Joyce is
currently a staff anesthetist at Wesley Long Community Hospital in
Greensboro, North Carolina.
ACKNOWLEDGEMENTS
The author thanks Pat Fleming, CRNA, AANA past-president, and
William White, CRNA, BS, for their technical suggestions for the text
and Janet M. Joyce and Rhea Griffs for their grammatical and spelling
corrections. The author also extends special thanks to Kevin Causey for
preparing the manuscript for publication.
".. fIshould die
before I wake.."
That little gnawing fear expressed in the simple childhood
prayer becomes a tragic reality every year for those people
afflicted with Malignant Hyperthermla ... many of whom
are children.
Fatalities resulting from malignant hyperthermia are
unexpected, unfair and almost always, unnecessary.
Unexpected because the patient-child or adult-shows
no outward signs of this genetic disorder. And there is no
simple diagnostic test. Most people have never heard of
malignant hyperthermia until it strikes.
Unfair because it is triggered by the patient's reaction to
certain common anesthetics used during surgery. The
life-threatening episode that results has nothing whatsoever
to do with the condition requiring the surgery.
Unnecessary, in most cases, because preparedness and
prompt treatment can arrest the episode before it reaches
dangerous levels. Persons who know of their susceptibility
can have surgery safely using nontriggering anesthetics.
When MH strikes unexpectedly during an operation, it can
be brought under control by early diagnosis and immediate
treatment.
As a medical professional, you can combat this silent
killer. For the latest information on diagnosing and treating
malignant hyperthermia, contact the Malignant
Hyperthermia Association of the United States (MHAUS) at
(203) 655-3007. It may mean the difference between life or
death.
*
144
MHAUS
PO. Box 191
Westport. CT 06881-0191
Journal of the American Association of Nurse Anesthetists
oil"
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14
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Mean postanesthesia recovery times (min)1
Thiopental/
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85*
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PRECAUTIONS.) (shrotonus.
pressure.
perfusion
Incerebral
decreases
substantial
and
:
Anormal
Urine.
ystarnus.
Uoe
Senes:
Ear
Pain,
ypem
i
p
al
Con
junctival
hypersensitivity
with
aknown
orinpatients
Iscontraindicated
general
anesthesia
When
known.
ASUSENDDEPENDENCE: None
DRUG
orItscomponents.
toDIPRIVAN
effect
titrated
tothedesired
and
Dosage
should
beIndividualized
nduetien:
AND
ADMINISTRATION:
ofgeneral DOSAGE
onlybyprsontrained inthe
beadministered
should
DIPRIVAN
Injection
ASA
I
classified
55 years
ofageand
adult
patients
under
status.
Most
clinical
tothepatents ageand
according
and
enrchnment
andesygen
"Iatrw uilaI ventilation,
oflapatent
Faclities formnintenance
anesthesia.
when
or
when
for
induction
of
DIPRIIAN
Injection,
to
2.5
mg/kg
to
require
2.0
and
II
arelikely
avaIlabIa
beImmediately
must
ciculatory resuscitation
Injection
should
DiPRIVAN
narcotics.
For
induction,
orlintramuscuiar
benzodiazepines
with
oral
withbood orplasmaebecausepremedicated
IV catheter
through
thesame
should
notbecoadministered
Injection
signs
until
theclinical
the
ofthepatient
against
40mg every
10seconds)
(approximately
component betitrated
oftheglobular
that
aggregates
have
shown
Invitro
tests
been
established.
hasnot
compatibility
ofanesthesia.
theonset
signifi- show
The
and
animals.
from
humans
with
blood/plasma/serum
occurred
vehicle
have
oftheemulsion
treating
of
Inecton
before
with
the
Intravenous
use
familiar
and
experienced
Illis
Important
to
be
cancelis
notknown.
patients
Status
ClassesorIV.These
those
inASA
patients
and/or
debilitated,
hypovoiemic
elderly,
vehicle
In
The
DIPRIMN Injection.
whie handling
hemaintained
meet
emnftk
Strict
should
ofDIPRIVAd
Injection
thedosage
ofDIPRIW4A
Injection;
totheeffects
sensitive
AND
ADMIN- maybemore
(See
DOSAGE
ofmlcroerganlemL.
rapid
growth
of
DIPRIVAN
Inecion Ies pable
conditions
according
totheir
10seconds)
50%
(20 mgevery
inthese
patients
byapproximatei
bedecreased
Handlng Procedures.)
ISTRATION
EGU
IDE.)
DOSAd
(See
PREATIOaS
and
should
be
ofadministration
maintenance
rate
and
aslower
dose
General:
Aloer induction
PRECAUTONS:
Inpatients
may
beIncreased
ofDIPRIVAN
Injection
theeffects
anesthetic
agents,
aswithmost
DOSAGE
ASA
Ill orIV.(See
and
those
rated
disorders,
with
and/or
patients
debilitated
used
Inelderly,
toinduction.
shortly
prior
ornarcotic
premedicbions
Intravenous
sedative
received
hypotensionwhohave
forearly
signs
ofsignificant
monitored
becontinuously
should
AND
ADMINSTATION.) Patients
orIntermittent
Injection
byInfusion
byadministering
DIPRIVAN
canbemaintained
Anesthesia
ofklower
extremities, Maintenanee:
fluid,
elevation
ofIntrvenous
increasing
therate
may
Treatment
and/or
bradycardia.
frequency
rate
ortheamount
and
determine
theInfusion
The
patient's
clinical will
IVbolus
Injection.
andmaypersistlfor
Apna often
occurs Induction
ofatropine.
useof
pressor oradministration
Injections.
caution ofIncremental
Injection
isanemulsion,
Because
DIPRIVAN
bereuired.
support may
60seconds.
Vlentilatory
than
counters,
syringe
pumps
recommended
that
drop
Injection
by
infusion,
Itlls
administering
DiPRIVAN
When
diabetic
as
primary
hyperlpoproteinemla,
metabolism
such
oflipid
Inpatients
withdisorders
should
beexercised
controlled Infusion
rates.
pumps
beused
toprovide
orvolumetric
hyent pemia,
andpancreatitis.
rate
Infusion
with
in
a
variable
mg/kg/mn
administered
01
to
0.2
DiPRIVAN
Injection
Centlneees
leleelen:
Is
of
the
awakened
patient
of
evaluation
an
adequate
period
never
used
alone,
Injection
Is
Snce
DIPRIVAN
surgery.
Maintenance
underging
general
forpatients
oygen
provides
anesthesia
oxdds
and
60%-70% nitrous
from
the
ofthepatient
priortodischarge
fromgeneral
anesthesia
satisfactory
recovery
toensure
Indicated
reported
Dry
DIPRIVAN
recommended
Injection
DIPRIVAN
recommended
circulation
consequently,
pressure,
CONTRAINDICATIONS:
WINNINGS: Injeton
Mwocwdl
Genealized
administration
DIPRIVAN
clinical
always
techniques
supperting
circulatory
agents,include
room
mia
DIPRIAN
III
Phcal
therefore,
Addiresponses.
tionally,
response
more
during
IViocaine
recovery ortohome.
bysir kedIon a
may
bereduced
1jerion, which
intravenous
pain ou during
lrarlerti local
(<1%6).
botwowelibeen
reported
rarely
thromboels)
hone
(iAmof a1%solution). seuele (phebitsor
were
reported
o venous
sequelse
noInstances
intravenous
catheters,
using
dedicated
cortrolied studies
bdasare
orantecubital
veinstheforearm
ithe larger
inuction. Pain
canbeminimized
upto14
tisstues
ainwhs
or
Injection
intentional
artrsvesationand
used.Ali
accldertai
efteotsOne
induce tissue
animals
didrot
Injection
reaction.
Infra-arterial
caused
rnilrn
nomajor
equelsi.
than
pain,
there
were
insa
patent,
and
other
has
been
reported
antra-arterial
injection
anous
clinical
unpremediceted
response
of
Injection
during
toprovide
satisfactory
foliow
theInduction
dose
inorder
Immediately
byinfusionDiPRIVAN should
Injection
period
foloing theinduction
thisinitial
phs. During
anesthesia theInduction
orcontinuous
10to15minutes.
infusion
mg/kg/mmn)
forthefirst
are
generally
required
0.151to0020
higher
rates
ofinfusion
In
ofmaintenance.
Changes
during
thefirst
half-hour
by30%- 50%
should
subsequentiy
bedecreased
rates
tosurgcal
Indicate
aresponese
and/or
tearing)
that
rate,
blood
pressure,
sweating
(increases
inpulse
vitalsigns
of pervesculer
ofDlPRIAN Injection 2 mg
may
becontrolled
bytheadministration
ofanesthesia
stimulation
orlightening
of
10tosubcuteneous
rate.
ifvital
sign
changes
are
byincreasing
theInfusion
boluses
and/or
(5.0OmL)
Incremental
(2.5ml) orS50mg
local
in
lowing
linicl
tissue
incases
In
temporal
relationship
has
occurred
insa
opisthotonus,
including
Perirtive rryclona, rarely
orInhalation
barbiturate,
vasodilator
such
asanarcotic,
minute
period,
other
means
after
alive
notcontrolled
responses.
tocontrol
these
should
beInitiated
agent
therapy
avariable
rate
oxide
can
becombined
with
surface)
60%-70%
nitrous
minor
srIa procedures
(le,body
For
administered.
Injection
hasbees
which
(le,
stimulating
surgical
procedures
anesthesia.
Withmore
satsfactory
InjectiInfusion to provide
byhypotension
ma accompanied
bronchospasm
anderyh
which
mayinclude
syndrome
Rarely,
aclinical
toproid asatisfactory
agents
should
beconsidered
suppiementation
withanalgesic
drugs
Inmost irtira-aedontinsO
theuse
ofother
Injection, although
theadministration
ofDiPRIVAIN
shortly
after
hasoccurred
andrecovery
profile.
Injection
unclear.
toDIPRIVAN
makes
the
Instances
until
amild
intheabsence
of
signseof anesthesia
alims betitrated
dowwawd
Infusion
rates
should
anihasusually
Included
hasno vagoc activity, premedication
DrugInteractions:
AsDIPRIAN
rates
higher
administration
ofDIPRI n oneat
inorder
toavoid
stimulation
isobtained
tosurgical
Inveailone due
toconcomitant
tomodify
poten
tialincreases
(eg,
atropine
orglyopyrrolate)
cholinri agents
during
maintenance
mg/kg/mmn
should
be
Generally,
rates
of .05toO0.1
thanareclinically
necessary.
stimuli.
orsurgical
agents(e, succinyicholine)
tooptimize
recovery
inorder
orlitrInpatientsawith
intramuscular
maybe
ofDIPRVAN
Thekiduhon
DIPRIVAN
relationship
Ineton
DIPRIAN
anesthetic
light
clinical
achieved
response
times.
Injection
reduced
doseerequirements
beadministered
ofDIPRIVAN
In ion 25mg(2.5ml) or50 mg(5.0mI) may
Increments
combinationslInltle~nt bolue:
meperldin~a
andfertanyl)
and
with
narcotics
( , morphine,
premedication,
particularly
venous
when
boluses
should
beadministered
TheIncremental
undergoinggera surgery
oxideinpatents
etc).
These
agents withnitrous
hydirate,
dropenidol,
barbiturates,
chloral
(eg,benzediazeppnes,
ofnarcotics
and
sedatives
10surgical
stimulation
or anesthesia.
indicate
a
Invitalsigns
decreases
andmayalso Inmore
effectsof
DPIVAN Injection
mayIncrease
theanesthetic
such
asatropine,
usad
Inaneathesia,
avariety
ofagents
commonly
hasbeen with
DiPRIVIAN
Injection
andcardiac
output.
andmean
arterial
pressures
insystolic,
diastolic,
muscle
andnarcotic
analdiazepam,
depoarzing andnondepoisrizing
beadjsted according sopolamnine,gplyopyrrolate,
Injection
admiitrto should
tihe
rate
ofDiPRIVAN
mainteniance
ofanesthesia,
During
regional
anesthetic
agents.
(See
Drug
Interactions.)
gesics,
aswell
aswith
inhaistional
and
analgesic
agents
(eg,
inthe
presence
ofsupplmental
ofanesthesia
and
may
be
tothedesired
level
-agents
(eg,
Isoflurane,
enfiurane,
administration
ofpotent
inhalational
The
concurrent
nitrous
oxdeor opiolds).
GUIDE
___________DOSAGE
evaluated.
These
rihalahas
not
been
extensively
with
DIPRIVAN
Injection
halothane)
during
maintenance
and
AND
ADMINISTRATION
effectsDIPRIVAN
Injection. INDICATION DOSAGE
and
cerdlorespiratory
toIcream theanesthetic
tonaelaet can
also
bearcpedted
of
Intensity
orduration
ofaction
change
inonset,
notcause
aclinically
significant
DIPRiIAN Injection
does
Dosage
should
beindividualized.
Inductien
result
pronounced
response
used
changes
reduced
of
relxats).
succinyicholine
andnodolrzg muscle
useduring
anesthesia
with commonly used
premedications
ordrugs
Nosignificant adverse
Interactions
light
relaxants,
likely
blociling
agents
(eg,
thecommonly
used
neuromuscular
Adu: Are
agents,
and
local
anesthetic
agents)
have
inhalational
agents,
analgesic
(Including
a range
ofmuscle
been
observed.
studes
havnot
been
performed
fertility-:
Animal
carcinogenicity
Muteeela, Impalnnrenitef
CarolnoganeeL
ASA
Ill erIVPatents:
Are torequire
Eldem,
DebIitated, llypevlemle endler
20mgevery
10seconds
until
induction
onset).
1.0to1.5
mg/kg
(approximately
40 mgevery
10seconds
2.0to2.5mg/kg
(approximately
torequire
onset).
untii
induction
relaxants,
withpropofol.
Tests
formutagenic
ity
toshow
anypotentalfor
mutagenicity
bypropofol.
InvitroandInvivo
animatests
failed
_________
rate
likely
Adule: Generaily,
0.110o
tothedesired
clinical
effect.
rlahle
Infusion
-titrated
MI~U"
n(I to12mg/kg/).
0.2mg/kg/mm
conversion
using
Saccharornyces
theAmes
(using
Samnromeha
sp)
mutation
test,
gene
mutatio/gene
included
0.06
to
Ill
er
IV
Generally,
Debiliteled,
Iyvoemit
ondlor
Elderly,
micronucleus
teat.
InChinese
hamsters
and
amouse
ceevlsise,
Invitro
cytogenetic
studies
0.1mg/kg/mmn
(310o6
mg/kg/h).
human
recommended
doses
upto15m/g y(6times themaximum
Studies
infemale
rats
atintravenous
of25mg1050mg,asneeded.
IntermittentBblue Increments
didnotshow
impaired
fertility
Male
fertility
induction
dose)
for2weeks
before
pregnancy
today7o
Inrats
was
notaffected
insa
dominant
lethal
study
atIntravenous
doses
upto15mg/kg/day
fors5days.
to
therapeutic
agents
prior
should
notbemixed
withother
Injection
Compatibility
andSteblity:
ratseand
rabbitsast
intravenousadoses
of
studies
havebeen
performedlin
Pregnancy
Category
e: Reproduction
adminitation.
ofImpaired
furhuman
Induction
dose)
and
have
no
evidence
15mg/kgiday
(6times
therecommended
be
prior
toadministration,
Itshould
only
When
DIPRIVAN
Injection
isdiluted
Dilution PnrioeMAdminleration:
inrats
touthe
fetus
due
topropofol.
Propofui,
however,
has
been
shown
tocause
maternal
deaths
tlity orharm
2mg/mI because
USl,and
ishould
not
bediluted
tosaconcentration
diuited
with
5%Dextroselnjection,
period
indans treated
with
1 mg/kgitlay
(or6times
andrabbits
anddecreasedsurvival thelactating
with
plastic
stable
when
Incontact
wth glass
than
Indikuted
form
ithas
been
shown
tobemore
itIsan emulsion.
inducrtindotie/Thepharmacologicalrativtyanesteslof thedrugon themther
therecoromended
human
gestation
pup during
revealed
study
resultsLssafrequent
eventsare
derived
principally
from
marketing
excpeience
inapprortimately
7million
patients
andfrom
publications;
there
are
data
tosuppont
anaccurate
estimae
oftheir
incidence
rates.
The
following
estimates
ofadverse
events
forDIPRIVA4N
Injection
are
derived
from of1573
patients
included
Inthe
UI~nadan induction
and
maintenance
studiesThese
studesewere
conducted
using
avariety
insufficient
lengths
1%
-AI
reports
adverse
events
ofpremedicants,
varying ofsurgical
procedures
and
vriousother
anesthetic
agets. Most
weremildandIransien.
The
following
adverse
events
were
reported
inpatients
treated
with
DIPRIVN Injection.
They
are
presented
within
each
body
system
inorder
ofdecreasing
frequency.
Incidences
Greater
than
events
regardless
ofcauality derived
from
clinical Mil
Body
asaWhole:
Fever.
Cardovascular:
Hypotension'
(see
also
CLINICAL
PHARMACOLOGY),
Bradycardis,
DIPRIAN
AAMPaoint:
lessathan
E3STUART
Made inSweden
Manufactured
for:
PHARMACEUTICALS
A business unit of ICI Americas Inc.
Wilmington, Delaware 19897 USA
All States Medical Placement Agency, Inc.
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w
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6Z
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I~Developed
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An Educational Service of Anaqusst
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excellent income, and work with interesting
people in a variety of practices. Join Group
One Anesthesia's corps of highly skilled
CRNAs!
We provide comprehensive malpractice
coverage with limits of $1 million/$3
million, a competitive income, paid
licensing including the renewal of your
existing licenses, a generous per diem, plus
housing and transportation while you're on
assignment. We coordinate all the details
and are committed to a level of service you
won't find anywhere else in the industry.
We take the anxiety out of your
adventure!
41
It's The Same
Way We
Approach Your
Locum TInens
Assignments
w
Daniel & Yeager
Anesthesia Specialists
Group One
1-800-955-1919
ANESTHESIA
7220 Governors Drive S.W
Huntsville, Alabama 35806
1-800-634-1077
2610 Horizon, SE, Ste. B-2, Grand Rapids, Mich., 49546
IIIII
Illlllllllllllllll
NURSE
ANESTHETISTS
NURSE
ANESTHETISTS
Expanded services have created additional full
time openings for CRNA's at this 566-bed
regional referral center located in northcentral
Pennsylvania. Successful candidates will enjoy
limited call in a stimulating teaching environment. Will service all types of surgery including
neurosurgery, trauma, open heart, kidney transplants and epidural services for obstetrics
employing latest techniques and equipment.
These positions will enjoy competitive salaries
and comprehensive benefits program including
relocation assistance.
Send resume detailing education and
experience to: R.L. Hauck, Administrative
Director, Human Resources (30-24),
Gelslnger Clinic, Danville, PA 17822. Equal
Opportunity Employer M/F/H
Geisinger
Mayo Clinic Jacksonville has
openings for CRNA's in an expanding practice currently employing 5 Anesthesiologists and 10
CRNA's. A full range of surgical
procedures is performed, including cardiac, vascular and neurological.
Compensation is competitive and
includes an excellent benefits
package. Please send a resume
to:
m1
Personnel Box NA
MAYO CLINIC
JACKSONVILLE
4500 San Pablo Rd.
Jacksonville, FL 32224
Smoke Free & Drug-Free Employer
Where Does
P_
PARISH ANESTHESIA
ASSOCIATES, LTD., A.P.M.C.
Seeking superior CRNA's to join us in providing anesthesia
services to three area hospitals and two ambulatory surgery
centers in metropolitan New Orleans.
Our staff includes thirty-five CRNA's, fifteen
anesthesiologists, one RN, and ten office personnel.
Our benefits include:
* Competitive salary
* Thirty days paid vacation & seven paid holidays
* $500 Annual education allowance
"SPaid
Paid professional
professional liability
liability insurance
insurance policy
* Paid disability insurance policy
* Paid health insurance policy
* Paid $50,000 term life insurance policy
* 401-K Plan - 7.5% pension plan
* Flexible spending (cafeteria) plan
* In-house "pool"
* CRNA's taking call average $80 K/yr. plus
* $30/hr. base, $5 diff evenings & nights, $8 diff
week-ends time & one-half overtime
It
Hi t
Areyou...
* Unable to schedule leisure time?
*Affected by increasing administrative demands?
* Making acritical decision on where and how to practice?
*Worried about increasing liability and malpractice costs?
* Eager to try something new and different?
Beginning today, as an independent contractor, you can practice
pain-free medicine. With Medstaff National Medical Staffing, Inc.
youcanenjoy...
* Opportunities to explore a variety of practice settings
*Awide range of travel opportunities
*Excellent remuneration
* Increased leisure time
* Freedom from administrative headaches
For more details call Michael Miller at 1-800476.756.
MEDSTAFFIc.
Call our Recruiter Randy Johnson,
Chief CRNA at (504) 456-5190
4
San
,
National Medical Staffing, Inc.
KAISER-HAWAII
iKSER pRMrNE
Come Live Where Others %cation!
HONOLULU, HAWAII
Live and enjoy year-round recreation
* swim, fish, sail, scuba,
sunbathe on clean sandy beaches
Work with a congenial group of MDAs and CRNAs
* competitive salary
* comprehensive insurance coverage
(medical, dental, disability, life and liability)
* relocation assistance
* vacation and sick time
* excellent retirement options
Telephone: Fred Foster, CRNA, (808) 834-9827
for additional information
Kaiser Foundation Medical Center
3288 Moanalua Road, Honolulu, Hawaii 96819
Department of
Veterans Affairs
aid
CY44As
We are a
r
tt'
qpeiris
fo the
rautes
e~rieroedto
VA ir~
MDI~I EDC
cm
at
I~f:A
university
affiliated
i~
oae
'hear
Departmnent CN Is
The
of Anesthesiology at the Dartmouth-Hitchcock
Medicarenter, Hanover, NH looking
Nurse Anesthetist
join our group of 15 ORNAs, 18 Anesthesiologists and 20
Anesthesiology Residents.
~have
ntegoiggroup
a solid
challenging, progressive
any range
of of surgical services including OB, pediatrics, neuro
practice. Specific responsibilities will include anesthesia care in
20 operating rooms and anesthetizing areas that offer a
ellas
alay rtesand
rtesfull
alay
for eprienx C
idQ1s
benef its packae,
inclid.irq:
The successful candidate must
background of clinical experience providing anes-
In addition, the candidate should have the ability and interest to
work in a
andmdclcne
goigacademic
~ ~
t of the Bluegrass stater.
We oferocaetiive
We
ofer
ltv~e
for a
cardlothoracic surgery. We offer a competitive salary and
and y~
benefits package with time and compensation for CME, paid
gradate asaswelcxnprhenivemalpractice insurance, flexible Monday-Friday work schedules
gradate
aiveand
as
no night or weekend coverage.
The Dartmouth-Hitchcock Medical Center Islocated inthe
Connecticut River Valley between the Green Mountains of
Vermont and the White Mountains of New Hampshire. We are
--COportunitiestoe n~
2 hours by car from Boston and
irmw ea
i-rXca
lfe
-Heath
-Heath/lfe
i.IraK~elocal
--Retir grnt system (jilLlwlrx
tax-sh eted annuity savings)
--26 vacation days; 13 sick
d~iitiorial
days per
-10
the Fall of 1991 we are looking forward to moving into
College. In
our entirely new facility on a 200 acre campus inLebanon, NH.
Interested applicants are requested tecall or write to: Brigid
Gillespie, Recruiter, The Hitchcock Clinic, OffIce of Human
year
Resources, 2 Maynard Street, Hanever, NH 03756.
(603) 646-7355. An equal opportunIty employer.
W.B.
T4
'0:
Dartmouth-Hitchcock
rnMedical
Center
de.
Robert
e.terI '!)
VA Medical center (128-aX)
Lexirqton, KY 40511
The Hitchcock Clinic
Hanover, New Hampshire
(606) 281-4906
CRNA
FIND NEW CHALLENGE
IN NEW ENGLAND
TheFORBES
of Harvad Square inCambridge Massachusett,
fi
n
d
Mount Auburn Hospital. We ae amajou multidisciplinry teaching hospital affiliated
If you are searching for a new career
You will
challenge and opportunity, we would like to
with Harvard Medical
School. Joining ourAnshloo team can provide you with
the stimulating professonal enionet you need to practice
and build upon your specialty,
Our location will also caige your imagination with iIts
abundance of interesting choices. Cambridge and Boston hv
some of the best museums, concerts, theaters and retaurants
inthe nation. Your weekend choices can range from skiing in
Vermont to swimming at Cape Cod to whale watching off
Gloucester
Employec
Cambridge
lMA
Anshsooyof
0o2238. Equal
Opportunity
Mount Abr
GROUP
CRNA Specialists
Just outide
Mt. Auburn street.
This
many cultural and educational activities provided by Dartmouth
paid holidays
SEX)RE
31/2 hours from Montreal.
Isarural environment offering year-round outdoor activities and
relaxing lifestyle free of the stresses of urban life. Inaddition,
communities have the opportunity to take advantage of the
talk with you today!
We specialize in the placement of CRNAs. Our
medical specialists can connect you with
outstanding opportunities across the United
States.
We are not asking you to make any commit-
ment. All fees are paid by the employer, and
all matters are held in strict confidence. Let
I
401
Suite
:rmel
107
Road
03 222
I704J1-1931
(Fax)
The
Right
Career
Choce
Your
First Choice
In Miami
-I
Jackson Memorial Hospital at University of Miami/
Jackson Memorial Medical Center is opening a new
decentralized maternity center. This 50-bed postpartum maternity facility has 2 delivery/operating
rooms and will be staffed with nurse anesthetists.
The CRNA Supervisor will have operational
management and supervisory responsibilities for the
center, salary contingent on experience. Qualified
candidates will have OB experience.
Staff CRNA positions are also available on the
main complex as well as our Maternity Center. Starting
salary contingent on expenience. Shift differentials 20%
3pm-1 1pm, 25% 11 pm-7am/7pm-7am.
Our benefits package is worth over $15,000 and
includes $1,000 relocation bonus, housing assistance, free CEU's and 100% tuition reimbursement.
For more information, call Tony Troia, CRNA, Chief
Nurse Anesthetist toll-free at 1-800-443-8888.
Jackson Memorial Hospital, Dept. of Anesthesiology,
1611 N.W. 12th Ave., Miami, FL 33136.
You may not hear
the ocean from this
ad, butcome to New
Hanover Regional
Medical Center and
you'll enjoy it on a regular basis. That's
because we're only 10 minutes away
from some of the most beautiful
beaches on the East Coast.
You'll also discover a professional
atmosphere just as rewarding. This
568-bed regional medical center combines state-of-the-art technology with
'" JACKSON MEMORIAL HOSPITAL
a special spirit of concerm. The resuft?
An invigorating environment that encourages optimum care and cooperation. We invite you to these exciting
opportunities at New Hanover:
trAT Uwivmts
Y OFMA/LAO5O
MMORIL MOCAL CENTUR
THE NURSES' CHOICE
Equal Opportunity/Affirmative Action Employer.
CRNAs
We are seeking CRNAs to join our
expanding Department of Nurse
Anesthesia. We prefer individuals
who possess some experience with
regional anesthesia. 10,000-12,000
cases per year, all surgical specialties
except transplant.
New Hanover Regional Medical
Center offers a competitive salary,
excellent benefits, paid interview and
relocation expenses, as well as collegial relationship with the anesthesiologists. For more information, call
or send your resume to: Barbara
Ray, Employment Manager, NEW
HANOVER REGIONAL MEDICAL
CENTER, 2131 S. 17th Street, WIlmington, NC 28402, (TOLL FREE)
1-800-822-6470.
tunity Employer.
An Equal
CRNAs
To meet the specific and very special needs of CRNAs,
Hospital Staffing Services, inc.
is proud to announce
the creation of its new OR Travel Diwision.
We are looking for experienced CRNAs
who havea solid backround in Hospitalor
Amubulatory Surgery Center Operating Rooms.
Open heart experience is desireable.
In return for your experience and competence
we will provide you with the following:
Annualized salary of $1 14,000+
Free housing
(Jenerous travel reimbursement
"Write Your Own Ticket'9s bonus program
$250$1,000 referral bonuses
for other OR personnel
Professional liability insurance coverage
at no cost to you
The attention and support that
an OR professional deserves.
Oppor-
CALL 1 (800) 735.4774
-I
FOR YOUR APPLICATION.
NEWGRADS WELCOME!
U
Ip";
tl z
At FORSYTH MEMORIAL HOSPITAL, located in Winston-Salem, North
Carolina, we know that a solid nursing staff is at the heart of everything we
do. That's why we've structured a nursing support system that gives our
nurses what they need to enjoy their work and get their jobs done right.
Yes, we offer competitive salaries, in-service programs, seminar funds,
on-site day care and a good benefits plan. But we've gone beyond that.
We also maintain an administration that listens to nurses, involves them in
management issues and makes a real effort to understand their goals and
protect their interests. It's a support system that's engineered to maximize
the special skills and talents of every nurse in our hospital.
We invite CRNAs to join us today in one of these areas:
GENERAL SURGERY
You will be part of our new 15-room surgical suite, complete with stateof-the-art monitoring equipment. Surgical services include general, vascular,
ENT, urology, neurosurgery and orthopedics.
OBSTETRICS
* GENERAL SURGERY
* OBSTETRICS
At FORSYTHMEMORIAL HOSPITAL,
Patients Aren't Only People Who
Get Better While They're Here.
Our newly completed Women's Center, which includes 5 operating rooms
where all OB/GYN surgical procedures are performed, is one of the most
modern in the state.
As a CRNA at Forsyth Memorial Hospital you will work closely with
Anesthesiologists and fellow CRNAs to provide the best in academic and
clinical support.
Winston-Salem, N.C., a progressive city of 148,000, has everything to make
your personal life gratifying. Nearby lakes, beaches, and mountains offer a
variety of recreational, cultural and social attractions.
Tobfind out more, please call or forward your resume to: Rita Taylor, RN,
BSN, Nurse Recruiter (COLLECT) (919) 760-5420 or (TOLL FREE) 1-800777-1876, FORSYTH MEMORIAL HOSPITAL, 3333 Silas Creek Parkway,
Winston- Salem, N.C. 27103.
= FORSYTH MEMORIAL HOSPITAL
An Affiliate of Carolinna Medicorp, Inc.
An Equal Opportunity Employer
WE BELIEVE THAT
CAING 6s AN AT.
Certified Registered Nurse Anesthetists
The University of Texas M.D. Anderson Cancer Center, one of the world's leading
comprehensive cancer institutions, is seeking full time and per diem CRNAs.
Graduation from an approved School of Nursing, accredited School of Nurse Anesthesia,
current RN license and certification or eligible for certification required. In addition to the unlimited
professional challenges and rewards at M.D. Anderson, we can offer you:
*
*
COMPETITIVE SALARIES plus...
Premium per diem rates
Comprehensive benefits package
Low incidence of call and take call from home
State-provided professional liability coverage
Participatory retirement plan
Reimbursement for interviewing expenses
State-of-the-art anesthesia and monitoring equipment
*
*
ii
*rr
* Active continuing education
/941.199.
Sw tNO PAST
IANT PrlUtE
cstIU
programs
* Conference travel allowance
* Interest-free relocation loan
*
* Professional membership dues reimbursement
* Special recreational features such as swimming pool,
jogging track and tennis courts
Interested professional CRNAs are encouraged to contact Maria Farah, (713)
792-8004 collect, Division of Human Resources, 1515 Holcombe
Blvd. HMB205, Houston, Texas 77030, or Dr. Hollis E. Bivens,
Chairman, Department of Anesthesiology at (713) 792-6911.
Security Sensitive.
I II
t\I\'I
I-;III
()I
I 11 MAN )k RS
II\\
ON
CAN('I:R('}:N-iT
Equal opportunity/offirmolive action employer. Smoke-free environment.
NURSE ANESTHETISTS
Grass Roots Health Care
CRNA
CRNA needed to join 2-CRNA, 2-MDA
department in a 159-bed regional medical
center. No open heart, no neuro.
Beautiful mountain area, university
town, outdoor recreation abounds, one hour
to major city.
Please contact Carol Holt at (606)
784-6661, ext. 3357 or during evenings and
weekends leave message on machine at
(606) 784-1829.
Send resume to:
Committed to bring quality, modern health care to
rural people who embody the mountaineer spiritof sef
reliance, Appalachian Regional Healthcare (ARH)
operates anetwork of community hospitals and clinics
ineastern Kentucky, Virginia, West Virginia and a
reference laboratory inLexington, Kentucky.
While ARH isn't for everyone, it's perfect for professionals who seek a broader variety of cases, stimulating challenge, the family atmosphere of asmall rural
hoptl potnt
o euainadavneet
and the warmth and affordability of small-town living.
STAFF AND POOL CRNA POSITIONS ARE
AVAILABLE.
Excellent annual salary ($65,000/48 hour work week)
and fringe benefits.
nexp rses
Mdical
enterRembursementarinterisandVkx
Clire
St.
St Caie
Cntrailabe.
edca
pa Con
acn
einl Prmloa e Bxam
ct.O
222 Medical Circle
Morehead, KY 40351
ApplcinRini~~e
A oc8)6
1220 Harrodsburg Rd., Le~ng .oK'~3 1-800888.7045 or (6) 281-244 owr ).
MA
ELI cMpunF~
rA
Practice Your Profession The Way It's
Meant To Be Practiced
At Saginaw General Hospital, one of Mid-Michigan's largest acute
care referral centers with 337 beds, our ORNA's are given the freedom
to practice as independently as possible in our state-of-the-art
surgical areas.
You're encouraged to make your own decisions, learn new skills,
and grow with our friendly, professional team of eight MD's and four
cRNA's.
Our growing and busy surgical department provides advanced laser
and other sophisticated procedures in the areas of Orthopedics,
Urology, ENT, Thoracic and Vascular (excluding open heart),
OB/GYN, Cancer care and more.
Regional anesthesia experience is desirable.
We provide an excellent, negotiable salary beginning at $56,264!
40-hour week (plus overtime), fully paid medical/dental/life/
malpractice insurances, tuition reimbursement of up to $1,200/year,
four weeks paid vacation the first year, fully vested retirement!
pension program after five years, paid interviewing expenses and more.
Plus, you'll find that the Saginaw region-the fifth largest metro area
W4
A
SAGiiIN%
G11NJ11 L
in Michigan-features affordable housing, abundant educational and
GENERALrecreational
areas.
H
SPITA
O
L
cultural activities, and easy access to many of Michigan's prime
ll~E~ I~iL
To arrange a convenient interview, please call Andrew Wilson, Sr.
Vice President, 517/771-4130, or send a resume in confidence to:
Saginaw General Hospital, Human Resources Department, 1447 N.
Harrison, Saginaw, Ml 48602. Equal Opportunity Employer M/F/H/V.
#
Iii
r
i
Sai
I
CRN Anesthetist
As a nurse, you're looking for a career that will
challenge you professionally, as well as provide
personal satisfaction. There are several choices,
but you are looking for the BES. Discover
St. Vincent Hospital, in Santa Fe, New Mexico!
Qualified candidate must be a graduate of an
accredited school of Nursing Anesthesiology
and possess curent CRNA
certification
EASE THE
e
and NM
RNARNA licensure/elgibility. A documented
knowledge of dinical anesthetics and anesthetic
machines (ventilators, monitors, etc.) is required.
One year active CRN practice in suigical/obstetrics, as well as experience with lumbar anesthetics
is preferred.
In addition to professional challenge, we provide
our nurses with a caring supportive environment,
as well as competitive salaries and benefits.
Contact StL Vincent Hospital, Attn:
HuMn Resources, P.O. Box 2107, j1
Santa Fe, NM 87504 of canl aliect
(505) 989-5266. EOE, M/F/'H
j
(Principals only)
--
A
anurse anesthetist, you're aware of the increasing
s
pressure of providing safe, quality care to your patients in
addition to administrative concerns normally associated with
your practice.
Anesthesia Partners isexpanding our client base and we are
looking for qualified CRNAs. We offer independence and
lucrative remuneration. In addition to our reliable management
services, you'll have access to quality assurance consultation.
And you'll have the option to be covered by an outstanding
professional liability insurance program.
Contact Medical Staff Development at 1-800-476-9S51, ext. 4313 and
find out more about how Anesthesia Partners can ease the pressure!
SANESTHESIA
PARTNERS, INC.
Partners in Health Care Management ~
NURSE
CRNAs
Duke University has immediate openings for CRNAs or
Board Eligible Graduates to join staff of 50 Anesthesiologists and 45 CRNAs to provide team-approach anesthesia care for all types of cases.
Highly competitive benefits package includes 20 vacation
days, 12 holidays, 12 sick days, health plan, dental plan,
pension, malpractice insurance, life Insurance, and
disability plan. Also, educational conferences exceeding
AANA continuing education requirements. Salary based
on experience. 40 hour work week. Call (919) 6846201. Reply to: Nancy Kapoor, CRNA, Chief , Nurse
Anesthesia, Duke University Medical Center,
Box 3094, Durham, NC 27710.
The tradition of excellence continues at Grant Hospital
of Chicago. Our convenient Uincoln Park location,
collaborativeprctice, and a brand new benefits structure
keepus
hea ofthedynamic changes intoday's nursing.
Currently we have a full-time position available for
a CRNA. Inaddition to working with 4 other nurse
anesthetists, you will administer intravenous and
inhalation anesthetics. Other duties will include
monitoring of patients' condition under anesthesia and
following documentation procedures of the department.
Interested applicants must be AANA certified. Previous
experience as CRNA is highly desired.
Good assessment sills and ability to communicate
effectively important. Availability to take calls required.
Gran
H~taloffrs a comprehensive benefits package
which Includes 4 ek'actoan10%uln
reibursement. Toshdulanpoitepesecall
Ren
umtoacruitment
at (31)83-3503. Grant Hosital of
Chicago, 550 W
Chicago, IL6064 EQE in/f.
Wbt
Emme~
Hosptai
Dii Univuiy IsM Eqial
Oppoitun
y/lfIkn w Acion
Eaqiloyer.
Ml en
cju(tlit%'
is
im/ft)rttlnt
77777777,
loYtou.
WE'RE INARUSH
TO BETIER
THE WORLD...
for our patients and the exceptional health care professionals who practice here. We're Rush-Presbyterian-St. Luke's
Medical Center, a 1,079-bed, university based, tertiary care
facility, and we're seeking a few talented nurse anesthetists.
Here you'll find a team committed to providing the best
possible practice environment. We offer vast clinical and
learning experiences utilizing the latest monitoning equipment
inareas such as: OB, open heart, pediatnics, neurosurgery
and liver transplantation. Additionally, you will have opportunities to interact with both faculty and our outstanding group of
clinical preceptors. It's all here.
We offer a base salary of $55,000 for new graduates with
limited 24 hour call and optional liver call benefits, four weeks
vacation with an additional annual CE week allowance and
much more.
Ifyou are acertified or certification eligible nurse anesthetist,
and you would like to know more about the opportunities
available, send your resume to: Pamela Mims, RushPresbytenian-St. Luke's Medical Center, 729 S.Paulina St.,
Chicago, IL 60612. Equal Opportunity Employer.
SRush-Presbyterian-St. Luke's Medical Center
Providence Memorial Hotsptal,
El Paso, Texas, a 436-bed scale -cafe
has a fll-time opening for a
C Awt
experience
w to four years'
in all tewhniques and proce-
dures, indluding proficiency in qpidural
and spinal anesthesia.
A city cf 500,000, El Paso ofen yearround ottdoor sports, cultural and
enteitairunent ement. El Paso is two
and a half hours from the New Mexico
mcuntain and jus mnutes from
Juarez, Mexico Providernce is
adjacent to a unuversity for educational
and sporting everts.
Accepta diallenge mnd join our tean at
El Paso's finest medical facility. We
odfer exceilest benefits and salaries.
Please call or send your resnne to
Providenc Memorial Ilosptal, 2001
North Oregon, El Paso, Texas 79902
(915) 542-6662.
Call toll-free:
1-800-282-6662
A' 41
vH-A3 Member of Volunay Hospitals of Amica, kic.0
C.R.N.A.
-
p
Myr
FLORIDA
COME UIVE WHERE OThERS VACATION 111!
COASTAL
SOUTHWEST
FLORIDA
hie Ina palmtreeparadise
liveInoneofthefastest
growing
counties
in the
fastest
growing
stateinthenation.
- liveinandenjoyyear-round
outdoorrecreation:
swim,fish,,
sail,scuba,
sunbathe
onsandybeaches
Incrystalclearwater;
enjoystunning
sunsets
andoffshoreIslands.
-
Workwitha congenial
groupof MDAs andCRIIA'S
- toppay
- comprehensive
Insurance
coverage
(fullypaidmedical/dental/
Lafe/dlsablfity/llabiity)
- education
benefits
- relocation
paynment
- vacation
& sickdays
- excellent
retirement
plan
DOHYT WAIT until youare 6510o
live in paradise live in ii while
you are young and have the income 10 truly enjoy all we have to
offer.
PHOnIE
St13/332-5344collecttot moreInformation
andto arrange
a visit.
MedcalAnesthesia
2472 Congress
Street
Ft. Myers.Florda33901
Money isn't everything.
Yes itis.No itisn't.
Yes it is.
Because we recognize the immense value of our
professional CRNAs, we offer one of the highest base
salaries in the nation -- in excess of $75,000. But with
everything else we offer, money just pales by
comparison.
Here, a team approach encourages professional
autonomy in consultation with anesthesiologists. And
you can choose from the challeng of opn-heart
surgery, trauma and transplants, to opportunities In
regional anesthesia, invasive monitoring techniques and
pain management.
We offer excellent educational opportunities
including an on-site Master's program, 5.5 weeks of
paid time off, incentive bonuses for new gauates to
$4,000 and relocation assistance from outside southeast
Michigan to our world-class 937-bed hospital. Now,
with all that, is a $75,000 a year base salary really
everything? We don't think so. But you can spend the
rest of your career deciding.
Send your resume to: Wanda Sciplo, RN, BSN,
Manager, Nursing Employment, Henry Ford
Hospital, Clara Ford Pavilion, 2nd Floor, 2799
West Grand Boulevard, Detroit, MI 48202. Or call
the Anesthesia D~epartment at (313) 876-2545. An
Equal Opportunity/Affirmative Action Employer.
%f'nrj5Zv Health System
-
Thinking seriously about locum tenens?
Don't worry yourself
to the bone
wondering which
company to choose.
"
,Y
e
J. Stephens Mayhugh
a n d A s s o c ia tes
provides the
opportunities you seek
vi est h
fpr
,
J
and the honest treatment
you deserve.
Enjoy the independence of locum tenens anesthesia backed by JSM's resources
and experience. Your preferences, needs and concerns get full consideration from
our staff. Fair and ethical treatment of both CRNA and customer is our standard.
Your compensation will be excellent, payment guaranteed. Full-time and part-time
opportunities are available.
For more information call any time
1-800-426-2349
J. Stephens Mayhugh and Associates
Locum Tenens Anesthesia Services
Providing CRNAs for temporary assignments nationwide
Precise Control
Precisc
Before Surgical Incision
During Maintenance
Overpressuring with Forane® rapidly achieves
the desired anesthetic tension in the brain,
giving you confidence that your patient is
ready for surgery.
Alveolar concentrations of Forane® are easily
monitored and adjusted to accommodate your
patient's changing anesthetic requirements.
Precise Control with Forane' Through Induction, Maintenance and Recovery
Inspired
20
40
60
80
Alveolar
Brain
100
Minutes
cardiovascular
'Overpressuring requires the use oif an inspired concentration that can cause
depression if administered for a sufficient period of time. Thus, theanesthetist
must
mntor blood pressure and heart rate during the period oiverpressure is used.
closely
generated from a computer simulation,t depicting the relationship between inspired,
alveolar and birain partial pressures throughotut a surgical procedure. lDuring tmaintenance,
brief pertiols iof overpressure are used toi accommialate the patient's lhanging anesthetic
requirements during times of Increased surgical stimulation.
G;raph
t GUS ComputeriSiiulation
IiS isa
reisered trademarkof QuincySireeit rortaiss, Phuvnia,AZ.
-OnC
zntrol
Upon Recovery
Precise control of anesthetic depth and
rapid elimination of Forane® through
the lungs facilitate an uneventful
postanesthetic course for your patient.
Please refer to Prescribing Information on the following page.
Anaquest
I Forane
(isoflurane,USP)
Precise Hands-On Control
JA
Forane®
(isoflurane ,USP)
WARNINGS
Sincelevesofanesthesia
maybe..ltaredaottyandrapidly,onlyvapories producingpredictablcocentrtions should
be used Hypotansionand respiratory
depreesionincre.as anstea isdeepened
Increasedbloodtos.cumparabteto thatseen witthhatothaneha. bean obsercedin patiectsundergoingaborione
FORANE iolrncttSP)markedlyincreasecerebralbloodflo atdespoerlsoanesthesia Theretnaybe atran
sin
u ncerebralspintalfluid ptaur whichis folly revertble with hyperventilation
PRECAUTIIONS
PreciseHands-On Control
CAUTION: FederalLam ProhbiteDispensingwithoutPrescription
DESCRIPT'ION
FORANEl(isofuraos.
USP)eanioflammablslquid
administeredbynvaporioing.isaagenerslainhalation
anesthstic
drug
It is 1-chlorc-2,2,2tifuoroethyl
diffuoromethyl
ether,andits structuralformulais
F
N
F
F-
I
I
C-
C-
I
0-
I I
F
C-
H
I
Cl
F
Somephysicalconstanta
are
194b
Molecularweight
Doibong
pointat 760mm Hg
Refractiv ondexsip2
48
C (uncortt)
I 2990.13005
1 496
238
Specificgravity2h 12t °C
Vaporpressurein mmHg**
296
367
4t0
'"Equationfor maporpressuore
celculation
D
A-8056
log 1l'p
- A T inhere
0
D - - 1884b9
TI- "Cov 27316t(ealvin)
Partitioncoefficienta
at 37 "C
Vditerlga
Dloodtgac
Oillgas
Partitioncoefficienta
at 2h "C -rubber endplastic
Conductime
rubberiges
Dutylrubberlgas
Polyvinyl
chlorigas
081
1 43
9018
820
760
1100
Pnlyethylengae
Polyurethanalgae
Polyolefinlgee
-.20
cf 4
i- 1I
Dutylacetatelgee
-25
Purifyby gee chromatography
>999
Lamer
of flammabilbty
in oarygenor
nitrousoide at 9oulelec and23'"
None
Lower bimitof flammabibity
in oxygenor
Greaterthan useful
nitrousonideat 900toulesfsecand23 "concentretion
inanetheia
teotucane
aaclar, roorlesicstable
containing
noeadditioss
in cbemicalssabibas Isofuranshiseamildlypungent,
musty,toerealtodorSamplestored toindirect
sunbight
inclear.colorleeg
gleesforfineyearn,
s melltascomplesn
directly
exposedfor30 hoursto a2amp tftcolt,60cyclelong waenU
V lightmwera
unchanged
incooitionaadtermined
by gaschromaetogsaphy
Ifaene inonenormalsodium
etettue.-rosttanol solution,
a strong
baes Ir oversox
montha
consumedsesntiallynoelkabi.indicativmof
strong
basetability sonuranedoeanot decomposcinsthepresenc.
of
sodalime,
and dogsnotstteckaluminum,Itin.bras, ironor copper
lhmit
lbqud
CLINICAL PHARMACOLOGY
FORANEl(isoturane
USP)lisaninhelation
aneshsticTheMAC (minimum
alneolarconcentration)lin
man sas
Ifolaos
Age
100%Orygen
70%N.O
26814
4
4
7
1.29
1t15tO5
Oh6
6tuh
105
037
f1
puogencymwhich
limitfathe
rate
ofinducinosalthoughsricessineslimstion
oritrechebrenchalsecrstions
dootsappeartobestimulated Pharyngeal
andlaryngeal
reflmaes
arereadily ounded Thetenetofanesthesia
maybechangedrapidly
with eaonuesne
isofluraea
is a profoundrespiratory
deprseait RESPIRATION
MUSTDE MONITOREDCLOSELY
AND DUPPORTEDWHEN
NECESSARY
Acanestheticdoe is increased,
tidalvolumedecreaaes
aodrespiratory
reateunchanged Thisdepe
signisperpallyreoesed byasurgical
stimoulation,
awn at deep e als ofanesthesia
Isofurneokse a sighresponse
reminiscenof thatsenmwithdiethyleother
and onfurane,althoughthe frequancyislse thnmithnfurne
Dioodpreegure
decrese mithinduction
of anesthesia
but returnetowardnormalwithsurgicalstimulation
Progreseive
inraesin
depthof anesthesia
producecorreeponding
decreaseein blood pressureNitrousside diminishesthe
inapatoryconcentration
of teoflurane
reqiredto reacha desiredtenetofanesthesia
andmayreducethe aterial hypinen
si en reith soflurene,alone Heart rhythmasremarbably
stable With controlledvmntilation
and normalPeCO.,
cardiatoutputlismaintainsddespiteincreaingdepthofanethesia primarilylthmugh
anincreassinheart rstamhich
compeneetes
fora reductioninstrobecolumeThehypemcapotarwhich
stendespontaneouacventtletionoduring
aflurane
anesthesi furtherincreasesheart rateandriaisscardiac
output ahowe
awaealowle sonurne doesnorensitise
the myncardium
to soogenouely
adminietered
epinephrinein thedog Limiteddataindicatethat subcutanecus
injec
lionof 02t mg of opinephrinaItO mL of I.200b00 solution)doesnotproduca an increasein nentriculararhythmia
in petienta angtheted withisoflurana
Musclerelareation
isoftenadequateforinto-abdomcinal
operations
atnormal mevl of anesthesia
Completemuscle
peralysia
ceobeattainedwith smalldoaasofmusclerelaxante
ALL COMMONLYUSEDMUSCLERELAXANTSARE
MARKEDLY
POTENTIATED
WITH4
ISOFLURAPIE,
THEEFFECTBEINGMOSTPROPOUND
WITH THENONDEPOLARnZ
INOTYPE Neotigmiserewersesathe
effactofnondepolarising
musclerelaaantu
nthepresence
of sourane All com
monlyused musclerelaxants
are compatiblewithisolutane
15
Isoflurans
can producecromnary aodilationathe arteriolartalevlin
selected
aimal mdla thedrugieoprobebly
alsoa comonary
dilatorin humanstantlurne.lbhe
someothercoronaryarteriolardiletors,
has beanshaoito dinert
bloodfromcollteraldependantesyncerdbum
tonormallyperfuasdareasin ananimalmodel c'oronary
stel") Chonical
that
hanenotrestahliehed
infarctionanddeathasoutcom parrameters
stuiesodtemluainmyoardnlechmi,
the coronary
aleriolar dilationpropxr1 9 l saofltrn is
mithcoronarystealormyocardialiectema in palientawithcoronary rtery diseasa
Pbarsoaelae: leolurane undergoes
minimalbiotransformation
in man In Ihe postanesthesia
period,only0 17%
of the iofluranetakes
up can be recoversd
so urinarymatabobtea
aesociated
FORANEblolurane,USP)maybe usedlot inductionandmaintenanceof generalanesthesia Adequatedate bane
not been devwloped
to estabbebh
its apphication
in obstetricalanesthesia
CONTRAINDICATIONS
sesitivity
Enown
to FORANE(icofusene, USP)orto otherhalogenatedagents
Enownor suspected
geneticsuaceptibilityto malignanthyperthermia
ADVERSE REACTIONS
Aderse reactionsencounteredtinthadminstratonof FORANllteourane, USP)arein generaldagedepgrndette
tensionsof phamacophystologic
effectaand includerespiratorydepreseton.hypotnsionanderrhyfbmtas
Shivering nausea,vomitingcodtaus banebeenobeernedin the postoperatios
period
Acmith altothergeneralanasthetica.
transienteleaftonsin whbite
bloodcoonihaebeenobservedowntn the absence
of surgical tresa
ScePRECAUTIONS
for informationrogardtngmalignanthyparthetmie
OVIRDOSAGE
In the enentof onerdoage or wnhatmayappearto be ocerdoage. tt. tollowng actionshouldttlabkti
Stopdrugadministration establisha clear airway
andinitiate assistedot controlledveniaeiot withpots ioeygeti
DOSAGE AND ADMINISTRATION
PremedleelleecPremedication
shouldbe selected
accordingto the neadof theindividualpetient,tebintg
intoaccount
that secretiona
aremeeklystimulated
by FORANEitonurene, USP)endthe heart ratetende
lo be increasedThe use
of antichoorgoc drugsin a melter of choice
spired Ceecealle: The concentration
of isoflurane
beingdelivered froma osporiestduring anesthesia
should
befrown Thismaybecaccomplished
byusing
at
Inductionotandrecoreryfromisonurane
anesthesiaamerapid Isofurenehasamild
INDICAS'IONS AND USAGE
Oeracol: Aswith any potent generalanesthtic, ORANE (eourane. USP shouldolybeadotisteted inan ado
quatatyequippedanethenlng nvionmentbthoemho areams Warwththepharmacologyofthedtig ad quatfted
by trainitg andeaperienceto managethe anesthetieed
patient
Ragardlesaeottheeanaethetce
empsyed.maintanciteof
normal
hemudynarocea
n portantto teaoidano i nyccatda
45 6
7
isthamia in patientswithcoronaryarterydteae . . .
laforesatls te Patten: feoffurane.
a. well ac othergeneretanestheticsnay causea slght dacreaseintntlletuiol
functonofor2or3dys followinganestheia As withotheranesthetics,smallchangeein moodsandsymptot ay
persit for uptoS6daysafter administration
Lahereleryitli
Transientincreasasto DSPretentionbloodglutcose
aodsetoum
cteecintne withdecreasein DUN,
srmcholesterol
andalkralinephocithatasehame
bean oberoed
Drig Iatsreteea: teotlaata potentiatasftcmacle relaiant
effectof allmueclerelacait mostnodalfynondepoetigeng
musclerelaxant andMAC (mtnimumalveolatconcentraton)ie reducedby concomitant
administtetionof NO
Se CLINICAL PHARMACOLOGY
Cacslmegeaeels:Swiss
fCRmice weregivenisoffuranetodeterminewhstbet u eoxsposute
might indiuceoneoplaste
tsoflurenewas
givenat 112,118and1132MAC too
tour in oteroeapoauresand
for 24expoeureetothe pups doting the
firstnise meebaof ifeThe nicemerebittedat ft monthsof age Thetnctdenceof tumorsin thesemtcewnns
the same
aseinuntrsetedcontrolmicewhich wre giventheame bacground ge,butnotthe nestheic
PrgaaoiayCatge7 c: Iofurane has
been shownto heneepossiblearsesthettc-related
Ietotc effectin mice when
giventodoes Stimeethe humandoes Thereame
noadequttae
codmellconrotled studiesin pregnantwmeenIeafure
shouldbe usedduring pregnancyonlyif the potentialbeneft ustittesthepotential rtekto the fetus
Nursing Melaes: Itanot knowcnmwhther
thisdrugisemreted inhumanmilk Becastsaneydrugseere
ecrsted
in humanmilk. caution shouldbe eamised whenisolurane isdministered
to anaming oman
Udaflgmeat
ltyprlaecla: In sosceptible
imdivmduals
isnlane antethesiamayuiggera siteisalmacle hypermasaaboc
steteleadingto highottygendemandandthe clinicaleyndromebnom s malignanthyperthermi The syndrome
includesnonepecific
featureseuch aemusclerigidity.tchycardia, tachypna cyanocis,
arthyfhmiae,and cnstebte
bloodpreseer s fhotuldalaobenotedthatmaeyothesenonspeiftc signsmayppear withlightanesthesie.acute
hyposia.etc) An tncreaeeis overallmetabobam
maybe reflectedin an elenatedtempereture
(mhichmayriserapidly
earlyorlta in thecaw, butusuallyisnotthe ftrstsign
ofaugmentd metabolsm)andanincreaed usge of he CO
absorptionesystem
(hotscaniaterfPeOsandpH maydecrease,andhyperkatemia dabasedficitmayappea lnea
mentincludeediscontinuance
of triggering
agenrafog , aelfirne, administration
of intraenouc dantrotenesodiumi
andapplbcation
ofesupportine
therapy Suchtherapytncludesotgorouseffortfeto
restorebodytemperture
tonormal,
respiratoryandncirculetory
support esindtcated,
andmanagement
of eectrolytetludatdbase drngement ICon
suItprecribing informationfor dantfmlcne
sodiume
intrenenous
for additionalinformationon pasientmanagementI
Renal fetloremayappear later.end urinefore shouldbe sustainedif possible
vsporisere
calibratedspecificallyfor isoflurane.
hI mapoticara
from whichdeliveredtvows
canbecaclated. sui~chapcaliittes
deliveringa saturated
input wnhich
is thendiluted Thedelimired coccentla
lion fromsucha maporiermaybe calculatedusing the foriul
% isofurgna-
10Py Fy
FT
inhere
P0 P0 P0v FT.
(PA
PV)
Pressureof atmoephere
Vaporpressure
otsonuane
Flo of gasthroughvaporiasr
Imimiol
htalgasnow (miLmin)
teoflrans conteins nostebilier Nothingin the agentalterscalibratioi oroperationof lths csotniet
lnductbos:Inductionwith isofluranein ottygenorit combinationwith oygerinitrousoide iclires maypriotate
coughing,breathholding,orlaryngopem Thesedifficultieemaybe avided bytheuscetoaiypntiicieif tiiilta
shortactinghbarbiturste
Inspiredconcentrations
oll6tu 30% isonurneusuallypttoducenotgialaniesthesi ita7lic
t0 minutes
Malabeas: Surgicallevelsofanesthesia
maybesusrainedmwitha
lto 26% coincentrstiottwhen
nitrausmadc
ieus
edconcotmtanlyAnaddionatltbtof 0%maybe requaredwhenaoruan aagimen
usig orygen atoneIf addedrelatfo
isrequired,supplsmental
donesofmusclerelaxantamaybe ued
Thblevelofbloodpresaureduringmaintenancean iomefuniocfiof urnmconcentrtion in theeabance
of oher
costcaliogproblems Eocessivmdacreases
maybeduetodepthbolansthsia andinscbisnce maybe itrtst
by lightening
anesthesia
HW SUPPLIED
FORANEt(isonurana,
USP).NDC 10018938040ispecbagedinttlt0mLantbt coiliotebustlra
9serege:Storeat
roomtemperatureIt" 30"C(6t' D 6F)Iloliariecitaie ii. aditiieni ha beetidemonstrated
lo be stableat roomtemperaturefor periodsin socesof tamyears
Referencee
IJC Dill.stat, Anesthesiology
6e 273 279. 19t7
2 RFHohey,at .1. Anesthesiology88 21 30.19ee
3 CW Duffinonc sa. Anesthesiology
6D280.292,1987
4 5 Rais.t at. Anesthesiology
59 9t 97.1983
6SStogcffandASKet. Aoesthesiology7 17188 189
8 EJTuimar,to at. Anesthesiology
70 189198 1969
7 DT Mangano.EditorialViems Anesthesiology
70 t17t617D,
1gug
Revised2 80
References:
GUS Computer Simulation. Registered trademark of Quincy Street Corporation. Phoenix, AZ. References used to generate this program include:
1. Eger El II: Anesthetic Uptake and Action. Baltimore, Williams & Wilkins, 1979.
2. Lowe HJ, Ernst EA: The Quantitative Practice of Anesthesia-Use of Closed Circuit. Baltimore, Williams & Wilkins 1981.
3. Parbrook GD. Davis PD, Parbrook EO: Basic Physics and Measurements in Anesthesia. Baltimore University Park Press, 1982.
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