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Patient Care - Hypnotic DrugsHypnotic
Drugs:
The drugs
should be given orally if possible and used with caution in elderly patients
and in patients with anemia, high fever, heart failure, renal failure, hepatic
insufficiency, myxedema, or pulmonary disease.
Idiosyncrasies are rare. Urticaria, fever, or other allergic
manifestations may occur, as well as hangover, excitement, and other CNS
symptoms.
It is quite aware, that certain hypnotic drugs suppress the rapid
eye movement
(REM) - Stage of sleep. After a prolonged action of the medication,
withdrawal should be tapered to prevent undesirable clinical manifestation,
increased dreaming, unpleasant dreams and nightmares,
and insomnia.
B.
Barbiturates -
Route of Excretion:
1. Long-acting barbiturates are excreted by the kidney
2. Short
acting preparations are metabolized in the liver
Most preparations may be given orally or parenterally.
Phenobarbital
and amobarbital are the most frequently used parenterally; they should be given
IV only in emergency situations, such as status epilepticus.
As a rule,
oral and parenteral dosage is the same.
Phenobarbital is a cerebral depressant they may cause confusion,
excitement, and disorientation. Barbiturates are contraindicated in patients
with acute and intermittent porphyria and must be used with great caution in
severe hepatic insufficiency. Patients
who become addicted often show serious mental and physical deterioration. When
drugs are withdrawn from such patients, the decrement
in dosage should be 100 mg/day or less to prevent such serious
physiologic reactions as disorientation, hallucinations, and convulsions.
Acute
barbiturate poisoning accounts for a significant percentage of Suicides or
attempted suicides, but 80-90% of these patients will recover if treated
promptly.
Long-acting Effects are noticeable in 30-45 minutes and last 4-8
hours. Hangovers are frequent. The dosage of phenobarbital (Luminal) is 100-200
mg at bedtime; for daytime sedation, the dosage is 15-30 mg QID.
Short-acting to intermediate-acting Effects last 2-4 hours are
uncommon. Smaller doses may be effective in the elderly.
Oral doses given at bedtime are pentobarbital (Nembutal) 100-200 mg;
Amobarbital (Amytal), 100-200 mg; secobarbital (Seconal), 100-200 mg.
C. Chloral hydrate is a rapidly effective hypnotic that seldom produces
excitement or hangover and does not suppress REM sleep. Sleep usually begins in
15-30 minutes and lasts 5-8 hours.
The drug can be given safely to patients of all ages. However, since
it is detoxified chiefly by the liver, it is contraindicated in patients with
severe hepatic insufficiency and in patients with severe cardiac disease.
Side
effects include a burning sensation of the mucous membranes and gastric
irritation. A reduction product, trichloroethanol, may give a positive result
for urine sugar with Clinitest tablets. Chronic administration of chloral
hydrate will potentiate the hypoprothrombinemic effect of warfarin
anticoagulants.
The sedative dose is 250-500 mg. The hypnotic dose is 2-3 gm; the
larger dose usually is required for adequate effects. The drug may be given as
250- or 500-mg capsules or as syrup with a concentration of 500 mg/5 ml.
Beta-Chlor,
a complex of chloral hydrate and betaine, hydrolyzes or decomposes slowly in
the gastric contents, yielding chloral hydrate. There is no disagreeable taste;
gastric irritation is said to be less than with chloral hydrate alone. Each
870-mg tablet yields 500 mg of chloral hydrate.
Paraldehyde has a rapid, smooth hypnotic action (within 10-15
minutes)
It is often used in the treatment of tremor following alcohol
withdrawal.
Unfortunately, it has a disagreeable taste, a pungent odor, and
irritant effects on mucous membranes. As a result of nausea, vomiting,
esophagitis, gastritis, etc. Excretion is chiefly by the liver and lungs. The
drug must be administered cautiously to patients with severe liver disease. It
may be used in the presence of renal insufficiency.
Paraldehyde should be prescribed orally whenever possible. Profound
metabolic acidosis may follow chronic ingestion of large doses of the
substance. Storage of the solutions may have been the result of the
complication.
Paraldehyde is unstable and decomposes to acetaldehyde and acetic
acid. Chronic paraldehyde intoxication results in tolerance and dependence;
withdrawal symptoms include delirium tremens and hallucinations. Dosages are as
follows:
1. Oral. Usually 8-10 ml, but varies from, 3-20 ml. crushed ice,
orange juice, tea, milk, or wine will help mask the taste.
2. Rectal.
Olive oil or mineral oil enemas in suspension may be given. The usual rectal
dose is 10-20 m!. Fresh solutions should be used to avoid serious rectal burns.
It is often necessary to anesthetize the mucous membranes of the anus to
prevent local irritation that may lead to expulsion.
3. Intramuscular. The usual dose is 4-8 ml. sterile abscesses may
result from IM injections, and quantities greater than 4 ml should not be given
in one injection site. Antihistamines
Diphenhydramine (Benadryl), in doses of 50-100 mg at bedtime, may provide
excellent sedation for patients with severe hepatic or renal insufficiency and
for elderly patients (in smaller doses). Diaz epoxide the use of this class of
drugs has come under great scrutiny due to their addictive nature and
unnecessary use.
The narcotic License and permit to use are regulated by the drug
enforcement agency. 1.
Chlordiazepoxide (Librium). The sedative dose is 30 mg/day; 10-20 mg/day
is recommended for geriatric patients;
Oral or parenteral doses of 200-300 mg/day may be used during
alcohol withdrawal, but the sedative effect may be prolonged at these doses.
Adverse
effects are primarily of CNS depression. Delirium, ataxia, and vertigo may
occur. Skin rashes are rare. Agranulocytosis, menstrual irregularity, and
marked stimulation of appetite have been reported. Plasma levels of the drug
fall slowly over several days when the drug is discontinued.
Withdrawal
symptoms (disorientation, hallucinations, and convulsions) have been seen after
discontinuation.
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