Operative tips 295

solution available in 1- and 5-ml. vials and a 1-ml. disposable syringe.

Dexamethasone phosphate sodium is approximately 3,000 times more soluble in water of 25° C. than is hydrocortisone. This solubility gives it several advantages. It is so rapidly absorbed that response is evident almost as quickly after an intramuscular as after an intravenous injection. A small amount is an adequate dose, and small bore needles can be used for all injections, making it more comfortable for the patient. Dexamethasone phosphate sodium does not leave a residue of crystals at the injection site.

The presence of tuberculosis, whether active, healed, or questionably healed, is an absolute contraindication to steroid therapy. Ocular herpes simplex and other conditions—including chickenpox, vaccinia, pregnancy, diabetes mellitus, hypertension, peptic ulcer, osteoporosis, fresh intestinal anastomoses, diverticulitis, thrombophlebitis, psychotic tendencies, and renal insufficiency—are also contra-indications.

Dexamethasone phosphate sodium

Sig: First day: Inject 1 or 2 ml. intramuscularly, according to patient's body weight. Second day: Take four tablets, 0.75 mg., in two divided doses. If swelling is still evident the tablets can be continued for a third day in the same manner.

Mild premedications. Mild premedications do not cause any circulatory or breathing depression, muscular atony, or bewilderment, as some barbiturates do in heavy doses. They should not produce any side disorders or any hematizing effect.

To be ideal the mild premedication must have a triple effect. First, a slight hypnotic effect—which can be obtained with such barbiturates as pentobarbital, 50 mg.—is desirable. Second, a slight vagolytic effect, which is accomplished most safely and quietly by tincture of belladonna, inhibits the action of the parasympathetic nervous system and also de-creases secretion. Third, a long-term analgesic effect is advocated. This effect may be achieved by numerous drugs. Chercheve advocates one troche of belladonna the night before, one in the morning upon awakening, and one an hour before the intervention. The hour before implant insertion he also recommends pentobarbital.

Other good mild premedications include:

Elixir of the three bromides (60 ml.)

Sig: Take three tablespoons the day before

and two tablespoons the day of the visit to the dentist.

Pentobarbital sodium capsules (50 mg.)

Tablets: Dispense six.

Sig: Take one capsule 1 hour before dental appointment.

Pentobarbital sodium can also be used as a pre-medication for general anesthesia and should then be given 1 hour before the operative procedure. Patients receiving barbiturates should always have someone accompany them to and from the office.

Phenobarbital (%t to   gr.)

Tablets: Dispense twelve.

Sig: Take one four times a day. Chlordiazepoxide (10 mg.)

Capsules: Dispense twelve. Sig: Take one four times a day.

Strong premedications. Although the weaker premedications are usually more than adequate for all types of implant interventions, occasionally a strong premedication may be prescribed. The opera-tor must realize that many side effects can appear unexpectedly in a healthy patient when administering a strong medication. For this reason, the patient should be controlled under safe conditions, such as are afforded in a hospital.

A few precautionary notes are in order. Hypnotics, such as strong barbiturates, are eliminated from the body very slowly, sometimes taking from 3 to 4 days. These drugs may also cause cardiac depressive effects. Strong vagolytics can be useful but can create atropinic delirium if misused.

Scopolamine can cause delirium, excitation, and inhibition of the breathing centers in some cases. As for strong analgesics, such as morphine and other opium derivatives, they sometimes produce undesirable side effects, such as respiratory and circulatory depressive disorders. Barbiturates are also capable of causing excitement in elderly patients.

If the patient has a hepatic or renal disorder, a strong premedication is always contraindicated. These patients will be unable to detoxify the drug and excrete it properly.

Strong premedications include pentazocine and promethazine.

Pentazocine (50 mg.)

Tablets: Dispense twelve.

Sig: Take one four times a day.

Promethazine (25 mg.)

Sig: Take one tablet 1 hour before and another during the intervention itself.