Applying nursing theory to the practice of nurse anesthesia

Applying nursing theory to the practice of
nurse anesthesia
SUSAN A. MARTIN, CRNA, MSN
Destin, Florida
With the currentmovement of anesthesia
education into graduateprograms, changes
in curriculumare inevitable. These changes
will include advanced nursingtheory. How
the issues of nursingtheory apply to the
practiceof nurse anesthesiaare examined.
Applications of Betty Neuman's systems
theory are used in specific examples of the
anesthesia role. The profession of nurse
anesthesia may benefit significantlyfrom the
contributionsof nursing theory.
Key words: Graduate education,
Neuman systems model, nursing,
nursing theory.
Introduction
The practice of nurse anesthesia has been historically defined from a functional perspective. This
is readily illustrated by reviewing the Scope of
Nurse Anesthesia Practice as defined by the American Association of Nurse Anesthetists. (AANA).P 2)
This publication summarizes 11 functions that outline and define the scope of practice of the nurse
anesthetist. The majority of functions described
are primarily "technical" in orientation, such as
item f, which states that the scope of nurse anesthesia practice includes managing a patient's airway
and pulmonary status using endotracheal intubation, mechanical ventilation, pharmacological support, respiratory therapy, or extubation.
August 1996/Vol. 64/No. 4
Other functions addressed by the AANA reflect judgment-related challenges for the nurse anesthetist, such as selecting the appropriate anesthetic technique. When compared with current
nursing practice acts, the scope of practice as defined by the AANA in 1992 is devoid of a conceptual or theoretical framework. The AANA has
stated in its Standards for Nurse Anesthesia
Practice its belief that "Standards, based upon
sound philosophy, theory, science and principles,
serve to upgrade clinical practice."'1 p4)
The goal of this article is to explore existing
theoretical principles of nursing and their potential application in nurse anesthesia education and
practice. The significance of this goal is accentuated by the Council on Accreditation of Nurse Anesthesia Educational Programs' Standards for Accreditation, which states that accredited programs
must "design a curriculum that will award a master's or higher degree level to students who will
enter the program on or after January 1, 1998, and
who successfully complete graduation requirements." 2 The National Commission on Nurse Anesthesia Education explains that the AANA has
gradually increased the educational requirements
in response to the demand for more complex services [which require] expanded knowledge and
technological capabilities." 3 This Council further
requires that a program must adopt a curriculum
plan and/or program design that is within the construct of graduate education. Requirements for
graduate nursing education as determined by the
369
National League for Nursing include a mandate
"to expand knowledge of nursing theory as a basis
for advanced nursing practice." 4 Subsequently,
nursing theory courses are becoming mandatory
curriculum in nurse anesthesia programs that are
housed in colleges of nursing.
The appropriateness of the medical model traditionally used as a framework in nurse anesthesia
programs is now being questioned, just as in the
past nursing professionals and educators had questioned the use of the medical model in nursing.
The medical model is described by Englehardt as
"rejecting philosophical speculation and giving
way to rational or logical decision making. Physicians use their clinical experience and observation
of patients as a basis for developing reliable diagnoses and treatments. The goal has been in the
'tacit knowing' of medicine." 5 Englehardt goes on
to support the notion that medical practice, too,
can benefit from a theoretical basis which may add
an "analytic regard" to the tacit knowledge.
The question is simple: if the AANA feels that
graduate education is important enough to mandate it as a curriculum requirement, should not we
then consider changes in the framework within
which CRNAs practice? Unfortunately, the answer
or solution is not so simple because nurse anesthetists must first recognize a theoretical void in their
practice (considering that one of the problems our
profession faces is the notion that we are technicians and further considering that any profession
must, by definition, be supported by a conceptual
framework) and decide that it may be filled by the
inclusion of a theoretical framework. Developing
theory is not a simple undertaking. Perhaps the
profession of nurse anesthesia would be better
served by adopting and adapting theoretical
nursing models on which the practice of nursing
has been based. To facilitate a better understanding of nursing theory and nursing practice, it is
necessary to review nursing theory in practice.
Review of literature: Nursing theory in practice
Practice is sometimes viewed as the "down to
earth action carried out by the doers," while theory is viewed as somewhat esoteric, in some cases
unnecessary or at best, marginal. 6 Nursing theory
influences nursing practice in a variety of ways.
Fawcett suggests that nursing theory distinguishes
nursing from medicine by directing our actions
and controlling the clinical environment. 7 This is
accomplished through the ability of the theory to
define the arena of nursing by defining clinical
problems to be considered, settings in which nursing practice occurs, legitimate recipients of nursing care, and nursing process, format, and content.
370
Nursing models serve as the basis for clinical information systems (admission forms, care plans, and
discharge summaries, to name a few). Conceptual
models also guide the development of patient classification systems. Fawcett states emphatically that
"nursing models were devised to move nursing
away from ritualistic and task-oriented care to
thoughtful practice." 7 They were created to "shape
nursing into what it ought to be." 7
Speedy claims that nursing theory explains
our practice by changing the way nursing is
understood. 6 This is accomplished through the
testing of nursing theory in the clinical arena.
Adapting basic scientific knowledge (validated by
research) is the primary determinant of nursing
practice. "Nursing practice so based in theory and
research has a firm foundation far removed from
trial and error, guesswork or intuition."6
Allen asserts that nursing theory empowers
nurses to question the status quo. He points out
that the aim of critical theory is to expose the contradictions, oppression, and power imbalances that
inhibit the freedom and autonomy needed to develop as a profession. 8 This requires the establishment of open, unconstrained communications,
which will better assist patients in making informed choices about their care.
Critics of nursing theory argue that the process of incorporating nursing theory into practice
may be too difficult to realistically achieve at the
bedside. The application of theory may require
greater conceptual sophistication of theoretical
ideas, 8 theories are often too vague and abstract to
apply,8 the models are limited by the values and
beliefs of their originators, 9 and the credibility of
nursing models is challenged when the patients
see no difference in nursing care when a theoretical framework is used. 10 Although the criticisms
may be valid for generalists in nursing whose practice incorporates a wide range of specialties and
skills, advanced specialty practitioners may benefit from an easier application of conceptual frames
of reference by virtue of the more narrow focus of
their practice. Benner defends nursing theory in
practice by asserting that nurses are using theory
in their daily practice but are unaware of the basis
for their competence."
With these arguments and assertions in mind,
Betty Neuman's nursing thoretical framework will
be applied to the practice of nurse anesthesia.
Neuman's theory is only one of several nursing
theories that could be appropriately applied to anesthesia. Neuman has been chosen due to her orientation with systems theory, an approach that involves processes and outcomes and, thus, seems
most appropriate to the practice of anesthesia.
Journalof the American Association of Nurse A nesthetists
The Neuman systems model
Neuman's model is based on an individual's
relationship to stress, the reaction to it, and reconstitution factors that are dynamic in nature. 12 The
aim of this model, called the total person approach,
is to provide a unifying focus for approaching varied nursing problems and for understanding the
basic phenomenon: man and his environment.
Neuman's theory is neatly classified as a systems
theory that evaluates processes and outcomes toward greater organization. The person is defined
by Neuman as an open, holistic system interacting
with and to the environment. The environment is
defined as "all that interfaces with the person."' 2
The environment is the source of stressors for
the person that has the potential of disrupting the
person's normal lines of defense (a normal range
of responses to stress). Stressors may be beneficial
or noxious depending on the strength of the flexible line of defense (an individual's combination of
responses to stress). With humans in a constant state
of change, interacting with the environment, varying degrees of wellness exist. If a person's total
needs are met, that person is in a state of optimal
wellness. Conversely, a reduced state of wellness is
the result of unmet needs.
Three key concepts in Neuman's theory are
stress, homeostasis, and patient perceptions. The
nurse's role is to focus on variables affecting the
person's response to stressors, allaying risk factors
associated with them. The nurse assesses, manages,
and evaluates the patient, acting to impede states
of disorder. Interventions by the nurse, "can begin
at any point at which a stressor is either suspected
or identified. One would carry out the intervention of primary prevention since a reaction had
not yet occurred, though the degree of risk or hazard was known or present. The intervener would
attempt to reduce the possibility of the individual's
encounter with the stressor or in some way attempt
to strengthen the individual's flexible line of defense to decrease the possible reaction."12
The impact of multiple stressors can reduce
the effectiveness of the person's buffer system allowing a reaction to a stressor to occur.
Discussion: Applying the Neuman systems model
to anesthesia
Nurse anesthetists are nurses first, and as such
view their role in terms of assessing, planning, implementing, and evaluating the care of the client.
The unique scope of practice of the nurse anesthetist differs significantly from the other nursing specialties in that its primary focus includes:
1. Preanesthetic preparation and evaluation.
August 1996/ Vol. 64/No. 4
2. Anesthesia induction, maintenance, and
emergence.
3. Postanesthesia care.
4. Perianesthetic and clinical support functions. 2)
These functions of the nurse anesthetist, when
considered in light of Neuman's framework, strive
to support the normal line of defense of the client
by impeding the stressors the client experiences
(or remembers). The majority of actions carried
out by the nurse anesthetist are directed at decreasing physical and emotional stress from the initial
preoperative counseling, through the administration of anxiolytics, vagolytics, and anesthetics, to
the postoperative follow-up visit. Neuman's theory
also emphasizes the promotion of homeostatic balance in the maintenance of the person's whole system. Homeostasis is a concept that is well integrated in current anesthesia practice as evidenced
by the constant vigilance required of the anesthetist during the delivery of anesthesia nursing care.
Neuman believes that although nurses receive
training in the natural and behavioral sciences,
they are expected to conceptualize it in their own
way. She has developed many applications of her
theory in order to provide meaningful ways of incorporating conceptual frames of reference into
practice. One such way is in her assessment tool.
This tool relates to the total person and considers
three basic principles:
1. Good assessment requires knowledge of all
the factors influencing a patient's perceptual field.
(The identification of these factors takes place during the preanesthetic assessment.)
2. The meaning that a stressor has to the patient is validated by the patient as well as by the
caregiver. (This is demonstrated in the preoperative classification of anxiety that serves to identify
three distinct coping patterns in patients facing
surgery. Nurse anesthetists may choose to give special counseling to patients classified with high- or
low-level anticipatory anxiety, since these are associated with lack of participation by the patient during the postoperative period.)
3. Factors in the caregiver's perceptual field
that influence assessment of the patient's situation
should become apparent. (This principle is obviated by the use of the preanesthetic evaluation in
developing the perioperative care plan.)
These few examples illustrate the ease and
appropriateness of applying nursing theory to the
practice of anesthesia.
Summary
Since nurse anesthesia programs have progressed to the realm of graduate education, it is
371
fitting that theoretical frames of reference be incorporated into the practice of nurse anesthesia.
As demonstrated in this article, this task can be
easily accomplished and appropriately applied to
the practice of nurse anesthesia. The primary obstacle with using nursing theory is not its complexity but the reluctance of the practitioners to accept
nursing theory as a vital part of their professional
development. This reluctance seems inconsistent
with the usual dialogue of professionalism. A
stronger foundation in nursing and a conceptual
framework from which to practice are only a couple of the contributions made by nursing theory to
nurse anesthesia. Further contributions have yet to
be explored in the new marriage of anesthesia and
graduate education.
REFERENCES
(1) Guidelines and Standards for Nurse Anesthesia Practice. In: ProfessionalPractice Manualfor the Certified Registered Nurse Anesthetist. Park
Ridge, Illinois: American Association of Nurse Anesthetists. 1992.
(2) Annual Report of the President, 1989. 56th AANA Annual Meeting, Boston, Massachusetts. AANA NewsBulletin. Special Supplement.
1989;43(10):11-15.
(3) Report of the National Commission on Nurse Anesthesia Education. Introduction. AANA Journal.1990;58:389-393.
372
(4) Council on Accreditation of Nurse Anesthesia Education Programs. Official Council Listings. AANA Journal.1993;61:630-638.
(5)
Engelhardt H. Tristam EH, Jr. ClinicalJudgement: A Critical Ap-
praisal Boston, Massachusetts: D. Riedel Publishing Company. 1979.
(6) Speedy S. Theory-practice debate: Setting the scene. The Australian Journalof Advanced Nursing. 1989;6:12-20.
(7) Fawcett J, Archer CL, Becker D, et al. Guidelines for selecting a
conceptual model of nursing: Focus on the individual patient. Dimensions of Critical Care Nursing. 1992;11:268-277.
(8) Allen DG. Nursing research and social control: Alternative models of science that emphasize understanding and emancipation. Image J
Nurs Sch. 1985;17:58-64.
(9) McKenna HP. The selection by ward managers of an appropriate
nursing model for long-stay psychiatric patient care. J Adv Nurs.
1989;14:762-775.
(10) Fawcett J. Conceptual models and nursing practice: The reciprocal relationship. JAdv Nurs. 1992;17:224-228.
(11) Benner P. From novice to expert. Am JNurs. 1982;82:402-407.
(12) Neuman B. The Neuman Systems Model. Norwalk, Connecticut:
Appleton-Century-Crofts. 1982.
AUTHOR
Susan A. Martin, CRNA, MSN, is a recent graduate of Southern
Illinois University at Edwardsville Nurse Anesthesia Program. She
currently practices at Ft. Walton Beach Medical Center and Emerald
Coast Day Surgery Center. She has earned two previous degrees in
nursing: A BSN from Abilene Christian University in Abilene, Texas,
and an MSN from the University of Texas Health Science Center in
Houston, Texas. Her work experience is primarily in intensive care
units, including cardiovascular, liver transplant, and pediatric units in
Houston and Los Angeles.
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ADMINISTRATION,
patients.
obseredin pediatric
isfrequently
eventinclinicaltrials,apnea
OTHEPRODUCT adverse
WITHMICROBAL
COITANINATION
EMULSION
WAS
ASSOCIATED
NUIECTANLE
WHEN
HANDIGDINRIVAN
patients.
(N=159)
fromclnicaltrialsinICUsedation
eventsinclude
data
of adverse
inA lts:Thefollwingestimates
ICU
Sedaton
DEATH.
ILNESS,AND/OR
OTHER
LIFE-THREATENING
IFECTION/SEPSIS,
ANDWITHFEVER,
Probable
causality
wan
by individual
casereportformrevlew.
weredetermined
Probably
relatedincidencoratesfor ICUsedation
be usedin eldedy,
rateof administration
should
A lwer induction
doseanda slowermaintenance
PRECAUTIONS
General:
of
thepresence
In manyinstances
responsesnorechallenge.
doseresponsereationshipand/orpositive
baseduponanapparent
Patients
shouldbecontinuously
of Dosage)
Individualzation
(SeeCLINICAL
PHARMACOLOGYorASAIIUIV
patients.
debilitated,
rates
for
ICU
sedation
incidenco
unknown.
Therefore,
the
causal
relationship
therapy
made
and
concomitant
concomitant
dlsease
the rateofintraveous
increasing
Treatment
mayinclude
and/orbradycardia.
sigs of significant
hypotension
monitored
for
causalrelationship.
to havea probable
whichappeared
ofclinicaltrialpatients
oftheperentage
represent
estimates
generally
and
oftenoccursduring
of atropine.
Apnea
agents,
or administration
oflwer extemiies,useof pressor
uid,elevation
Emulsion
isan emulsion,
DIPR/ANInjectable
Because
Ventilatory
support
maybe required.
60 seconds.
maypersist
formorethan
diabetic
suchan primaryhyperlipoproteanemia,
in patients
withdsordersof lipid metabolism
cautionshouldbe exercised
ores
established
foreachistitution
surgery
criteriafor
dischargefromtherecovery/day
andpancreatitls.
Theclinical
bypedipemia,
Etrasystole, Vntricuar
tan 1%-ProbayCasallyRelated
Cardiavascutar Edema,
greater
Incidence
Emulsion
t WhenDIPRIUN
Injectable
fromthecareof6w anesthespsiol
ofthe patient
shouldbesatisfiedbeforedischarge
Tachycardia
HeartBlock,
(continued)
andchildren,
attentionshould
during.nrecoveryphase.adults
maybea riskofseizure
toanepileptic
patientwthere
administered
Hypertension,
if
the
larger
veins
pan
canbe
Emulsion.
Trnsent
of
DIPRtAN
Injectable
pain
on adminrtration
bepaidtominimize
Myocardial
Infarction,
byprorinjectionofIVlidocane
mayalso bereduced
intravenous
injecton
areusedPainduring
fossa
oftheforearmorantecubital
ICU
Sedation
Sedation
MyocrdialIchomia,
patients
(45%)whenasmallveinofthehandwasutilized
occurred
frequently
inpediatric
Painor injection
(1mltofa 1%solution).
Bradycordia,
Cardiovascuiar Bradycardia
Premature
Vntricuiar
pan wanminimal(incidence
veins
wereutilized,
pretreatment
or whenantecubital
Withlidocalne
withoutlidocainepretreatment.
ST
Contractions,
nave
beenreported
rarely(<1%).Intwowell-controlled
(phetis orthrombosis)
sequelae
lessthan10%)andwelltolerated.Venous
Cardiac
Output,
Pd:17%/]
SegmentDepression,
up to 14daysfollowing
wereobserved
sequelae
no intancesof venous
cathetrs,
intravenous
usingdedicated
Hpotension
cliical studies
Supraventricular
in
hanbeenreported
itra-aiterial
Pnds:8%
didnotinduce
localtissueeffectsAccidental
injection
in animals
inductionIntraartenal
Tachycardia,
Tchycardia,
tissuesof
onperivascular
Intentional
injectionintosubcutaneous
and,otherthanpain,therewerenomajorsequelae.
patients,
Ventricuiar
Fibrillation
of lecalpain,swelling,
therehavebeenrarereports
the potmadetingperiod,
tissuereaction.
During
animalscausedminimal
PHARMACOLOGY)
Central
Nerous
rarely
Emulsion.
Pan
operativemyoclonia,
ofDIPRIVAN
Injectable
folowig accidental
eoravasatios
tissuenecrosis
blisters,and/or
CentralNervous
Dreams, Chills/Shivering,
Abnormal
System
han
Injectable
Emulsion
inwhichDIPRPAN
relationship
incanes
intemporal
has occurred
conlsionsandopisthotonos,
including
Movement[Peds 17%)
System:
Amorous Intracranial
Agitation,
andhypatension,
erythema,
broechospasm,
whichmayinclde angioedema,
of anaphytuos,
Clinical
features
beenadministered.
Site:
Buming/Stinging
Injection
Hypertension,
Behavior,
Anxiety,
makes
the
in mostinstances
administration,
althogh useof otherdrugs
Injectable
Emulsion
occur
raNlyfollowingDIPRIVAN
or Pan,17.6%
BcigJri Seus,
to
relationship
edemaintemporal
havebeerrarerepotsof pulmonary
Injectable
Emulsion
unclearThere
relationship
toDIPRPAN
(Pods.
1(1%)
Thrashing,
g Chil
Somnolence,
Emulsion
han
DIPRIVAN
Injectable
is unknown.
although
a causal
relationship
Injectable
Emulsion,
ofDIPRIVAN
the administration
Hyperipomia'
Metaholic/Nutritional:
Thinking
Clonic/
Shivering,
withDIPRPJAN
Injectable
cardiac
arresthavebeenassociated
anysole,
and
Reports
of bradycardia,
no vagoyticactivity.
Anes
Respiratory
Respiratory:
Abnormal
Movement,
Myoclonic
to modify
should
be considered
(og,atropine
orgycopynolale)
agents
ofantcholinergic
administation
Theintravenos
(seealsoCLINICALAcidosis
Emulsion.
Combativeness,
orsurgicalstimuli.
agents
(a, succanyichotine)
dueto concomitant
vagaltone
potential
increaesan
During
PHARMACOLOGY)
Delirium,
Confusion,
Prtcedre.)Theadministration
Handling
ad DOAGEANDAMINISTRATION,
(SeeWARNIMGS
leeinleCregeHSedaiOn:
Weaning*
Dziness,
Depression,
madeslowly
inthe rateofadministration
infusionandchanges
Emulsion
shouldbeiitiatedasacontinuous
of DIPRIVAN
Injectable
Skinand
Lability,
Emotional
of
- Individualiation
PhARMACOLOGY
(SeeCLINICAL
andavoidacuteaverdosage.
hypotension
min)inorderto minimize
[Peds: 5%]
Rush
Appendages:
Euhoria,
Fatigue,
depression,
whichmaybe
and/orcardiovascuar
i'V
of ugniffantl
for earlysigns
Patients
shouldbemonitored
Dosage.)
of1%-3%
Eventswithoutan'or % hadanincidence
and/or
Emulsion,/ ffuid administration,
of DIPRN Injectable
to discontinuation
profound.Theseeffectsare responsive
Headache,
Hypotonia,
Incidenceofevents3%to10%
Emulsion
inDIPRPVAN
Injectable
variabilrty
medications,
thereis wideinterpatient
vasopressortherapyAs withothersedative
Hysteria,
Insomnia,
maychangewithtime.Failureto reducethe infusionratein patentsreceiving
andtheserequirements
dosagerequirements,
Neuropathy,
Moaning,
titration
of the drug.Thus,
blondconcentrations
high
Emulsion
forextendedperiodsmayresuRinexcessively
VANInjectable
DIPR
Related
thn 1%-ProbabhCausally
Incideeseless
Rigidity,
Opisthotonos,
Emulsion
infusionfor
Injectable
areimportantduringuseof DIPRIUAN
levels
of sedation
to
responseanddailyevaluation
Seizures,
Somnolence,
CU sedation,
especiayoflog duration.
Opioids
andparalytic
agents
shouldbedicontinued
andrespiratoryfunction
optimized
Tremor,Twitching
beadjusted
tomaintain
a
ofDIPRraAN
ljectable
Emubson
shouts
trammechanical
vestitation.
Infusions
proto wens patients
Diarrhea, linus,Liver
Cramping,
ICU
Sedation Digestive:
Sedation
level
of
Thmnughoid
twweaning
processthhr
froes
mechanical
vesidatory
support.
level
ofsedation
priortoweaning
pahientu
right
DryMouth,Eniarged Function
Bodyas a Whole. Anaphyaxis/
in theabsence
of respiratory
depression.
Because
of the rapidclearance
of DIPRIVAN
Injectable
sedation
maybe maintained
Abnormal
Parotid,Nausea,
Anaphylactoid
anxiety,
infusionmayresultin rapidawaeningofthe patientwithassociated
of a patient's
abruptdiscontinuation
Emulsion,
Vomiting
Swallowing,
Reaction,
ventiationdificult. I is therefore
weaningfrom mechanical
making
ventilation,
agitation,and resistanceto mechanical
Perinatal
Disorder
Hematolugic/
a tightlevelof sedation
in orderto maintain
Emulsion
be continued
of DIPRIVAN
Injectable
recommended
thatudministration
Disorder,
Coaguation
Lymphatic:
Premature
Atrial
Cardiovacuar
Since
canbe discontinued.
priorto extubationat whichtimethe infusion
until10-15 minutes
the weaning
process
throughout
Leukocytssis
Contractions,
mayoccurwhen
in serumtriglycerides
emulsion,elevations
in an oil-is-water
Emulsionasformulated
DIPRIANInjectable
Phlebitis,
Hives/ltching,
Syncope
Injection
Site:
shouldbemonitored
atriskof hyperiipldemia
forextendedperiodsoftime.Patients
is administered
InjectableEmulsion
DIPRIVAN
Nerous
Redness/Discoloration
Central
shouldbeadusted
if fatis
Injectable
Emulsion
of DIPRIVAN
triglycerides
orserumtudidty.Administration
for increaesis serum
Metabolic/
iypertonialDystoria,
System:
tocompensate
inthe quatityofcoecurrntlyadministeredlipids
fromthebody.Aredaction
cleared
beingloadequately
BUNIncreased,
Hyperkalemia,
Agitation
Nutritional:
Paresthesia
Emulsion
Injectable
1 rt of DIPRIVAN
formulation;
Injectable
Emulsion
anpartofthe DIPRIVAN
of lipidinfused
fortheamount
Creatinine
Hyperipemia
pemalivahon
Digestive:
diarrhea,
asthosewith bums,
to
deficiency
such
whoarepredsposed
approimately
0.1 g of fat(1.1kcal).Inpatients
contains
Increased,
Malgia
Mucculosknletal:
with
DIPRIVIt
Injectable
prolonged
therapy
during
should
be
considered
for
supplemeotal
sepsis,
the
need
and/onmajor
Dehydration,
Decreased
Wenng
Respiratory:
hasbeen usedingramquantities
disodiom
edetate
- including Calcium
oftracemetals
EDTA
ina strongchetetor
Emulsion.
Hyperglycemia,
Lung
Function
thatanmuchas10 mgof elemental cabe lest penday
it possible
Whenusedinthismanner
to treatheavymetaltoxicity.
Skinand
orzincdeficlencyof decreaned levels
Emulsion
therearesoreports
Injectable
Although
withDIPRIVAN
viathismechanism.
Acdosis,
ushing,
Pruritus
Appedages:
a
drug
holiday
withoat
providing
loger
than
5
days
not
be
inused
for
Emulsion
should
Injectable
adverse
events,
DIPRPAN
related
Osmolality
SpecialSenses: Amblyopia
onrare
urine losses.Athighdoses(2-3gramsperday),EDThasbeenreported,
on measured
to safelyreplaceestimated
Increased
GrnenUrine
Cloudy
Unine
Urugenital:
lonction
have
nofshown
any
in paents
withnormal
unimpaired
rend
to6we
rendl
tubules.
Studoes-to-date,
occasions,
tobetosic
Respiraory:
Bronchospasm, Hypoxia
atroleforrendl
dosodiom
edetate.
Inpahiests
withDIPRIVAN
Injectable
Emulsion
certaiig t.Ug5%
ahleration
hrmonat
fuschion
in
Throat,
Burning
then
bemositmred
onatnmate
days
bedreckod
befame
ishtation
ofsedation
and
Unidowe
urinalysle
andurine
sedenent
shouts
imponrment
1%-CaualRelatnship
Incideeceestleoan
Cough,Dyspnea,
withomnal
failure
and/or
hopatic
of DIPRFAN
Ijectable
Emuo topahients
sedation.
Thelong-term
admlehrtcahion
during
Hiccough,
han
nothben
evaluated.
insidhicwncy
Hypervnntilation,
pressure
sr
anpatients
withincreaned
istracranidl
DIPRIVAN
Injectable
Emulsion
is used
Nernnerglel
Aseitesla:
When
ICU
Sedation
Sedation
Hypoventitation,
beavoided
because
of6we
omsuftat
decreases BodyasaWhole. Asthenia,
decreanes
inmean
arterial
pomssure
shouts
impaired
corebodl
carcutation,
uigreticast
Awareness,
Fever,
Sepsis,
Laryngospasro,
Hypooia,
pressure,
aniofusion
orsiow
and
decreases
an
cerebodl
perfusion
premeure.
Toavoid
uigodicairt
hypoeensioe
in cerebral
perfusion
Trunk
Pan,
ChestPain,
Snoozing,
Pharyngitis,
frequent,
and/or
tarpon
bolases
of
shouts
beuliandisstead
ofrapid,roam
ofapprooimately
2itmgevnryig seconds
bolos
Extremitles
Pain,
Whole
Body
Upper
Tachypnna,
dosage
willgenerally
mshlin reduced
inauto
Slower
induction
titrated
toclisical
maspoeses
DIPRtrAN
Injectable
Emulsion.
Fever,
Weakness
AirwayObstruction
the
andhypocathia
shouts
accompany
increused
ICPhrsuspected,
hyperenbiation
requirements
(1 to 2 mgkg).When
Increased
Drug
Effect,
Skinand
(See
DOSAGE
AND
ADMINISTRATION.)
ofDIPRIVAN
Inectable
Emulsion.
admioistrahion
NeckRigidity/Stiffness,
Rush
Conunctival
Appendages:
gesuatric
pahients,
pahients
with
shoots
beutiloed
anpremedicated
pahierts,
Slower
rates
ofadminstation
Can Ameslteel:
TrunkPain
Hyperemia,
beconoected
priortoadminstrahion
of
unstable.
Anyffuid
deticits
shouts
Void
sthat,
orpahiests
who
arehemodynarocally
recant
Arrhythmia,
Atrial
Cardiovacuar Arhythmia,
Daphoresis,
Urticaria
othermessuoms,
ng,
ffuldfoerapy
maybecoetmaiodicated,
Inthmse
paherts
where
addithooal
DIPRIVAN
lsjectable
Emulsion.
Fibrilahtion,
Adial
SpecialSenses: Diplopia,EarPain,
6we
hypatenoior
which
isansociated
with6we
of premser
agents,
may
beuseful
to offoet
elevation
oflower
eotremeties,
ormae
AtrioventricularHeart
EyePain,Nytagmus,
withDIPRIVAN
Intale Emulsion.
induction
ofasesthesia
Block.Bgeminy,
Bgeminy,
Taste
Perversion,
reetl aletes, such
usoperaig
thatperformance
ofactivities
requiring
leraPees:
Patients
shouts
beadvhred
leemnose
CardiacAnst
Bundle
Bleeding,
Tinnitus
furrome
timeafton
geneodl
anesthesia
orsigning
legal
documents,
maybeimparred
motorvehicle
orhacardoos
machionry
Branch
Block,
Extrasystole, Urogenital:
KidneyFailure
Urine
Olagunia,
oronedaion.
Right
Arrest,
Cardiac
Retention
in pahients
with
ljectatile
Emubsion
maybereduced
doserequiaements
of DIPRIVAN
Drg bieretleem:
Theinduction
ECG
Abnormal,
HeartFailure,
leg,
-UDICATIUSA
ADUSAGE
is
as
in
in
n
n
ion
in
components,
is
beadiebdalered
-of -
letme
is
in
is
tneete
critally
is
nariorascalar
minimize
publications
in
Aduk:
significance
clinical
THE
eady
induction
is
local
minimized
Hyoeso'
injection
Decreased
SHypertension
%
(seealsoCLINICAL
rarely,
(>5
Hallucinations,
clinical
Anesthesia/MAC
isindicated
zinc zinc. zinc
is
zinc
zinc
zinc
AnesthesialMAC
Fibrilation,
ronpedidine,
andfnntaoyl,
etc.)and
partiuladyl
withnarcotics
lng,murphine,
intramuocuter
onintravenous
paemedication,
agents
may
chleral
hydrate,
dropenidol,
etc.)These
)ng,bensodiazepenes,
badiurates,
ceestileaboes
ofopleids
andsedatives
decreanes
an
andmay
ahso
resuht
inmore
pronounced
ofDIPRIVAN
Islectable
Emulsion
6we
anesthetic
orsedative
effects
incremse
or sedation,
the rateof
of anesthesia
Duringmainenance
pressures
andcardiacoutput
systolic,diastolic,andmeanarterial
andmay
tothe desiredlevelof aesthesiaorsedation
according
should
beadjusted
administration
Emulsion
Injectable
DIPRIVAN
of potent
administration
(eg,nitrousoide oropioids).Theconcurrent
agents
analgesic
of supplemental
inthe presence
bereduced
hasnot been
Injectable
Emulsion
withDIPRIVAN
duringmaintenance
enflurane,andhalethane)
)ng,leoffurane,
agents
inhalational
andcardiorespiratory
or sedative
the anesthetic
toincrease
canalsobe expected
agents
evaluated.
Theseishatational
edeesively
RevD06/96
Manufactured
for
Zeneca
Pharmaceuticals
UnitofZeneca
Inc.
A Business
DE19850-5437
Wilmington,