THROMBOPHLEBITIS FOLLOWING INTRAVENOUS ANESTHESIA AND SEDATION: AN ANNOTATED LITERATURE REVIEW Stephen S. Gelfman, D.D.S.* Edward J. Driscoll, D.D.S.** Survey data suggest some seven million intravenous general and sedation anesthetics are administered each year in this country by oral surgeons alone. An increasing number of other dental practititoners have been using intravenous sedation since the introduction of diazepam, an anxiolytic agent. Although rational administration of diazepam and other ultra-short acting agents appears to be safe, predictable, and widely accepted by both the dentist and patient, venous insult manifests itself in a significant number of cases of thrombophlebitis. A review of the recent world literature suggests that venipucture equipment and technique, site of venipuncture, saline flush following drug administration, and strict attention to aseptic technique may decrease the incidence of this painful, annoying, post-operative complication. In recent years, the use of intravenous medications for the purpose of inducing anesthesia and sedation in an outpatient dental setting has grown vastly. Estimates using available data suggest approximately seven million intravenous general and sedation anesthetics are administered in this country annually by oral surgeons alone.1 2 The introduction of intravenous diazepam as an anxiolytic agent for general dental procedures by Davidau (1965 ) 3 and the synthesis of the ultra-short acting barbiturate methohexital, with early clinical use and publications by Hubbell4 and others, have now broadened the applications of intravenous techniques into the armamentarium of the general dental practitioner 'Anesthesiologist, Neurobiology & Anesthesiology "
Branch, National Institute of Dental Research. Chief, Anesthesiology Section, Neurobiology & Anesthesiology Branch, National Institute of Dental Research.
194
as well. Papers by Healy, et al.,5 Foreman,6-8 Gregg,9 Driscoll, et al.,10 among many, have stressed the relative physiological safety and beneficial amnesic properties of these drugs when used in a rational regimen. Other works by Hutchinson, et al.,1' Trieger, et al.,'2 Vickers,'3 and Korttila and Linnoila14 15 have confirmed the clinicians' observations that initial recovery from these agents is rather fast and uneventful. Personal communications'6 by one of the authors (EJD) with a source involving a relatively large number (several hundred) of both oral surgeons and other practitioners using various intravenous medications has revealed, however, that the incidence of thrombophlebitis has now reached significant levels. Accordingly, in an attempt to study the reported incidence of this complication and to assess the problem on a national scale, the literature was reviewed by an appropriate computer search. Special attention was directed to the occurrence of thrombophlebitis following intravenous administration of diazepam as well as other preanesthetic and anesthetic agents. A thorough search of the recent world's literature yielded a rather disappointing pool of information. For the most part, the data on thrombophlebitis are related to indwelling catheters, used for a variety of medical purposes, which remain in place for long periods of time including days and weeks. In dental practice, the intravenous techniques are short and scalp vein needles are usually employed rather than catheters. Also, this specific complication is seen only infrequently and with certain specific drugs, diazepam being one of the most common offenders. Consequently, the incidence and other findings on catheter-associated thrombophlebitis may ANESTHESIA PROGRESS
not be readily extrapolated to out-patient dental utilization. It is interesting that thrombophlebitis, the phenomenon being reported on, is not adequately described in many of the reports, even in those in which data are supplied. This makes data interpretation difficult, since there is a wide range of signs and symptoms associated with the condition. The clinical signs of thrombophlebitis include a raised, tender, hardened, inflammatory response following the course of the affected vein.17 Reports of onset of these signs and symptoms vary from 24-48 hours'8"9 to longer than two weeks.20 Although clinically the inflammatory response may subside in the matter of days, the tenderness may persist for several months.19 Langdon reported a case of thrombophlebitis in a 52-year-old female who received 10 mg of valium via a hand vein before undergoing esophagogastroscopy and suffered with lingering signs of tenderness for over three years.21 The etiology of this potentially debilitating condition is uncertain, and for the most part unknown. Klein22 and Cheney23 have postulated a foreign body response to catheter or drug, or mechanical irrigation of the vessel wall. Banks, et al.24 and Collins, et al.25 suggest bacterial contamination as a prime causative factor. Page, et al.26 and Elfving, et al.27 suggest acidic intravenous fluids predispose to thrombophlebitis. Due to the limited solubility of diazepam, the manufacturer has marked the product for intravenous use in a solution containing propylene glycol, alcohol, benzoate sodium for buffer, and benzyl alcohol for preservative. When this solution is diluted in either saline or human plasma, the yellow-white precipitate, well known to the clinician,28,29,30 is formed. Jamieson reported a series of cases where incomplete dissolution of thiopental in sterile saliene was implicated in thrombophlebitis.19 Both precipitate and particulate matter are capable of eliciting the foreign body response postulated by Klein. In an effort to decrease the incidence of thrombophlebitis associated with particulate chemical irritation, Jusko,28 ChamNOVEMBER-DECEMBER, 1977
biras,18 and Langdon21 suggest a saline flush to immediately follow drug injection. Langdon found 23 of 328 (7%) when a 150-250 mg saline flush was used. This saline flush is controversial and speculative. A study by Grower, et al. has shown that injection of precipitated solutions of up to 1 mg of diazepam per ml of saline will redissolve in plasma.30 Although seemingly in contradiction to the manufacturer's recommendation for intravenous use, the flush recommended by Langdon is widely used by oral surgeons and other clinicians as a prophylactic measure to prevent thrombophlebitis.'6 Mechanical insult and irritation following venipuncture are to some extent inevitable and unavoidable. This insult is often aggravated by intra-operative movement by the patient, a common occurrence when light general anesthesia or sedation techniques are employed. For this reason, every effort should be made to utilize the best equipment available, to secure the indwelling needles, to utilize suitable intravenous sites, and to refine venipuncture techniques to the fullest extent possible. In a study of complications following intravenous catherization, Collins, et al.23 found the vast majority of catheters cultured from patients with thrombophlebitis demonstrated bacterial contamination. Banks found 53 of 118 (46%) positive cultures of which 28 (53%) grew out organisms comparable to those of the skin of the same patients at the catheter site.24 He was able to decrease positive cultures to less than 2%o with skin preparation using an iodine in 70%o alcohol solution. Banks found the incidence of positive catheter cultures was not related to duration of intravenous therapy or severity of phlebitis as had previously been reported by Bently and Lepper.31 The choice of the venipuncture site itself is often implicated in the incidence of thrombophlebitis, an item of importance in dental use since a number of elective sites are usually available. Nordell, et al., in a study of 52 patients, found 5 diagnosed cases of thrombophlebitis (10% ).32 Of 26 hand or wrist venipunctures, he found 3 thrombophlebitises. Fifteen forearm punc195
tures produced the other 2 cases of phelbitis while of the 11 patients undergoing antecubital fossa venipuncture, none were found to have developed thrombophlebitis. Chambrias found a two-fold increase in incidence of thrombophlebitis following hand as opposed to antecubital fossa venipuncture 18 Langdon, who reports by far the largest series of clinical cases using diazepam with data on thrombophlebitis, suggests assiduous attention to the venipuncture site. This is especially significant when the patient's occupation such as surgeons, typists, etc. would make thrombophlebitis especially disabling and categorically advises that small veins be avoided. The reported incidences of thrombophlebitis vary from a low of 2%21 up to 15%.33 One well-controlled Swedish study of over 1000 cases reported venous complications of many types at 31%.20 It would appear from a study of the literature that thrombophlebitis following intravenous drug injection can be significantly reduced if the causes are more thoroughly understood and adequate precautions are taken with respect to known associations, such as proper selection of venipuncture site, slow injections, special precautions when using specific drugs like diazepam, etc. The authors are instituting a broad-based study of the incidence of thrombophlebitis in dental patients undergoing short-term intravenous therapy, utilizing the information cited in this review. Access to a study population of nearly a thousand intravenous cases a year will allow closer observation and study of most of the recognized enigmas. Attention will be directed to all aspects of the patient's physical condition, medical history including the use of birth control pills, and social situation and habits, such as alcohol and tobacco consumption, etc. Technical details like problems in venipuncture, vein size and shape, needle size, catheter utilization, speed of injection, use of intravenous flush, etc. will be evaluated. Also observed along with diazepam will be other clinically popular commonly used drugs in their appropriate doses, concentrations, etc. Pain and discomfort on injection and other clinical symptomatology will be studied in relationship to this annoying 196
and potentially serious complication. All of the patient-related medical, technical, pharmaceutical, and other data will be computerized so that the most interesting and informative correlations can be derived. REFERENCES 1. ASOS anesthesia morbidity and mortality survey J Oral Surg 32:733 1974. 2. Lytle J J Anesthesia morbidity and mortality survey of the Southern California Society of Oral Surgeons J Oral Surg 32:739 1974. 3. Daviau A A Premedication for difficult patients or prolonged treatment Rev Stomat 67:589 1965. 4. Hubell A 0 Methohexital sodium anesthesia for oral surgery J Oral Surg 18:295 1960. 5. Healy T E J Robinson J S and Vickers M 0 Physiological responses to intravenous diazepam as a sedative for conservative dentistry Brit Med J 3:10 1970. 6. Foreman P A Intravenous diazepam in general dental practice N Z Dent J 65:243 1969. 7. Intravenous sedation: a technique for the routine dental treatment of the apprehensive ambulant patient Anesth Prog 15:218 1966. 8Control of the anxiety/pain complex in dentistry J Oral Surg 37:337 1974. 9. Gregg J M Ryan D E and Lewis K H The amnesic actions of diazepam J Oral Surg 32:651 1974. 10. Driscoll E J Smilack Z H Lightbody P M and Fiorucci R D Sedation with intravenous diazepam J Oral Surg 30:322 1972. 11. Hutchinson B R and McNeill T D M Recovery from methohexitone anesthesia N Z Med J 62:428 1963. 12. Trieger N et al. A comparative study of psychomotor effects of intravenous agents used in dentistry 0 Surg 0 Med and 0 Path 30:34 1970. 13. Vickers M D The measurement of recovery from anaesthesia Brit J Anaesth 37:296 1965. 14. Korttila K and Linnoila M Recovery after intravenous sedation A comparison of clinical and paper and pencil tests used in assessing late effects of diazepam Anaesth 31(6):724 1976. 15.Recovery and skills related to driving after intravenous sedation: doseresponse relationship with diazepam Brit J Anaesth 47(4):457 1975. 16. ADSA Committee on Fellowship in general anesthesia Dr M Jaffe-Chairman: Exams '74-'77. 17. Beeson P B and McDermott W (ed) CecilLoeb Textbook of Medicine ed 14 Philadelphia W B Saunders Co 1975. --
ANESTHESIA PROGRESS
18. Chambiras P G Sedation in dentistry: intravenous diazepam Aust Dent J 17(1): 17023 1972. 19. Jamieson D Desjardins C and Caron J Thrombophlebitis following thiopentone injection Can Anaesth Soc J 19(6):659-661 1972. 20. Hastabacka J Tammisto T Elving G and Tiitinen P Infusion thrombophlebitis Acta Anaesth Scan 10:9 1965. 21. Langdon D E Thrombophlebitis following diazepam JAMA 225:1389 1973. 22. Klein R L and Falor W H Central venous thrombosis: A complication of catherization and hyperalimentation Am Surg 39(3):162163 1973. 23. Cheney F W Lincoln J R Phlebitis from plastic intravenous catherers Anaesth 25:650 1964. 24. Banks D C Cawdrey H M Yates D B Harries M G and Kidner P H Infections from intravenous catheters Lancet 1:443 1970. 25. Collins R N Brown P A Zinner S H and Kass E H Risk of local and systemic infection with polythylene intravenous catheters N E J 'Med 279:340 1968. 26. Page B H Raine G Jones P F Thrombophlebitis following intravenous infusions Lancet 2: 970 1954.
27. Elving G Saikku K Effects of pH on the incidence of infusion thrombophlebitis Lancet 1:953 1966. 28. Jusko W J Gretch M and Gassett R Precipitation of diazepam from intravenous preparations JAMA 225(2):176 1973. 29. Friedenberg W and Barker J D Jr. Intravenous diazepam administration JAMA 224(6):901 1973. 30. Grower M F Ayer W A and Getter L Solubility of injectable valium in plasma and saline Anesth Prog 23(2) :45 1976. 31. Bently D W and Lepper M H Septicemia related to indwelling venous catheters JAMA 206:1749 1968. 32. Nordell K Mogensen L Nyquist 0 and Orinius E Thrombophlebitis following intravenous lignocaine infusion Acta Med Scand 192(4): 263 1972. 33. Baker A B Induction of anesthesia with diazepam Anaesth 24:388 1969.
Send reprints requests to: Dr. Stephen S. Gelfman, National Institute of Dental Research, Building 10, Room 2B05, Bethesda, Md. 20014.
ACE STERILE ANESTHESIA EXTENSION TUBES
ACE extension tubes are available in 20" and 30" tubing lengths wih/without medication sies at needle end for introducing additional or emergency medication when needed. ACE extension tubes are fabricated from high quality medical grade tubing. The tubing is odorless, non-toxic and maintains exceptional ciarity. Individually packaged In a sterile, convenient space-saving see-through pouch. A-20-20" length
approx. 2.5cc capacity
Price ea./Quantity
174/5,000 pcs. 18s/1,000 pcs. 204/less than 1,000 pcs. A-20-M -20" lengt Price ea./Quantity 294/1,000 pcs. 314/less than 1,000 pcs.
A-30 -30" length approx. 3.0cc capacity
Price ea./Quantity 174/5,000 pcs. 18h/1,000 pcs. 204/less than 1,000 pcs. A-30-M -30" lengh Price ea./Quantity 304/1,000 pcs. 324/less than 1,000 pcs.
20'TUE--
- -[
____ A-20M
20TUBE A-3M
Ei-
30TUBE=
VALIUM VALIUM VALIUM Valium 5mg/mi, 2mlampul . per box of 10.....$ 8.35 Valium 5mg/mmlOmlI m.vial...... pervial.....$ 3.95 Valium 5mg/mi, IOmi viol . . per box otl O. $ 38.00 Valium 5mg/mi, 2mi teblejct dkposable syringe
......................... per box of 10.
HALOTHANE ALL PRICES SHOWN INCLUDE SHIPPING Send for our latest catalogl Complete Surgical and Anesthesia needs.
10.75
HALOTHANE
HALOTHANE Halothane .... 250mlbottle, each bottle.$ 17.20
case of12 bats, each battle.$16.20
Please enclose check with order.
For Service and Dependability!
ACE Surgical Supply Company, Inc. 1034 Pearl Street, Brockton, MA 02401 * (617) 588-3100 NOVEMBER-DECEMBER, 1977
197
Branch, National Institute of Dental Research. Chief, Anesthesiology Section, Neurobiology & Anesthesiology Branch, National Institute of Dental Research.
194
as well. Papers by Healy, et al.,5 Foreman,6-8 Gregg,9 Driscoll, et al.,10 among many, have stressed the relative physiological safety and beneficial amnesic properties of these drugs when used in a rational regimen. Other works by Hutchinson, et al.,1' Trieger, et al.,'2 Vickers,'3 and Korttila and Linnoila14 15 have confirmed the clinicians' observations that initial recovery from these agents is rather fast and uneventful. Personal communications'6 by one of the authors (EJD) with a source involving a relatively large number (several hundred) of both oral surgeons and other practitioners using various intravenous medications has revealed, however, that the incidence of thrombophlebitis has now reached significant levels. Accordingly, in an attempt to study the reported incidence of this complication and to assess the problem on a national scale, the literature was reviewed by an appropriate computer search. Special attention was directed to the occurrence of thrombophlebitis following intravenous administration of diazepam as well as other preanesthetic and anesthetic agents. A thorough search of the recent world's literature yielded a rather disappointing pool of information. For the most part, the data on thrombophlebitis are related to indwelling catheters, used for a variety of medical purposes, which remain in place for long periods of time including days and weeks. In dental practice, the intravenous techniques are short and scalp vein needles are usually employed rather than catheters. Also, this specific complication is seen only infrequently and with certain specific drugs, diazepam being one of the most common offenders. Consequently, the incidence and other findings on catheter-associated thrombophlebitis may ANESTHESIA PROGRESS
not be readily extrapolated to out-patient dental utilization. It is interesting that thrombophlebitis, the phenomenon being reported on, is not adequately described in many of the reports, even in those in which data are supplied. This makes data interpretation difficult, since there is a wide range of signs and symptoms associated with the condition. The clinical signs of thrombophlebitis include a raised, tender, hardened, inflammatory response following the course of the affected vein.17 Reports of onset of these signs and symptoms vary from 24-48 hours'8"9 to longer than two weeks.20 Although clinically the inflammatory response may subside in the matter of days, the tenderness may persist for several months.19 Langdon reported a case of thrombophlebitis in a 52-year-old female who received 10 mg of valium via a hand vein before undergoing esophagogastroscopy and suffered with lingering signs of tenderness for over three years.21 The etiology of this potentially debilitating condition is uncertain, and for the most part unknown. Klein22 and Cheney23 have postulated a foreign body response to catheter or drug, or mechanical irrigation of the vessel wall. Banks, et al.24 and Collins, et al.25 suggest bacterial contamination as a prime causative factor. Page, et al.26 and Elfving, et al.27 suggest acidic intravenous fluids predispose to thrombophlebitis. Due to the limited solubility of diazepam, the manufacturer has marked the product for intravenous use in a solution containing propylene glycol, alcohol, benzoate sodium for buffer, and benzyl alcohol for preservative. When this solution is diluted in either saline or human plasma, the yellow-white precipitate, well known to the clinician,28,29,30 is formed. Jamieson reported a series of cases where incomplete dissolution of thiopental in sterile saliene was implicated in thrombophlebitis.19 Both precipitate and particulate matter are capable of eliciting the foreign body response postulated by Klein. In an effort to decrease the incidence of thrombophlebitis associated with particulate chemical irritation, Jusko,28 ChamNOVEMBER-DECEMBER, 1977
biras,18 and Langdon21 suggest a saline flush to immediately follow drug injection. Langdon found 23 of 328 (7%) when a 150-250 mg saline flush was used. This saline flush is controversial and speculative. A study by Grower, et al. has shown that injection of precipitated solutions of up to 1 mg of diazepam per ml of saline will redissolve in plasma.30 Although seemingly in contradiction to the manufacturer's recommendation for intravenous use, the flush recommended by Langdon is widely used by oral surgeons and other clinicians as a prophylactic measure to prevent thrombophlebitis.'6 Mechanical insult and irritation following venipuncture are to some extent inevitable and unavoidable. This insult is often aggravated by intra-operative movement by the patient, a common occurrence when light general anesthesia or sedation techniques are employed. For this reason, every effort should be made to utilize the best equipment available, to secure the indwelling needles, to utilize suitable intravenous sites, and to refine venipuncture techniques to the fullest extent possible. In a study of complications following intravenous catherization, Collins, et al.23 found the vast majority of catheters cultured from patients with thrombophlebitis demonstrated bacterial contamination. Banks found 53 of 118 (46%) positive cultures of which 28 (53%) grew out organisms comparable to those of the skin of the same patients at the catheter site.24 He was able to decrease positive cultures to less than 2%o with skin preparation using an iodine in 70%o alcohol solution. Banks found the incidence of positive catheter cultures was not related to duration of intravenous therapy or severity of phlebitis as had previously been reported by Bently and Lepper.31 The choice of the venipuncture site itself is often implicated in the incidence of thrombophlebitis, an item of importance in dental use since a number of elective sites are usually available. Nordell, et al., in a study of 52 patients, found 5 diagnosed cases of thrombophlebitis (10% ).32 Of 26 hand or wrist venipunctures, he found 3 thrombophlebitises. Fifteen forearm punc195
tures produced the other 2 cases of phelbitis while of the 11 patients undergoing antecubital fossa venipuncture, none were found to have developed thrombophlebitis. Chambrias found a two-fold increase in incidence of thrombophlebitis following hand as opposed to antecubital fossa venipuncture 18 Langdon, who reports by far the largest series of clinical cases using diazepam with data on thrombophlebitis, suggests assiduous attention to the venipuncture site. This is especially significant when the patient's occupation such as surgeons, typists, etc. would make thrombophlebitis especially disabling and categorically advises that small veins be avoided. The reported incidences of thrombophlebitis vary from a low of 2%21 up to 15%.33 One well-controlled Swedish study of over 1000 cases reported venous complications of many types at 31%.20 It would appear from a study of the literature that thrombophlebitis following intravenous drug injection can be significantly reduced if the causes are more thoroughly understood and adequate precautions are taken with respect to known associations, such as proper selection of venipuncture site, slow injections, special precautions when using specific drugs like diazepam, etc. The authors are instituting a broad-based study of the incidence of thrombophlebitis in dental patients undergoing short-term intravenous therapy, utilizing the information cited in this review. Access to a study population of nearly a thousand intravenous cases a year will allow closer observation and study of most of the recognized enigmas. Attention will be directed to all aspects of the patient's physical condition, medical history including the use of birth control pills, and social situation and habits, such as alcohol and tobacco consumption, etc. Technical details like problems in venipuncture, vein size and shape, needle size, catheter utilization, speed of injection, use of intravenous flush, etc. will be evaluated. Also observed along with diazepam will be other clinically popular commonly used drugs in their appropriate doses, concentrations, etc. Pain and discomfort on injection and other clinical symptomatology will be studied in relationship to this annoying 196
and potentially serious complication. All of the patient-related medical, technical, pharmaceutical, and other data will be computerized so that the most interesting and informative correlations can be derived. REFERENCES 1. ASOS anesthesia morbidity and mortality survey J Oral Surg 32:733 1974. 2. Lytle J J Anesthesia morbidity and mortality survey of the Southern California Society of Oral Surgeons J Oral Surg 32:739 1974. 3. Daviau A A Premedication for difficult patients or prolonged treatment Rev Stomat 67:589 1965. 4. Hubell A 0 Methohexital sodium anesthesia for oral surgery J Oral Surg 18:295 1960. 5. Healy T E J Robinson J S and Vickers M 0 Physiological responses to intravenous diazepam as a sedative for conservative dentistry Brit Med J 3:10 1970. 6. Foreman P A Intravenous diazepam in general dental practice N Z Dent J 65:243 1969. 7. Intravenous sedation: a technique for the routine dental treatment of the apprehensive ambulant patient Anesth Prog 15:218 1966. 8Control of the anxiety/pain complex in dentistry J Oral Surg 37:337 1974. 9. Gregg J M Ryan D E and Lewis K H The amnesic actions of diazepam J Oral Surg 32:651 1974. 10. Driscoll E J Smilack Z H Lightbody P M and Fiorucci R D Sedation with intravenous diazepam J Oral Surg 30:322 1972. 11. Hutchinson B R and McNeill T D M Recovery from methohexitone anesthesia N Z Med J 62:428 1963. 12. Trieger N et al. A comparative study of psychomotor effects of intravenous agents used in dentistry 0 Surg 0 Med and 0 Path 30:34 1970. 13. Vickers M D The measurement of recovery from anaesthesia Brit J Anaesth 37:296 1965. 14. Korttila K and Linnoila M Recovery after intravenous sedation A comparison of clinical and paper and pencil tests used in assessing late effects of diazepam Anaesth 31(6):724 1976. 15.Recovery and skills related to driving after intravenous sedation: doseresponse relationship with diazepam Brit J Anaesth 47(4):457 1975. 16. ADSA Committee on Fellowship in general anesthesia Dr M Jaffe-Chairman: Exams '74-'77. 17. Beeson P B and McDermott W (ed) CecilLoeb Textbook of Medicine ed 14 Philadelphia W B Saunders Co 1975. --
ANESTHESIA PROGRESS
18. Chambiras P G Sedation in dentistry: intravenous diazepam Aust Dent J 17(1): 17023 1972. 19. Jamieson D Desjardins C and Caron J Thrombophlebitis following thiopentone injection Can Anaesth Soc J 19(6):659-661 1972. 20. Hastabacka J Tammisto T Elving G and Tiitinen P Infusion thrombophlebitis Acta Anaesth Scan 10:9 1965. 21. Langdon D E Thrombophlebitis following diazepam JAMA 225:1389 1973. 22. Klein R L and Falor W H Central venous thrombosis: A complication of catherization and hyperalimentation Am Surg 39(3):162163 1973. 23. Cheney F W Lincoln J R Phlebitis from plastic intravenous catherers Anaesth 25:650 1964. 24. Banks D C Cawdrey H M Yates D B Harries M G and Kidner P H Infections from intravenous catheters Lancet 1:443 1970. 25. Collins R N Brown P A Zinner S H and Kass E H Risk of local and systemic infection with polythylene intravenous catheters N E J 'Med 279:340 1968. 26. Page B H Raine G Jones P F Thrombophlebitis following intravenous infusions Lancet 2: 970 1954.
27. Elving G Saikku K Effects of pH on the incidence of infusion thrombophlebitis Lancet 1:953 1966. 28. Jusko W J Gretch M and Gassett R Precipitation of diazepam from intravenous preparations JAMA 225(2):176 1973. 29. Friedenberg W and Barker J D Jr. Intravenous diazepam administration JAMA 224(6):901 1973. 30. Grower M F Ayer W A and Getter L Solubility of injectable valium in plasma and saline Anesth Prog 23(2) :45 1976. 31. Bently D W and Lepper M H Septicemia related to indwelling venous catheters JAMA 206:1749 1968. 32. Nordell K Mogensen L Nyquist 0 and Orinius E Thrombophlebitis following intravenous lignocaine infusion Acta Med Scand 192(4): 263 1972. 33. Baker A B Induction of anesthesia with diazepam Anaesth 24:388 1969.
Send reprints requests to: Dr. Stephen S. Gelfman, National Institute of Dental Research, Building 10, Room 2B05, Bethesda, Md. 20014.
ACE STERILE ANESTHESIA EXTENSION TUBES
ACE extension tubes are available in 20" and 30" tubing lengths wih/without medication sies at needle end for introducing additional or emergency medication when needed. ACE extension tubes are fabricated from high quality medical grade tubing. The tubing is odorless, non-toxic and maintains exceptional ciarity. Individually packaged In a sterile, convenient space-saving see-through pouch. A-20-20" length
approx. 2.5cc capacity
Price ea./Quantity
174/5,000 pcs. 18s/1,000 pcs. 204/less than 1,000 pcs. A-20-M -20" lengt Price ea./Quantity 294/1,000 pcs. 314/less than 1,000 pcs.
A-30 -30" length approx. 3.0cc capacity
Price ea./Quantity 174/5,000 pcs. 18h/1,000 pcs. 204/less than 1,000 pcs. A-30-M -30" lengh Price ea./Quantity 304/1,000 pcs. 324/less than 1,000 pcs.
20'TUE--
- -[
____ A-20M
20TUBE A-3M
Ei-
30TUBE=
VALIUM VALIUM VALIUM Valium 5mg/mi, 2mlampul . per box of 10.....$ 8.35 Valium 5mg/mmlOmlI m.vial...... pervial.....$ 3.95 Valium 5mg/mi, IOmi viol . . per box otl O. $ 38.00 Valium 5mg/mi, 2mi teblejct dkposable syringe
......................... per box of 10.
HALOTHANE ALL PRICES SHOWN INCLUDE SHIPPING Send for our latest catalogl Complete Surgical and Anesthesia needs.
10.75
HALOTHANE
HALOTHANE Halothane .... 250mlbottle, each bottle.$ 17.20
case of12 bats, each battle.$16.20
Please enclose check with order.
For Service and Dependability!
ACE Surgical Supply Company, Inc. 1034 Pearl Street, Brockton, MA 02401 * (617) 588-3100 NOVEMBER-DECEMBER, 1977
197
