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http://www.ucdenver.edu/academics/colleges/pharmacy/Departments/ClinicalPharmacy/DOCPFaculty/Q-Z/Pages/Paul-Reynolds,-PharmD.aspx
Microscopic dark-field and histologic examinations for spirochetes are most reliable when lesions are present anxiety symptoms or heart problems cheap 25mg phenergan visa. Pregnant women with syphilis should be treated with a penicillin regimen appropriate to anxiety symptoms before period discount generic phenergan uk the stage of infection anxiety 9gag purchase phenergan without a prescription. Women who are allergic to anxiety xanax dosage discount 25 mg phenergan amex penicillin should be desensitized and then treated with the drug. Erythromycin and azithromycin are suboptimal treatment options because neither reliably cures maternal infection nor treats an infected fetus. Women should be observed for signs of a Jarisch Herxheimer reaction (an immune response to toxins released when spirochetes die), which may cause fever, nonreassuring fetal status, and preterm labor. Women with syphilis should be queried about illicit substance use, espe cially cocaine. Management decisions are based on the three possible maternal situations: 1) maternal treatment before pregnancy, 2) adequate maternal treatment and response during pregnancy, or 3) inad equate maternal treatment or inadequate maternal response to treatment (or reinfection) during pregnancy. The dosage should be based on chronologic age rather than gestational age and is 50,000 units/kg, intravenously, every 12 hours (for infants 1 week of age or younger) or every 8 hours (for infants older than 1 week). Alternatively, procaine penicillin G, 50,000 units/kg, intramuscularly, can be administered as a single daily dose for 10 days; no treatment failures have occurred with this formulation despite its low cerebrospinal fluid concentrations. Algorithm for evaluation and treatment of infants born to mothers with reactive serologic test results for syphilis. If a single dose of benzathine penicillin G is used, then the infant must be fully evaluated, full evaluation must be nor mal, and follow-up must be certain. When possible, a full 10-day course of penicillin is preferred, even if ampicillin initially was provided for pos sible sepsis. Use of agents other than penicillin requires close serologic follow-up to assess adequacy of therapy. Infants who have a normal physical examination and a serum quantitative nontreponemal serologic titer either the same as or less than fourfold (eg, 1:4 is fourfold lower than 1:16) the maternal titer are at minimal risk of syphilis if they are born to mothers who completed appropriate penicillin treatment for syphilis during pregnancy and more than 4 weeks before delivery, and if the mother had no evidence of reinfection or relapse. Although a full evaluation may be unnecessary, these infants should be treated with a single intramuscular injection of penicillin G benzathine because fetal treatment failure can occur despite adequate maternal treatment during pregnancy. Alternatively, these infants may be examined carefully, preferably monthly, until their nontrepone mal serologic test results are negative. Lyme Disease Lyme disease is caused by a spirochete (Borrelia burgdorferi) transmitted by the bite of a deer tick. The early localized stage of the disease is characterized by a distinctive ?bull?s-eye skin lesion (erythema migrans) that occurs in 60?80% of patients and nonspecific, flu-like symptoms. A late manifestation of Lyme disease is relapsing arthritis, usually pauciarticular and affecting large joints. Patients in the later stages of Lyme disease usually will be seropositive, but false-positive and false negative test results are common. Suspicion of early maternal infection is based on a history of exposure to tick bites, the presence of the distinctive erythema migrans rash, and nonspecif ic, flu-like symptoms. Because congenital infection occurs with other spirochetal infec tions, there has been concern that an infected pregnant woman could transmit B burgdorferi to her fetus. No causal relationship between maternal Lyme disease and congenital abnormalities caused by B burgdorferi has been documented. Recommended treatment of suspected early disease in pregnant women is amoxicillin, 500 mg three times per day, for 2?3 weeks. For women who are allergic to penicillin, erythromycin is recommended for 2?3 weeks. For patients who are unable to tolerate erythromycin, cefuroxime axetil is an alternative for patients with immediate and anaphylactic hypersensitivity to penicillin who have undergone penicillin desensitization. If entrance into such areas is necessary, long-sleeved shirts and long pants tucked in at the ankle are helpful. Prophylactic antibiotic therapy for deer tick bites is not rec ommended routinely. Perinatal Infections 433 Parasitic Infections Malaria Although malaria mainly is confined to tropical areas of Africa, Asia, and Latin America, international travel and migration have made malaria a disease to con sider in developed countries. Malaria infection may be more severe in pregnant women and also may increase the risk of adverse outcomes of pregnancy, including spontaneous abortion, stillbirth, preterm birth, and low birth weight. Because of the risk to both the woman and the fetus, and because no chemoprophylactic regimen is completely effective, pregnant women (or women likely to become pregnant) should avoid travel to malaria-endemic areas. If travel to a malaria-endemic area is necessary, appropriate consultation should be sought for chemoprophylaxis recommendations based on the malaria species and drug-resistance patterns prevalent in that area. Definitive diagnosis (of the mother and the infant) relies on identifica tion of the parasite on stained blood films. Treatment of infection is based on the infecting species, possible drug resistance, and severity of disease. If malaria is a diagnostic consideration in a pregnant woman or newborn, consultation with appropriate specialists is recommended for optimal patient management. Infection is acquired by foodborne transmission (consuming cysts in undercooked meat of infected animals or insect contamination of food), zoonotic transmission (by contact with oocysts from the feces of infected cats or by contact with con taminated soil or water), or through mother-to-child transmission during preg nancy. Congenital infection is more common after maternal infection in the third trimester; however, the sequelae from first-trimester fetal infection are more severe. Congenitally infected infants are healthy appearing at birth in 70?90% 434 Guidelines for Perinatal Care of cases. Signs of congenital infection at birth may include maculopapular rash, generalized lymphadenopathy, hepatosplenomegaly, chorioretinitis, hydroceph aly, microcephaly, and intracranial calcifications. Because the presence of antibodies before pregnancy indicates immunity, the appropriate time to test for immunity to toxoplasmosis in women at risk is before conception. The diagnosis of maternal infection is based on serologic test results for the detection of Toxoplasma-specific antibodies. Both immunoglobulin G (IgG) and IgM testing should be used for the initial evaluation of patients suspected to have toxoplasmosis. A positive IgG titer indicates infection with the organ ism at some time in the past. A negative IgM test essentially excludes recent infection, but a positive IgM test is difficult to interpret because Toxoplasma specific IgM antibodies may be detected for as long as 18 months after acute acquired infection. In addition, false-positive test results are common with commercially available kits. Before making treatment recommendations, con firmation of diagnosis should be made based on results obtained in a reference laboratory. Identification of acute mater nal infection necessitates immediate institution of treatment until results of fetal testing are known. Spiramycin, which concentrates in the placenta, may reduce the risk of fetal transmission by 60%, but as a single agent, it does not treat established fetal infection. Food and Drug Administration after serologic confirmation at a reference laboratory; it is recommended for pregnant women at risk unless fetal infec tion is documented. If fetal infection is established, pyrimethamine, sulfon amides, and folinic acid are added to the regimen because they more effectively eradicate parasites in the placenta and in the fetus than spiramycin alone. With treatment, even early fetal infection with toxoplasmosis can result in successful pregnancy outcomes. Congenital toxoplasmosis can be diagnosed serologically by the detection of anti?toxoplas ma-specific IgM or immunoglobulin A antibodies soon after birth or by the persistence of anti-toxoplasma IgG beyond 12 months of age. If the diagnosis is suspected (but unconfirmed) at the time of birth, ophthalmologic, auditory, and neurologic examinations should be performed. For healthy appearing infants and those with clinical signs of congenital toxoplasmosis, pyrimethamine and sulfadiazine (supplemented with folinic acid) are recommended for approximately 1 year. Infants with congenital toxoplas mosis should be managed in consultation with infectious disease specialists. Acyclovir prophylaxis to pre vent herpes simplex virus recurrence at delivery: a systematic review. Update on immunization and pregnancy: tetanus, diphtheria, and pertussis vaccination. However, when coloni zation with certain organisms occurs, the outcome may be devastating for the neonate, the mother, or both. Many of the nosocomial infections that occur in intensive care units are caused by pathogens acquired from the hospital environ ment (ie, health care-associated infections). Health care-associated infections result in increased morbidity and mortality, prolonged lengths of hospital stay, and increased medical costs. Definition of Health Care-Associated Infection Health care-associated infection is defined as an infection that is acquired in the hospital while receiving treatment for other conditions.
Or 1 5 yrs 125mg three times a day Over 5 yrs 250mg three times a day Doses may be doubled in severe infection anxiety at night 25mg phenergan overnight delivery. Notes: In confirmed cephalosporin allergy an alternative antibiotic should be prescribed anxiety symptoms peeing cheap phenergan on line. Less than 7 days old 50mg/kg every 12 hours Over 7 days old 50mg/kg every 8 hours Increase dose to anxiety symptoms difficulty swallowing trusted phenergan 25mg 150-200mg/kg/day in 2-4 divided doses in severe infections anxiety symptoms racing thoughts order phenergan cheap online, including neonatal meningitis. It is significantly removed by peritoneal dialysis and haemodialysis, dose as for normal renal function. Doses up to 50mg/kg 3 times a day, maximum of 2g 3 times a day, may be given in severe infection, the immunocompromised, or children with cystic fibrosis. Peritoneal dialysis: 50% of the normal dose should be given initially, then 25-50% of the normal dose once a day. Notes: a) In confirmed cephalosporin allergy, an alternative antibiotic should be prescribed. Ceftriaxone is generally not removed during haemodialysis or peritoneal dialysis, dose as for creatinine 2 clearance less than 10ml/minute/1. Notes: a) In confirmed cephalosporin allergy an alternative antibiotic should be prescribed. Ceftriaxone should not be mixed with calcium containing intravenous solutions and must not be given simultaneously with calcium containing solutions even via different infusion lines. Sequential infusions of calcium and ceftriaxone may be infused (in patients greater than 28 days old, provided they are via different site lines or well flushed between solutions. Peritoneal dialysis, normal dose every 12 hours ensuring one dose given prior to and one dose post dialysis session. Notes: a) Caution: children with obstructive sleep apnoea could be at risk from life threatening respiratory obstruction during sedation. Notes: a) Chloramphenicol use in paediatrics is generally restricted to treatment of severe infection and where a less toxic antibiotic is not available. Chloramphenicol eye preparations are only indicated when sensitivities show that fusidic acid is not appropriate. Lower doses are therefore required at this age, and should be controlled by blood levels. Also, chloramphenicol should only be given parenterally (as the succinate) to neonates as they cannot adequately metabolise the palmitate. It may also cause reversible brown staining of the teeth; however this may be prevented by brushing the teeth before use. Ensure solution is at body temperature before instilling to avoid discomfort and bladder spasms. To avoid excessive dosages in obese or grossly oedematous patients use ideal body weight. Start treatment 1 week before entering an endemic area and continue for 4 weeks after returning (see note e). Slow infusion is necessary to avoid arrhythmias, peripheral circulatory failure or acute encephalopathy. Orally, 1 month 2 years 1mg twice a day 2 6 years 1-2mg 3 times a day 6 12 years 2-4mg 3-4 times a day (max. Notes: a) Chlorpromazine should only be used where alternatives are not available due to the risk of side effects. Side effects include antimuscarinic effects, photosensitivity, occasionally abnormal liver function, agranulocytosis and rarely neuroleptic malignant syndrome and lupus erythematosus like syndrome. Chlorpromazine should not generally be used in infants under 1 year except for narcotic withdrawal in neonates. If converting from the oral to the intravenous route, give one-third of the previous oral dose. Prevention of Renal Graft Rejection and Steroid Resistant Nephrotic Syndrome = 200 microgram/L. In children and growing adolescents ciprofloxacin is only recommended where the benefits outweigh the risk of arthropathy. Liquid is not suitable for administration down a nasogastric tube as it may block the tube. Doses should be used for 7 days in conjunction with amoxicillin or metronidazole plus omeprazole. Administration: Reconstitute vial with 10ml of water for injection to give 50mg in 1ml concentration. Notes: Clarithromycin as with other macrolide antibiotics, interacts with drugs metabolised by the cytochrome P450 system therefore may increase plasma concentrations of drugs such as theophylline, carbamazepine, ciclosporin, tacrolimus, warfarin and digoxin. Orally, < 12 years initially 125microgram/kg twice a day (max 500microgram/kg, or 15mg twice daily) 12 18 years Initially 10mg twice a day (max 30mg twice daily) Increase doses at 5 day intervals until satisfactory response or maximum achieved. Orally, all ages, initially 10-20mg/kg/day in divided doses given every 2-4 hours. Clonazepam can be infused undiluted, into large vessels (preferably a central line). Salivary and bronchial hypersecretion may also occur, particularly if there are learning difficulties. If this occurs control may be re-established by increasing the dose or interrupting therapy for 2 to 3 weeks. Orally, initially, 25microgram at night for 1-2 weeks then increase to 50microgram at night. If required dose can be further increased by 25microgram every 2 weeks, side effects permitting. Notes: a) Blood pressure and pulse must be monitored on initiating treatment and after each dosage increase. Therefore in exceptional cases it has been used in combination with low dose aspirin (Seek expert advice). Administration: Reconstitution (using the appropriate displacement values) so the resulting concentration is 60mg of co-amoxiclav in 1ml. Notes: a) In confirmed penicillin allergy, cephalosporins may be an alternative treatment although approximately 10% of these patients will also be allergic to cephalosporins. Where severe allergy symptoms have occurred previously or the extent of the allergy is unknown an alternative antibiotic should be given. Notes: a) Codeine phosphate should be avoided in children with renal impairment and used with caution in patients with hepatic impairment. Notes: a) All other drugs should be administered at least 1 hour before or 6 hours after colestipol to reduce possible interference with absorption, especially digoxin and warfarin. Notes: a) Colistin has excellent antipseudomonal activity and is probably the first line choice for nebulised use. There must also be good reason to prefer it to a single antibiotic for use in acute otitis media. Less than 15 Avoid unless haemodialysis available, and then give half the normal dose. For peripheral injection, the manufacturers recommend a 25-fold dilution, in glucose 5% or sodium chloride 0. Dilution to less than 1 in 10 is not possible as the propylene glycol precipitates out. Notes: a) Sulphonamides displace bilirubin from protein binding sites, and so, because of the risk of kernicterus, co-trimoxazole is contraindicated in neonates and also the last month of pregnancy. Counsel patient/parent to report all rashes, sore throats, fevers and other manifestations of agranulocytosis. If level is above 150mg/L stop treatment until level falls below 120mg/L than restart treatment at a lower dose. It also contains sulphite which in susceptible patients can cause bronchospasm or anaphylaxis. For standard dosing; doses are given once a month for 6 months, then once every 3 months until patient is in remission for 1 year. Administration: Cyclophosphamide is a cytotoxic drug therefore it must be reconstituted by the oncology pharmacy department. Notes: Premedication: Cold Cap should be in place 15-20 minutes before starting cyclophosphamide.
Infected people whose source case has positive smears for acid-fast bacilli or cultures after 2 months of appropriate antituberculosis therapy and patients who do not respond to anxiety kit purchase phenergan 25mg with visa a standard treatment regimen anxiety 300 buy discount phenergan on line. Residence in geographic area with a high percentage of drug-resistant isolates be discontinued and rifampin should be given for a total course of 6 months anxiety symptoms like ms buy phenergan cheap online. Drugs to anxiety symptoms vs panic attacks phenergan 25 mg for sale consider include pyrazinamide, a fuoroquinolone, and ethambu tol, depending on susceptibility of the isolate. The goal of treatment is to achieve killing of replicat ing organisms in the tuberculous lesion in the shortest possible time. Achievement of this goal minimizes the possibility of development of resistant organisms. The major problem limiting successful treatment is poor adherence to prescribed treatment regimens. Some experts would administer 3 drugs (isoniazid, rifampin, and pyrazinamide) as the initial regimen if a source case has been identifed with known pansusceptible M tuberculosis, if the presumed source case has no risk factors for drug-resistant M tuberculosis, or if the source case is unknown but the child resides in an area with low rates of isoniazid resistance. If the chest radiograph shows one or more cavitary lesions and sputum culture remains positive after 2 months of therapy, the dura tion of therapy should be extended to 9 months. For children with hilar adenopathy in whom drug resistance is not a consideration, a 6-month regimen of only isoniazid and rifampin is considered adequate by some experts. These alter native regimens should be prescribed and managed by a specialist in tuberculosis. If an isolate from the pediatric case under treatment is not available, drug susceptibilities can be inferred by the drug susceptibility pattern of isolates from the adult source case. Data for guiding drug selection may not be available for foreign-born children or in circumstances of international travel. If this information is not available, a 4-drug initial regimen is recommended with close monitor ing for clinical response. Drug resistance is most common in the following: (1) people previously treated for tuberculosis disease; (2) people born in areas such as Russia and the former Soviet Union, Asia, Africa, and Latin America; and (3) contacts, especially children, with tuberculosis disease whose source case is a person from one of these groups (see also Table 3. Most cases of pulmonary tuberculosis in children that are caused by an isoniazid-resistant but rifampin and pyrazinamide susceptible strain of M tuberculosis complex can be treated with a 6-month regimen of rifampin, pyrazinamide, and ethambutol. In general, extrapulmonary tuber culosis with the exception of meningitis can be treated with the same regimens as used for pulmonary tuberculosis. For suspected drug-susceptible tuberculous meningitis, daily treatment with isoniazid, rifampin, pyrazinamide, and ethambutol or ethionamide, if possible, or an aminoglycoside should be initiated. When susceptibility to all drugs is established, the ethambutol, ethionamide, or aminoglycoside can be discontinued. Pyrazinamide is given for a total of 2 months, and isoniazid and rifampin are given for a total of 9 to 12 months. Isoniazid and rifampin can be given daily or 2 or 3 times per week after the frst 2 months of treatment. The evidence supporting adjuvant treatment with corticosteroids for children with tuberculosis disease is incomplete. Corticosteroids are indicated for children with tuberculous meningitis, because corticosteroids decrease rates of mortality and long term neurologic impairment. Corticosteroids can be considered for children with pleural and pericardial effusions (to hasten reabsorption of fuid), severe miliary disease (to miti gate alveolocapillary block), endobronchial disease (to relieve obstruction and atelectasis), and abdominal tuberculosis (to decrease the risk of strictures). Corticosteroids should be given only when accompanied by appropriate antituberculosis therapy. Most experts consider 2 mg/kg per day of prednisone (maximum, 60 mg/day) or its equivalent for 4 to 6 weeks followed by tapering to be adequate. Therapy always should include at least 4 drugs initially; should be administered daily, and should be continued for at least 6 months. Isoniazid, rifampin, and pyrazinamide, usually with ethambutol or an aminoglycoside, should be given for at least the frst 2 months. Ethambutol can be discontinued once drug-resistant tubercu losis disease is excluded. Rifampin may be contraindicated in people who are receiving antiretroviral therapy. Careful monthly moni toring of clinical and bacteriologic responses to therapy is important. For patients with pulmonary tuberculosis, chest radiographs should be obtained after 2 months of therapy to evaluate response. Even with successful 6-month regimens, hilar adenopathy can persist for 2 to 3 years; normal radiographic fndings are not necessary to discontinue therapy. Follow-up chest radiography beyond termination of successful therapy usually is not necessary unless clinical deterioration occurs. Untoward effects of isoniazid therapy, including severe hepatitis in otherwise healthy infants, children, and adolescents, are rare. However, for children with severe tuberculosis disease, especially children with meningitis or disseminated disease, transaminase con centrations should be monitored approximately monthly during the frst several months 1 Centers for Disease Control and Prevention. In most other circumstances, monthly clinical evaluations to observe for signs or symptoms of hepatitis and other adverse effects of drug therapy without routine monitoring of transaminase concentrations is appropri ate follow-up. In all cases, regular physician-patient contact to assess drug adherence, eff cacy, and adverse effects is an important aspect of management. Patients should be given written instructions and advised to call a physician immediately if signs of adverse events, in particular hepatotoxicity (eg, vomiting, abdominal pain, jaundice), develop. Patients who are receiving treatment for tuberculosis can be given measles and other age-appropriate attenuated live-virus vaccines unless they are receiv ing high-dose corticosteroids, are severely ill, or have other specifc contraindications to immunization. Tuberculosis treatment during preg nancy varies because of the complexity of management decisions. During pregnancy, if tuberculosis disease is diagnosed, a regimen of isoniazid, rifampin, and ethambutol is recommended. Pyrazinamide commonly is used in a 3 or 4-drug regimen, but safety during pregnancy has not been established. At least 6 months of therapy is indicated for drug-susceptible tuberculosis disease if pyrazinamide is used; at least 9 months of therapy is indicated if pyrazinamide is not used. Pyridoxine supplementation is indicated for all pregnant and breastfeeding women receiving isoniazid. The beneft of ethambutol and rifampin for therapy of tuberculosis disease in the mother outweighs the risk to the infant. Because streptomycin can cause ototoxic effects in the fetus, it should not be used unless administration is essential for effective treatment. The effects of other second-line drugs on the fetus are unknown, and ethionamide has been demonstrated to be teratogenic, so its use during pregnancy is contraindicated. Although isoniazid is secreted in human milk, no adverse effects of isoniazid on nursing infants have been demonstrated (see Human Milk, p 126). Breastfed infants do not require pyridoxine supplementation unless they are receiving isoniazid. Women who have only pulmonary tuberculosis are not likely to infect the fetus but can infect their infant after delivery. Congenital tuberculosis is rare, but in utero infections can occur after maternal bacillemia. If the physical examination and chest radiographic fndings support the diagnosis of tuberculosis disease, the newborn infant should be treated with regimens recommended for tuberculosis disease. If meningitis is confrmed, corticosteroids should be added (see Corticosteroids, p 752). Drug susceptibility testing of the organism recovered from the mother or household contact, infant, or both should be performed. Management of the newborn infant is based on categorization of the maternal (or household contact) infection. Although protection of the infant from exposure and infection is of paramount importance, contact between infant and mother should be allowed when possible. Cases of suspected or proven tuberculosis disease in mothers (or household contacts) should be reported immediately to the local health department, and investigation of all household members should start within 7 days. The mother (or household con tact) and the infant should be separated until the mother (or household contact) has been evaluated and, if tuberculosis disease is suspected, until the mother (or household contact) and infant are receiving appropriate antituberculosis therapy, the mother wears a mask, and the mother understands and is willing to adhere to infection-control measures. Women with tuberculosis disease who have been treated appro priately for 2 or more weeks and who are not considered contagious can breastfeed. If tuberculosis disease is excluded, isoniazid should be continued for a total of 9 months.
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Suggested analgesic regimens Opioids are the first choice drugs in many emergency and critically ill patients anxiety 7 minute test generic 25 mg phenergan overnight delivery. Acupuncture may be very useful for gastrointestinal and urinary cases in particular anxiety 30000 phenergan 25 mg with mastercard. Opioids: Currently anxiety bc order phenergan with mastercard, opioids are commonly used for analgesia in pregnant dogs and cats anxiety 2016 order phenergan amex. Evidence regarding the use of medetomidine and dexmedetomidine in dogs and cats during pregnancy is not available. Local anaesthetics: Generally considered to be safe and non-teratogenic201 they are highly recommended. Herbal analgesic medications: Due to a lack of information, these should be avoided Caesarean Section the physiologic changes associated with pregnancy outlined above influence the choice of anaesthetic and analgesic drugs for caesar ean section in queens and bitches. Premedica tion is normally recommended to decrease maternal stress and anxiety and to reduce the doses of induction and maintenance agents; in addition the use of opioids provides pre-emptive analgesia. Decreased gastrointestinal motility and the enlarged uterus increase the risk of vomiting and aspiration. Rapid control of the airway is essential therefore mask induction with an inhalant agent is not recommended. The administration of opioids prior to delivery has not been shown to adversely affect the outcome for the offspring. Due to their high oxygen requirements and reduced functional residual capacity of the lungs, pregnant animals are at risk for hypoxaemia and oxygen desaturation can occur rapidly at induction of anaesthesia. Drugs that are known to increase maternal and/or neonatal mortality include the alpha2 adrenergic agonist xylazine and the inhalant agent methoxyflurane. However due to the potential for emesis and cardiovascular depression, these drugs as a class are best avoided. Moon202 also reported that although ketamine did not increase puppy mortality it decreased the vigour of new-born puppies, therefore resuscitation efforts should be aggressive if ketamine is used. There was no differ ence in survival between puppies whose dams received propofol or alfaxalone. There is a lack of published information on kitten vitality after caesarean delivery. An opioid normally provides adequate sedation for venous access however acepromazine can be used if the dam is difficult to manage and requires more sedation than an opioid alone can provide. Where propofol or alfaxalone are not available, ketamine or thiopentone could potentially be used with the understanding that they may decrease vigour of the offspring and resuscitation efforts should be aggressive. Anaesthesia can be maintained with repeated boluses or a continuous rate infusion of propofol, but intubation and administration of oxygen is still required. Local anaesthetic techniques: Pre-incisional and / or post incisional line block (lidocaine or bupivacaine). Epidural/ Spinal analgesic techniques: Morphine can be administered pre or post-operatively to provide up to 18-20 hours of analgesia. Following intubation anaesthesia can be maintained with isoflurane and fentanyl can be repeated. Protocol without controlled drugs Preoperative: Acepromazine unless the bitch or queen is volume depleted. Protocol with limited availability of anaesthetic and analgesic drugs Preoperative: Acepromazine (see indication for use above). Induction and maintenance of anaesthesia: Depending on availability of drugs, choose from the protocols above. Local anaesthetic techniques: Epidural local anaesthetic (lidocaine) can be used as a sole technique but with caution. Epidural local anaesthetics cause sympathetic blockade with resultant vasodilation and hypotension which can be prevented or treated with intravenous fluids, but could be especially detrimental in compromised dams. With this technique the dam is conscious and therefore not intubated so there is an increased risk of aspiration; oxygen should be administered by face mask. Lactation Characteristics of a drug which would facilitate secretion into milk are high lipid solubility, low molecular weight and the non-ionized (charged) state. It is estimated that the neonate receives approximately 1% to 2% of the maternal dose of a drug. Opioids: the lipid solubility of the opioid influences its appearance in the milk; pethidine (meperidine)>sufentanil>fentanyl> morphine>hydromorphone, therefore a more hydrophilic opioid, such as morphine, may appear in smaller amounts than a more lipid-soluble opioid such as pethidine. It is recommended that suckling occurs after peak levels of the opioid have waned. Local anaesthetics: Lidocaine and its metabolites have low lipid solubility; at therapeutic doses the concentrations in milk are small and unlikely to be a risk. Ketamine: No reports on passage into breast milk were found, but it is expected to pass into breast milk. Due to important physiological changes which occur during this time frame, a further demarcation is defined as: neonatal (0?2 weeks), infant (2?6 weeks) weanling, (6?12 weeks) and juvenile (3?6 months). This distinction is made to highlight the metabolic changes that occur during these periods of maturation. While this may be a potential concern in the neonate, it is not necessarily so through all stages of maturation. While there are no reports in the veterinary literature suggesting increased dosing should be considered in the young cat or dog, personal experience with intensive monitoring of the young (3?6 month old) ani mal has shown opioid doses for analgesia may be equal to, and can be higher than, a mature adult emphasizing that administering the analgesic to effect, rather than a pre-determined dose, is the most important method of clinical dosing. For all these reasons, frequent pain assessment and treatment should be evaluated on a case-by-case basis and tailored to patient needs. The neonate has reduced clearance of many drugs as compared with older individuals largely because of. Opioids Lower doses of fentanyl or morphine are required for analgesia in the neonate (0?2 weeks) when compared to the 5-week-old puppy213 or kitten. Puppies and kittens are also more sensitive to the sedative and respiratory depressant effects of morphine than adults. Hydromorphone, oxymorphone and methadone may also be used; however, as with all opioids, starting at or below the lowest dose of the range and increasing to effect is recommended. Opioids can be reversed with titration of naloxone should there be clinical evidence of overdosing. Local anaesthetics Local anaesthetics are recommended, but careful dosing according to accurate body weight is imperative. A maximum dose of local anaesthetic is half the adult dose215 for both kittens and puppies up to 10 days of age. Lidocaine 2% is also available as a sterile gel, and is used for local desensitization of the vaginal vault or penis prior to urinary catheter placement. Alpha2 adrenoceptor agonists Alpha2 agents are sedative analgesics and are not recommended due to the cardiovascular effects. Sedatives these should not be used in young animals, especially when less than 12 weeks of age. Where any painful procedure is required in young animals, contact with the mother as soon as possible is recommended. Opioids Opioids may be included in a multimodal regimen to manage neuropathic pain, but not as a stand alone analgesic. Opioids may have reduced effectiveness, where tactile allodynia (Abeta stimulus) is a component of neuropathic pain and where opioid receptors in the descending inhibitory pathway are reduced or inactivated, which may occur in neuropathic pain. The naloxone titration technique to reverse side effects of opioids is recommended (see Table 1). Amantadine (3?5 mg/kg once daily orally) may be continued after ketamine is discontinued for longer-term therapy at home. Anti-epileptics Studies in humans and laboratory animals indicate that perioperative administration of gabapentin to animals with nerve injury may reduce the potential establishment of, or ongoing, neuropathic pain. A benefit of long term administration of gabapentin following trauma was reported in three cats;109 however, to date there are no prospective veterinary studies investigating the long-term effects of multimodal analgesia including gabapentin. Alpha2 adrenoceptor agonists Medetomidine and dexmedetomidine may be added to a multimodal regimen. Intra and postoperative pain management for intervertebral disc herniation is another example.