Comprehensive mental health care in a pediatric dialysis-transplantation program* JJ. VanLeeuwen, md, FRCPfc]; D.E. Matthews,
Summary: The dialysis-transplantation (D-T) program at The Hospital for Sick Children, Toronto has a mental health component directed by a psychiatrist and a social worker. As of Jan. 1, 1975, 53 kidney transplants
had been carried out on 44 children. Patients and their families are counselled continuously by the psychiatrist and the social worker before, during and after transplantation. Members of the multidisciplinary team meet
regularly
to
plan
treatment
for the children. Mental health issues are an integral part of team discussions and help determine D-T
policy. Psychological preparation, mental health consultation, therapeutic intervention and continuous program
counselling prevent many of the mental health problems that plague a D-T program. Resume: Soins mentaux complets dans un programme pediatrique de dialyse et de transplantation Au Hospital for Sick Children de Toronto on a cree un centre de soins mentaux un
dirige
par
un
psychiatre
et
travailleur social dans le cadre du
programme dialyse-transplantation (D-T). Au 1er janvier 1975 on avait pratique 53 transplantations renales chez 44 enfants. Les patients et leurs parents recoivent des conseils continuels du psychiatre et du travailleur social avant, pendant et apres la transplantation. Les membres de l'equipe
multidisciplinaire
se rencontrent
regulierement pour planifier le
traitement de ces enfants. Leurs discussions comportent toujours I'aspect des soins mentaux, ce qui les aide a formuler un systeme pour le programme de D-T. Grace a une bonne preparation psychologique, a des consultations psychiatriques, a des moyens therapeutiques et a des conseils permanents, on est parvenu a prevenir une grande partie des problemes mentaux qui sont le fleau de tout programme D-T. From the departments of psychiatry and social
work, The Hospital for Sick Children, Toronto ?This paper was prepared for the Sept. 20, 1975 issue of the Journal commemorating the centennial of The Hospital for Sick Children, Toronto, but because of space limitations could not be included.
Reprint requests to: Dr. J.J. VanLeeuwen, Department of psychiatry, The Hospital for Sick Children, 555 University Ave., Toronto, ON M5G 1X8
msw
Hospital for Sick Children transplantation is the ultimate goal for every child accepted into the dialysistransplantation (D-T) program. Criteria for patient selection are comparable to those applied in other centres.1 Contraindications include coexistence of an¬ other fatal condition,2 severe mental retardation and untreatable psychosis. Pre-existing psychosocial difficulties, re¬ gardless of their complexity, are not At The
considered contraindications. Children under 5 years of age
are
routinely accepted, although we have given kidney transplants to two young children, one aged 18 months and one 2 years. This policy is cur¬ rently under review because of the favourable growth3 and survival data being reported. As of Jan. 1, 1975, 53 kidney trans¬ plants had been done in 44 children. Seven children have had two trans¬ plants and one child has had three. Four children receiving transplants sub¬ sequently died and two others died while undergoing dialysis. not
The mental health program The psychosocial aspects of dialysis and transplantation in children, such as the physical, psychological and social stresses on the patient and his family, and the pressures and frustrations ex¬ perienced both collectively and indi¬ vidually by the D-T physicians, nurses and paramedical staff, are well docu¬ mented.4"10 However, there is insuffi¬ cient documentation on how mental health programs ameliorate psycho¬ social difficulties. Mental health plan¬ ning should be an essential part of the medical treatment from the time dial¬ ysis is first proposed to the family until the child is rehabilitated following a successful kidney transplant. The pro¬ gram at The Hospital for Sick Children has been developed by the authors, a psychiatrist and a social worker, who have been working with the D-T team for over 5 years. We follow all patients closely and the current program is the synthesis of our experience. Specifi¬ cally, our responsibilities are to main¬ tain the mental health of the child and his family, to consult with the D-T team and to participate in the formulation of D-T program policy. Our philo¬ sophy is preventive and we attempt to
keep the mental health perspective in balance with the medical, surgical and nursing aspects.
Preparation for dialysis-transplantation In an effective mental health pro¬ gram the preventive role that careful preparation for dialysis and transplan¬ tation can play in avoiding unnecessary psychological and social stress must be
recognized. Our preparation program11 results in a comprehensive psychosocial assess¬ ment of patient and family, including a social, psychiatric and psychometric evaluation. If there are several months to prepare a child and his family for dialysis, the child usually adapts well to treatment. Half our patients are re¬ ferred early enough for such prepara¬ tion; the other half are admitted with acute renal failure and require dialysis almost immediately. Depression and behavioural disturbances are more pro¬ nounced in the latter patients during the first months of dialysis. When unprepared patients receive a transplant before adjustment to their illness or dialysis, behavioural disturbances often appear after transplantation. This im¬ pression is reinforced by the difficul¬ ties reported by Bernstein.12 The social worker is involved with the family from the beginning. If the child's need for dialysis develops slow¬ ly, regular counselling during clinic appointments prepares child and family gradually. If the onset of the child's illness is sudden and he is admitted needing dialysis, preparation counsel¬ ling is concentrated. Emotional responses to the diagnosis are unpredictable and individuals vary in their capacity to cope with the shock, grief, guilt and anger.13 Recogni¬ tion of a family's way of coping with stress and remedial counselling is the focus of the preparation. We insist that both parents participate in initial med¬ ical and psychological interviews to avoid the tendency for fathers to be left out of critical discussions. The value of early preventive coun¬ selling is demonstrated in the following
report. 12-year-old Italian girl became to¬ tally silent and withdrawn after sudden hospitalization with acute renal failure. Her parents were excessively mournful in attitude and rarely spoke to her or the CMA JOURNAL/NOVEMBER 22, 1975/VOL. 113 959 case
A
staff as they sat by her bedside. It required a week of daily therapy with the child to alleviate her fear that she was dying. Fear of death had been reinforced by her par¬ ents' display of grief. Counselling of the parents helped them realize the effect they were having on their child. Together they shared their grief with us and felt sup¬ ported by each other and the hospital staff. This enabled them to follow our suggestions for a more helpful interaction with their child.
The psychological assessment can be predictive of a patient's intellectual and social potential. We have used it as a guideline for appropriate dietetic and medical teaching as well as for school collaboration. The composite mental
A home visit is usually made by the social worker and the dietitian. The visit often produces new and critical information. For example, one patient's mother appeared confused, anxious and lost while visiting her child in hospital. However, when the social worker and dietitian visited the mother at her farmhouse she was found to be competent and able to care for her child. The social worker usually visits the patient's school to explain the illness and to encourage long-term planning. Since only daytime dialysis is per¬ formed, our children are apt to miss 50% of their schooling. Because of this initial personal contact with schools and the later regular school contact by our D-T teacher, we have usually suc¬ ceeded in having the patient's curri¬ culum individualized. Some schools will supplement school attendance with home tutoring. Unless a child is too ill to attend school we never encourage home tutoring alone because it tends to cut off contact with friends and normal activities. For some patients we initiate the coordination of other com¬ munity services such as welfare, public health and social services. The psychiatric assessment has both a diagnostic and a therapeutic purpose. For the benefit of staff it is important that the relevant features of a child's intrapsychic nature be understood be¬ cause it is often the basis for a patient's nursing care plan, as in the following instance.
The D-T team is composed of the
health assessment is discussed with the D-T program director and later integrated into the patient care plan. Team
relationships
nephrologist-director, the fellows in nephrology, nurses from the dialysis unit and from a ward to which all D-T patients are admitted, a dialysis tech¬ nician, a dietitian, a psychiatrist, a so¬ cial worker, a recreation therapist, a schoolteacher and a physiotherapist. At a regular weekly conference each member contributes his particular insight to improve the perspective of the whole group. The social worker and the psychiatrist are responsible for familiarizing team members with the psy¬ chological problems as well as focusing attention on the child's long-term de¬ velopmental needs.14 Sometimes med¬ ical teams tend to become diseaseoriented and simplistic in their interpre¬ tation of complex psychological prob¬ lems such as poor dietary control and "uncooperative" behaviour.15 We can¬ not deny that this tendency occurs from time to time but we have observed staff develop greater psychological aware¬ ness and interpersonal skills as a result of regular mental health consultation and by other meetings that might be arranged. In all these meetings we try to help our staff express their feelings appropriately, discuss our patients' psy¬ chological development as an integral part of medical reports and try to make helpful suggestions about the links be¬ tween observed behaviour and under¬ lying feelings. These qualities of psychological awareness and sensitive interpersonal skills of the total D-T team are the key A 10-year-old boy had acute renal fail¬ ingredients in the kind of environment ure. His renal condition had greatly these children need. Medical programs deteriorated within a month, necessitating are easily organized but it takes special immediate peritoneal dialysis. He seemed qualities in the staff to ensure the unusually fearful and wanted someone child's ongoing personality develop¬ with him constantly. His father had died
suddenly 8 months earlier. Psychiatric evaluation indicated that this child had not resolved his grief about his father and this made him extremely anxious about the sudden threat to his own life and the separation from his family. The acute anxiety, compounded by his severe toxic condition, resulted in mildly disorganized thought processes and a tendency to compulsive behaviour. The individualized nursing care plan developed for this child included a nurse of his own, a quiet environment and controlled staff involve¬ ment to provide consistency in care and a sense of security.
ment. While isolated
case histories have been described in the literature1617 re¬ ferring to the individual needs of a
patient, comprehensive D-T program designs are rarely mentioned. The children are likely to be par¬ tially reared in the hospital for months or even years during their D-T treat¬ ment. Another important aspect of our program is carried out by the special education teacher, the recreationist, the physiotherapist, the nurses and the parents. They all play important roles in the structured daily activities of
960 CMA JOURNAL/NOVEMBER 22, 1975/VOL. 113
these children, whether in the dialysis unit or on the nephrology ward. Friendships can, but do not neces¬ sarily, develop among the children.
Age, compatibility and common prob¬ lems are the motivations. In our experi¬ ence these friendships need not be viewed differently than other situations in which children find themselves indiscriminately grouped. However, the common bond of dialysis and trans¬ plantation does create a special sensiti¬ vity among children who have been hospitalized together. This is particu¬ larly noticeable when a child on the program dies. When this occurs we have found it therapeutic to tell other D-T patients almost immediately. This prevents an emotional crisis if they hear about the loss accidentally and provides them with immediate support in their initial fear and grief. We have noted that children under 12 react intensely but briefly; they quickly turn to activity for relief from the emotional pain. The older child openly expresses grief and tends to share his feelings. When two children died in our dial¬ ysis unit the other children undergoing dialysis at the time commented later that they had been helped most by the fact that the staff in the unit who were not involved with the dying child re¬ mained calm and gave them personal support.
Staff also become upset when a child we find it helpful to call a team meeting the following day to clarify the cause of death and allow members to express their feelings. This facilitates the normal process of grief and necessary mutual support among staff who have lost a patient with whom they were expected to form a signifi¬ cant, intimate yet professional relation¬ ship. Death must therefore be acknowledged as an important loss to the staff.
dies, and
Transplantation The
use of living related donors is encouraged at The Hospital for Sick Children. So far only one patient has received a family-donated kidney. We tend to reserve this procedure for a time when further waiting for a cadaveric kidney would greatly endanger the life of the patient. We hesitate to
not
expose the donor to the risk of
ne¬
phrectomy when he or she is the breadwinner or the mother of a young family. The intrapsychic integration of the
transplant is a matter of great concern to some children and of little concern to others. Their attitudes are largely
determined by their ages. Cadaveric donors are preferred at The Hospital for Sick Children and we find children have an initial distaste for the idea.
questions about the They wonder if the kidney comes from an old person and fear such a kidney would not last long. In subtle ways they show guilt and con¬ fusion that they are alive while some¬ one else is dead and that they have benefited from the death. Kidneys are intuitively linked with sexual and re¬ productive functions. The thought of receiving a kidney from a donor of the opposite sex is disturbing. We openly discuss all these issues with the child before transplantation. We find this an effective preventive measure and on the whole we are impressed by the healthy psychological integration of the new organ, both on short- and long-term follow-up. Like Basch18 and Castelnuovo-Tedesco,19 we have seen some of the manifestations of delayed psychic integration of the transplant. Two girls briefly treated their kidneys as though they were babies; this was done with some humour on their part and was realistic, for their new kidneys were readily palp¬ able. Temporarily, several boys nicknamed their new kidneys. They ap¬ peared to regard them as a newly ac¬ quired companion. However, we have not encountered any of the more seri¬ ous complications described by these Children have donors.
authors. Several families have asked to be considered as potential donors for their children. We have responded by offer¬ ing specific individual and family inter¬ views before physical and immunologic screening. Many articles describe the psychological hazards when the donor is a living relative; in particular, parentchild donation magnifies pre-existing relationship conflicts.18"21 Our interviews are geared towards helping a family understand the complexities of the is¬ sue and resolving them long before the need to donate might arise. At the same time we must formulate an opinion as to the donor's psychological suitability.
inherent stresses imposed by the whole facilities for peritoneal dialysis but re¬ Medical and nursing transplant rejection process. They are quested guidance. came to The Hospital for Sick willing to delay another transplant for personnel such psychological reasons. Adolescents Children to learn the technique. The D-T social worker visited the northern hospital in particular appreciate a chance to to coordinate local services. Schooling and return to normal physical appearance a suitable foster home near the hospital if they have become cushingoid, over- were arranged. The social worker then weight or plagued with acne. flew to Simon's home viilage to discuss
Psychosocial difficulties Accounts of two clinical examples of psychosocial difficulties presented by patients in the D-T program and their
families follow.
A psychologically vulnerable family: Clarice, a 15-year-old dependent, overprotected girl, had Deen ill for several years before requiring dialysis. During the 1st year of dialysis she received a kidney but it was later rejected. Following the loss of her transplant, while in isolation, Clarice
had a manic psychotic episode that lasted several days. The psychiatrist treated her and offered specific consultation to the medical and nursing staff regarding her care. In the next 4 years she had two more transplants, which were rejected, and several severe infections, and finally had to return to peritoneal dialysis, of which she had an almost pathologie dread. This family has required extensive ongoing counselling and, at critical times, psycho¬ therapy. As a result of the unusual and prolonged stress, the family at various times has turned to astrology, vented their anger on hospital staff and tried selftreatment with the medications. Clarice's mother was an outgoing, likeable woman whose anxieties were uncontained and easily transmitted to her daughter. Both mother and daughter exhibited a manic type of defence mechanism against de¬ pression. The father was more self-contained but equally anxious. A brother, 3 years younger, had had some emotional and social deprivation as a result of the family's absorption in Clarice's illness. Each member of the family has required supportive therapy. The family were seen together at times of critical decisions, such as whether the second and third trans¬ plants should be performed and when the final decision was made to try home peri¬ toneal dialysis, which meant transfer to another hospital for training and super¬ vision. Despite these many setbacks the family gradually matured. The intense de¬ pendency relationship between mother and daughter, which had offered each of them
with his parents the prolonged treatment necessary and how it would affect them. Her visit relieved and reassured Simon's family, who had not seen him for months and did not understand his medical prob¬ lem. They also harboured a superstitious guilt about producing sick boys. Another boy had died of Alport's syndrome and a third had been given away at birth for fear the family might contaminate him; he was thriving in another community. An audiotape and pictures of Simon under¬ going dialysis, medical drawings and dis¬ cussions helped educate the family, the school staff, Simon's classmates, the local nurse's aid and the Indian Affairs repre¬ sentative. The family appeared to under¬ stand the issues and have kept in touch with the social worker. Simon had a suc¬ cessful transplant 3 months later and has returned to the north. The plan produced many dividends because the personal con¬ tact with the hospital and local resources established a good liaison, so that as mental health problems with Simon arose they could be resolved by telephone conversation.
Psychiatric disturbances Specific psychiatric disturbances are brought to the attention of the psychi¬ atrist most frequently by the social worker, although any team member may do so. The psychiatrist himself often recognizes incipient psychiatric disturbances through comments made at regular team meetings. Depression, the commonest disturb¬ ance, manifests itself in many different
for example, in a straightexpression of depressive feel¬ ings and occasionally a wish to "end it all"; in lack of appetite, apathy and diminishing interest in surroundings; in breakdown of routines such as medical In one family the parents reported to dietary regimen and school attendance; us that all members were willing to donate or in antagonism, aggressiveness or immediately. When we imposed our orderself-punishing behaviour such as refusly decision-making process the situation ing food or medication. changed. One older sibling declined be¬ A host of associated organic fac¬ cause of persistent open feelings of resentment for the patient. Another older secondary gratifications, was gradually re¬ tors,22 such as azotemia, anemia, elec¬ placed by the characteristic adolescent trolyte disturbances, hypertension and sibling considered his professional sports striving for independence. Clarice's mother career in jeopardy were he to have a such as steroids, affect the accepted this maturation almost with re¬ medications nephrectomy. A third member of the fam¬ lief. cerebral function directly. patient's the basic of family dynaily had, in our opinion, insufficient mental mics Recognition and and in behavioural persistence consistency Every abnormality has capacity to understand the nature and con¬ dealing with them were the chief factors to be evaluated in light of these many sequences of donating a kidney. in maintaining family integration. factors. We have treated a total of We have been repeatedly surprised five psychotic episodes over the past 7 A family requiring interhospital liaison at the changes in attitude in a family years. Fortunately they were brief. Two organization: Simon, a episodes when a child has undergone dialysis and community are described below, without American Indian boy, lives in and received a transplant that has a10-year-old northland Indian community 1 hour elaboration on the psychiatric treat¬ tiny failed. Though both child and family by bush plane from the nearest hospital. ment, to illustrate the complex inter¬ once earnestly desired a kidney, they Simon has Alport's syndrome with asso¬ action of the many possible factors now want a period of relief from the ciated deafness. The northern hospital has leading to such psychotic conditions. ways
forward
CMA JOURNAL/NOVEMBER 22, 1975/VOL. 113 961
In a previously well adjusted 16-year-old boy with a high anxiety level and an active fantasy life, delirium developed when he was critically ill with complications following transplant rejection and transplant nephrectomy. For several days he was confused, disoriented, restless, fearful and had lapses of memory. This toxic delirium eventually subsided after surgical drainage of an abdominal abscess. On a different occasion he had two brief episodes of extreme mental anguish and hallucinations. Besides having kidney disease he was now convinced he had become insane. It was disturbing and puzzling to the staff but the psychiatrist was able to diagnose this state as induced by ketamine hydrochloride,23 given for anesthesia at the time of renal biopsy. A 16-year-old girl came to us in terminal renal failure from a foreign country. She was critically ill and required immediate peritoneal dialysis. Culture shock and a complete language barrier made her feel totally lost. She became mildly psychotic for about 10 days. Disorientation seemed minimal but she began to cling to people by using hypochondriacal complaints. She sometimes confused the identity of her relatives. This delusional episode seemed more functional than organic. Such psychotic episodes can be accentuated, perhaps produced or prevented by the general hospital atmosphere as expressed in the psychological awareness of the staff and their skill in relationships, and in the psychological preparation for procedures. Despite efforts to provide care of good quality, it is realistic to expect that the stress of dialysis and transplantation in children will produce psychiatric disturbances, both functional and organic, from time to time.
Patient and family group meetings
for D-T patients is a demanding task, extending far beyond the confines of direct patient care. Whole families must be helped, a large team must be oriented to psychological issues, and mental health concepts must be integrated into overall policy planning. This can only be achieved with a program director who appreciates the importance of the juxtaposition of mental and physical health care. References 1. ABRAM HS: Psychological dilemmas of medical progress. Psychiatr Med 3: 51, 1972 2. ARBUS GS, SNIDERMAN S: Oxalosis with peripheral gangrene. Arch Pathol 97: 107, 1974 3. GRUSHKIN CM, KORSCH B, FINE RN: Hemodialysis in small children. JAMA 221: 869, 1972 4. KNAN
CH,
AHMADIAN
SY:
7. GRUSHKIN CM, KoRscH BM, FINE RN: The
outlook for adolescents with chronic renal failure. Pediatr Clin North Am 20: 953, 1973
8. STEINHAUER
PD,
MUSHIN
DN,
RAE-GRANT
Q: Psychological aspects of chronic illness. Pedjair Clin North Am 21: 825, 1974 9. KAPLAN DE-NOUR A, CZACZKE5 JW, LILos P: A study of chronic hemodialysis teams differences in opinions and expectations. J Chronic Dis 25: 441, 1972 10. KoRscH BM, NEGRETE VF, GARDNER JE, et
11.
12. 13. 14.
The mental health team meets with patients and parents in a number of group situations. Patient groups, such as adolescents, have been formed to discuss how teenage concerns such as dating, physical appearance, independence and vocational choice are affected by D-T treatment. From time to time parents meet in a formal group with the program director and mental health team to update their knowledge and help them come to grips with the stress of dialysis-transplantation. We believe it is important that both parents attend these meetings to encourage the development of mutual support. We come to know the patient's siblings through home visits, informal contacts and family group sessions. Often we treat the whole family in order to maintain and support total family stability.
22.
ConcIusioM
23.
Comprehensive mental health care
AU, HERNDON
Social and emotional adaptations of children with transplanted kidneys and chronic hemodialysis. Am J Psychiatry 127: 1194, 1971 5. LEraaviw P, NOBERT A, CROMBEZ JC: Psychological and psychopathological reactions in relation to chronic hemodialysis. Can Psychiatr Assoc / 17: 55-9, 1972 6. RAIMBAULT G: Psychological aspects of chronic renal failure and hemodialysis. Wephron 11: 252, 1973
15.
16.
17.
18. 19. 20. 21.
al: Kidney transplantation in children: psychosocial follow-up study on child and family. J Pedlair 83: 399, 1973 MATrHEWS DE: The psychological preparation of children for dialysis and transplantation. Paper presented at annual meeting of Canadian Society of Extracorporeal Circulation Technicians, Toronto, Sept 21, 1974 BERNSTEIN DM: After transplantation - the child's emotional reactions. Am J Psychiatr 127: 1189, 1971 A child on dialysis (E). Dial Transpi 2: 22, 1973 VANLEEUWEN JJ: Dialysis-transplantation. Ont Med Rev 41: 71, 1974 ABRAMS HS: The "unco-operative" hemodialysis patient: a psychiatrist's viewpoint and a patient's commentary, in Living or Dying; Adaptation to Hemodialysis, edited by LEvY NB, Springfield, IL, CC Thomas, 1974. pp 50-61 NORDAN R, OsTENDoiu' R, NAUGHTON JP: Return to the land of the living: an approach to the problem of chronic hemodialysis. Pediatrics 48: 939, 1971 SCHULTZ MT, McVICAR MI, KEMPH JP: Treatment of the emotional and cognitive deficits of the child receiving hemodialysis, in Living or Dying; Adaptation to Hemodialysis, op cit, pp 62-73 BASeR SH: The intrapsychic integration of a new organ. A clinical study of kidney transplantation. Psychoanal Q 42: 364, 1973 CASTELNUOVO-TEDESCO P: Organ transplant, body image, psychosis. Ibid, p 349 KEMPH JP, BERMANN EA, COPPOLILLO HP: Kidney transplant and shifts in family dynamics. Am J Psychiatry 125: 1485, 1969 BERNSTEIN DM, SIMMON RG: The adolescent kidney donor: the right to give. Am I Psychiatry 131: 1338, 1974 HAILSTONE JD: Psychiatric disturbance in chronic renal failure and its treatment by dialysis. Posigrad Med 1 47: 549, 1971 BRUMMIi-F WB, WHALEN JS: Pediatric experience with ketamine hydrochloride (Keta. lar), in Ketalar®, Parke, Davis and C Ltd, Montreal, 1971, pp 85-90 py
962 CMA JOURNAL/NOVEMBER 22, 1975/VOL. 113
Bricanyf (terbutaline sulfate)
tablets
ACTION: Bricanyl (terbutaline sulfate) produces bronchodilation by stimulation of the ., adrenergic receptors in bronchial smooth muscle, thereby causing relaxation of muacle fibres. This action is manifested by an increaae in pulmonary function as demonstrated by FEy, measurements. Bricanyl also produces a decrease in airway and pulmonary resistance. Following administration of Bricanyl tablets, a measurable change in flow rate is usually observed in 30 minutea, and improvement in pulmonary function occurs within 120-180 minutes. The maximum effect usually occurs within 120 - 180 minutes and significant bronchodilator activity has been observed to persist for 4-8 hours. INDICATIONS: Bricanyl (terbutaline sulfate) tablets are indicated as a bronchodilator for the symptomatic relief of bronchial asthma and for relief of reversible bronchospasm which may occur in association with bronchitis and emphysema. CONTRAINDICATIONS: Bricanyl (terbutaline sulfate) tablets are contraindicated when there is known hypersensitivity to sympathomimetic amines. Bricanyl like other sympathomimetic smines, should not be used in patients with tachysrrhythmias. WARNINGS: USAGE IN PREGNANCY: The safe use of Bricanyl (terbutaline sulfate) has not been established in human pregnancy. The use of the drug in pregnancy, lactation, or women of childbearing potential requires that the expected therapeutic benefit of the drug be weighed against its possible hazards to the mother or child. Animal reproductive studies have shown no adverse effects on fetal development. USAGE IN PEDIATRICS: Sricanyl (terbutaline sulfate) tablets are not presently recommended for children due to limited clinical data in pediatric patients. PRECAUTIONS: Bricanyl (terbutaline sulfate) should be used with caution in patients with diabetes, hypertension and hyperthyroidism. As with other sympathomimetic bronchodilator agents, Sricanyl tablets should be administered cautiously to cardiac patients, especially those with associated arrhythmias. In patients in whom the administration of Bricanyl tablets induces cardiac irregularities, the dose should be reduced or the administration of the drug suspended. The concomitant use of Bricsnyl tablets with other sympathomimetic agents is not recommended since their combined effect on the cardiovascular system may be deleterious to the patient. However, this does not preclude the use of an aerosol bronchodilator of the adrenergic stimulant type for relief of the acute bronchospasm in patients receiving chronic omi Bricanyl therapy. ADVERSE REACTIONS: Commonly observed side effects include nervousness and tremor. Other reported reactions include headache, increased heart rate, palpitations, ectopic bests, drowsiness, nausea, vomiting, sweating and dizziness. SYMPTOMS AND TREATMENT OF OVERDOSAGE: The symptoms of overdosage are similar to those described above under ADVERSE REACTIONS, and are attributable to excessive 8 adrenergic stimulation. To antagonize the effect of excessive JI stimulation, a fi- adrenergic blocking agent such as propranolol may be considered. DOSAGE AND ADMINISTRATION: The usual oral dose of Sricanyl (terbutaline sulfate) for adults is 5 mg administered at approximately six hour intervals three times daily, during the hours the patient is usually awake. In the event of excessive aide effects in individual patients, the dose may be reduced to 2.5 mg three times daily. A total dose of 15 mg should not be exceeded in a24 hour period. Sricanyl5 is not currently recommended for use in children. AVAILABILITY: Tablets containing 5 mg of Bricanyl are white in colour and carry a numerical inscription (i.e.5) which designates the milligram content of terbutaline sulfate. Bricanyl (terbutaline sulfate) 5 mg tablets are supplied in bottles of 100.
Astra Chemicals Ltd.
Pharmaceutical Division asiassuga, Ontario
Product
literature available on request.
Summary: The dialysis-transplantation (D-T) program at The Hospital for Sick Children, Toronto has a mental health component directed by a psychiatrist and a social worker. As of Jan. 1, 1975, 53 kidney transplants
had been carried out on 44 children. Patients and their families are counselled continuously by the psychiatrist and the social worker before, during and after transplantation. Members of the multidisciplinary team meet
regularly
to
plan
treatment
for the children. Mental health issues are an integral part of team discussions and help determine D-T
policy. Psychological preparation, mental health consultation, therapeutic intervention and continuous program
counselling prevent many of the mental health problems that plague a D-T program. Resume: Soins mentaux complets dans un programme pediatrique de dialyse et de transplantation Au Hospital for Sick Children de Toronto on a cree un centre de soins mentaux un
dirige
par
un
psychiatre
et
travailleur social dans le cadre du
programme dialyse-transplantation (D-T). Au 1er janvier 1975 on avait pratique 53 transplantations renales chez 44 enfants. Les patients et leurs parents recoivent des conseils continuels du psychiatre et du travailleur social avant, pendant et apres la transplantation. Les membres de l'equipe
multidisciplinaire
se rencontrent
regulierement pour planifier le
traitement de ces enfants. Leurs discussions comportent toujours I'aspect des soins mentaux, ce qui les aide a formuler un systeme pour le programme de D-T. Grace a une bonne preparation psychologique, a des consultations psychiatriques, a des moyens therapeutiques et a des conseils permanents, on est parvenu a prevenir une grande partie des problemes mentaux qui sont le fleau de tout programme D-T. From the departments of psychiatry and social
work, The Hospital for Sick Children, Toronto ?This paper was prepared for the Sept. 20, 1975 issue of the Journal commemorating the centennial of The Hospital for Sick Children, Toronto, but because of space limitations could not be included.
Reprint requests to: Dr. J.J. VanLeeuwen, Department of psychiatry, The Hospital for Sick Children, 555 University Ave., Toronto, ON M5G 1X8
msw
Hospital for Sick Children transplantation is the ultimate goal for every child accepted into the dialysistransplantation (D-T) program. Criteria for patient selection are comparable to those applied in other centres.1 Contraindications include coexistence of an¬ other fatal condition,2 severe mental retardation and untreatable psychosis. Pre-existing psychosocial difficulties, re¬ gardless of their complexity, are not At The
considered contraindications. Children under 5 years of age
are
routinely accepted, although we have given kidney transplants to two young children, one aged 18 months and one 2 years. This policy is cur¬ rently under review because of the favourable growth3 and survival data being reported. As of Jan. 1, 1975, 53 kidney trans¬ plants had been done in 44 children. Seven children have had two trans¬ plants and one child has had three. Four children receiving transplants sub¬ sequently died and two others died while undergoing dialysis. not
The mental health program The psychosocial aspects of dialysis and transplantation in children, such as the physical, psychological and social stresses on the patient and his family, and the pressures and frustrations ex¬ perienced both collectively and indi¬ vidually by the D-T physicians, nurses and paramedical staff, are well docu¬ mented.4"10 However, there is insuffi¬ cient documentation on how mental health programs ameliorate psycho¬ social difficulties. Mental health plan¬ ning should be an essential part of the medical treatment from the time dial¬ ysis is first proposed to the family until the child is rehabilitated following a successful kidney transplant. The pro¬ gram at The Hospital for Sick Children has been developed by the authors, a psychiatrist and a social worker, who have been working with the D-T team for over 5 years. We follow all patients closely and the current program is the synthesis of our experience. Specifi¬ cally, our responsibilities are to main¬ tain the mental health of the child and his family, to consult with the D-T team and to participate in the formulation of D-T program policy. Our philo¬ sophy is preventive and we attempt to
keep the mental health perspective in balance with the medical, surgical and nursing aspects.
Preparation for dialysis-transplantation In an effective mental health pro¬ gram the preventive role that careful preparation for dialysis and transplan¬ tation can play in avoiding unnecessary psychological and social stress must be
recognized. Our preparation program11 results in a comprehensive psychosocial assess¬ ment of patient and family, including a social, psychiatric and psychometric evaluation. If there are several months to prepare a child and his family for dialysis, the child usually adapts well to treatment. Half our patients are re¬ ferred early enough for such prepara¬ tion; the other half are admitted with acute renal failure and require dialysis almost immediately. Depression and behavioural disturbances are more pro¬ nounced in the latter patients during the first months of dialysis. When unprepared patients receive a transplant before adjustment to their illness or dialysis, behavioural disturbances often appear after transplantation. This im¬ pression is reinforced by the difficul¬ ties reported by Bernstein.12 The social worker is involved with the family from the beginning. If the child's need for dialysis develops slow¬ ly, regular counselling during clinic appointments prepares child and family gradually. If the onset of the child's illness is sudden and he is admitted needing dialysis, preparation counsel¬ ling is concentrated. Emotional responses to the diagnosis are unpredictable and individuals vary in their capacity to cope with the shock, grief, guilt and anger.13 Recogni¬ tion of a family's way of coping with stress and remedial counselling is the focus of the preparation. We insist that both parents participate in initial med¬ ical and psychological interviews to avoid the tendency for fathers to be left out of critical discussions. The value of early preventive coun¬ selling is demonstrated in the following
report. 12-year-old Italian girl became to¬ tally silent and withdrawn after sudden hospitalization with acute renal failure. Her parents were excessively mournful in attitude and rarely spoke to her or the CMA JOURNAL/NOVEMBER 22, 1975/VOL. 113 959 case
A
staff as they sat by her bedside. It required a week of daily therapy with the child to alleviate her fear that she was dying. Fear of death had been reinforced by her par¬ ents' display of grief. Counselling of the parents helped them realize the effect they were having on their child. Together they shared their grief with us and felt sup¬ ported by each other and the hospital staff. This enabled them to follow our suggestions for a more helpful interaction with their child.
The psychological assessment can be predictive of a patient's intellectual and social potential. We have used it as a guideline for appropriate dietetic and medical teaching as well as for school collaboration. The composite mental
A home visit is usually made by the social worker and the dietitian. The visit often produces new and critical information. For example, one patient's mother appeared confused, anxious and lost while visiting her child in hospital. However, when the social worker and dietitian visited the mother at her farmhouse she was found to be competent and able to care for her child. The social worker usually visits the patient's school to explain the illness and to encourage long-term planning. Since only daytime dialysis is per¬ formed, our children are apt to miss 50% of their schooling. Because of this initial personal contact with schools and the later regular school contact by our D-T teacher, we have usually suc¬ ceeded in having the patient's curri¬ culum individualized. Some schools will supplement school attendance with home tutoring. Unless a child is too ill to attend school we never encourage home tutoring alone because it tends to cut off contact with friends and normal activities. For some patients we initiate the coordination of other com¬ munity services such as welfare, public health and social services. The psychiatric assessment has both a diagnostic and a therapeutic purpose. For the benefit of staff it is important that the relevant features of a child's intrapsychic nature be understood be¬ cause it is often the basis for a patient's nursing care plan, as in the following instance.
The D-T team is composed of the
health assessment is discussed with the D-T program director and later integrated into the patient care plan. Team
relationships
nephrologist-director, the fellows in nephrology, nurses from the dialysis unit and from a ward to which all D-T patients are admitted, a dialysis tech¬ nician, a dietitian, a psychiatrist, a so¬ cial worker, a recreation therapist, a schoolteacher and a physiotherapist. At a regular weekly conference each member contributes his particular insight to improve the perspective of the whole group. The social worker and the psychiatrist are responsible for familiarizing team members with the psy¬ chological problems as well as focusing attention on the child's long-term de¬ velopmental needs.14 Sometimes med¬ ical teams tend to become diseaseoriented and simplistic in their interpre¬ tation of complex psychological prob¬ lems such as poor dietary control and "uncooperative" behaviour.15 We can¬ not deny that this tendency occurs from time to time but we have observed staff develop greater psychological aware¬ ness and interpersonal skills as a result of regular mental health consultation and by other meetings that might be arranged. In all these meetings we try to help our staff express their feelings appropriately, discuss our patients' psy¬ chological development as an integral part of medical reports and try to make helpful suggestions about the links be¬ tween observed behaviour and under¬ lying feelings. These qualities of psychological awareness and sensitive interpersonal skills of the total D-T team are the key A 10-year-old boy had acute renal fail¬ ingredients in the kind of environment ure. His renal condition had greatly these children need. Medical programs deteriorated within a month, necessitating are easily organized but it takes special immediate peritoneal dialysis. He seemed qualities in the staff to ensure the unusually fearful and wanted someone child's ongoing personality develop¬ with him constantly. His father had died
suddenly 8 months earlier. Psychiatric evaluation indicated that this child had not resolved his grief about his father and this made him extremely anxious about the sudden threat to his own life and the separation from his family. The acute anxiety, compounded by his severe toxic condition, resulted in mildly disorganized thought processes and a tendency to compulsive behaviour. The individualized nursing care plan developed for this child included a nurse of his own, a quiet environment and controlled staff involve¬ ment to provide consistency in care and a sense of security.
ment. While isolated
case histories have been described in the literature1617 re¬ ferring to the individual needs of a
patient, comprehensive D-T program designs are rarely mentioned. The children are likely to be par¬ tially reared in the hospital for months or even years during their D-T treat¬ ment. Another important aspect of our program is carried out by the special education teacher, the recreationist, the physiotherapist, the nurses and the parents. They all play important roles in the structured daily activities of
960 CMA JOURNAL/NOVEMBER 22, 1975/VOL. 113
these children, whether in the dialysis unit or on the nephrology ward. Friendships can, but do not neces¬ sarily, develop among the children.
Age, compatibility and common prob¬ lems are the motivations. In our experi¬ ence these friendships need not be viewed differently than other situations in which children find themselves indiscriminately grouped. However, the common bond of dialysis and trans¬ plantation does create a special sensiti¬ vity among children who have been hospitalized together. This is particu¬ larly noticeable when a child on the program dies. When this occurs we have found it therapeutic to tell other D-T patients almost immediately. This prevents an emotional crisis if they hear about the loss accidentally and provides them with immediate support in their initial fear and grief. We have noted that children under 12 react intensely but briefly; they quickly turn to activity for relief from the emotional pain. The older child openly expresses grief and tends to share his feelings. When two children died in our dial¬ ysis unit the other children undergoing dialysis at the time commented later that they had been helped most by the fact that the staff in the unit who were not involved with the dying child re¬ mained calm and gave them personal support.
Staff also become upset when a child we find it helpful to call a team meeting the following day to clarify the cause of death and allow members to express their feelings. This facilitates the normal process of grief and necessary mutual support among staff who have lost a patient with whom they were expected to form a signifi¬ cant, intimate yet professional relation¬ ship. Death must therefore be acknowledged as an important loss to the staff.
dies, and
Transplantation The
use of living related donors is encouraged at The Hospital for Sick Children. So far only one patient has received a family-donated kidney. We tend to reserve this procedure for a time when further waiting for a cadaveric kidney would greatly endanger the life of the patient. We hesitate to
not
expose the donor to the risk of
ne¬
phrectomy when he or she is the breadwinner or the mother of a young family. The intrapsychic integration of the
transplant is a matter of great concern to some children and of little concern to others. Their attitudes are largely
determined by their ages. Cadaveric donors are preferred at The Hospital for Sick Children and we find children have an initial distaste for the idea.
questions about the They wonder if the kidney comes from an old person and fear such a kidney would not last long. In subtle ways they show guilt and con¬ fusion that they are alive while some¬ one else is dead and that they have benefited from the death. Kidneys are intuitively linked with sexual and re¬ productive functions. The thought of receiving a kidney from a donor of the opposite sex is disturbing. We openly discuss all these issues with the child before transplantation. We find this an effective preventive measure and on the whole we are impressed by the healthy psychological integration of the new organ, both on short- and long-term follow-up. Like Basch18 and Castelnuovo-Tedesco,19 we have seen some of the manifestations of delayed psychic integration of the transplant. Two girls briefly treated their kidneys as though they were babies; this was done with some humour on their part and was realistic, for their new kidneys were readily palp¬ able. Temporarily, several boys nicknamed their new kidneys. They ap¬ peared to regard them as a newly ac¬ quired companion. However, we have not encountered any of the more seri¬ ous complications described by these Children have donors.
authors. Several families have asked to be considered as potential donors for their children. We have responded by offer¬ ing specific individual and family inter¬ views before physical and immunologic screening. Many articles describe the psychological hazards when the donor is a living relative; in particular, parentchild donation magnifies pre-existing relationship conflicts.18"21 Our interviews are geared towards helping a family understand the complexities of the is¬ sue and resolving them long before the need to donate might arise. At the same time we must formulate an opinion as to the donor's psychological suitability.
inherent stresses imposed by the whole facilities for peritoneal dialysis but re¬ Medical and nursing transplant rejection process. They are quested guidance. came to The Hospital for Sick willing to delay another transplant for personnel such psychological reasons. Adolescents Children to learn the technique. The D-T social worker visited the northern hospital in particular appreciate a chance to to coordinate local services. Schooling and return to normal physical appearance a suitable foster home near the hospital if they have become cushingoid, over- were arranged. The social worker then weight or plagued with acne. flew to Simon's home viilage to discuss
Psychosocial difficulties Accounts of two clinical examples of psychosocial difficulties presented by patients in the D-T program and their
families follow.
A psychologically vulnerable family: Clarice, a 15-year-old dependent, overprotected girl, had Deen ill for several years before requiring dialysis. During the 1st year of dialysis she received a kidney but it was later rejected. Following the loss of her transplant, while in isolation, Clarice
had a manic psychotic episode that lasted several days. The psychiatrist treated her and offered specific consultation to the medical and nursing staff regarding her care. In the next 4 years she had two more transplants, which were rejected, and several severe infections, and finally had to return to peritoneal dialysis, of which she had an almost pathologie dread. This family has required extensive ongoing counselling and, at critical times, psycho¬ therapy. As a result of the unusual and prolonged stress, the family at various times has turned to astrology, vented their anger on hospital staff and tried selftreatment with the medications. Clarice's mother was an outgoing, likeable woman whose anxieties were uncontained and easily transmitted to her daughter. Both mother and daughter exhibited a manic type of defence mechanism against de¬ pression. The father was more self-contained but equally anxious. A brother, 3 years younger, had had some emotional and social deprivation as a result of the family's absorption in Clarice's illness. Each member of the family has required supportive therapy. The family were seen together at times of critical decisions, such as whether the second and third trans¬ plants should be performed and when the final decision was made to try home peri¬ toneal dialysis, which meant transfer to another hospital for training and super¬ vision. Despite these many setbacks the family gradually matured. The intense de¬ pendency relationship between mother and daughter, which had offered each of them
with his parents the prolonged treatment necessary and how it would affect them. Her visit relieved and reassured Simon's family, who had not seen him for months and did not understand his medical prob¬ lem. They also harboured a superstitious guilt about producing sick boys. Another boy had died of Alport's syndrome and a third had been given away at birth for fear the family might contaminate him; he was thriving in another community. An audiotape and pictures of Simon under¬ going dialysis, medical drawings and dis¬ cussions helped educate the family, the school staff, Simon's classmates, the local nurse's aid and the Indian Affairs repre¬ sentative. The family appeared to under¬ stand the issues and have kept in touch with the social worker. Simon had a suc¬ cessful transplant 3 months later and has returned to the north. The plan produced many dividends because the personal con¬ tact with the hospital and local resources established a good liaison, so that as mental health problems with Simon arose they could be resolved by telephone conversation.
Psychiatric disturbances Specific psychiatric disturbances are brought to the attention of the psychi¬ atrist most frequently by the social worker, although any team member may do so. The psychiatrist himself often recognizes incipient psychiatric disturbances through comments made at regular team meetings. Depression, the commonest disturb¬ ance, manifests itself in many different
for example, in a straightexpression of depressive feel¬ ings and occasionally a wish to "end it all"; in lack of appetite, apathy and diminishing interest in surroundings; in breakdown of routines such as medical In one family the parents reported to dietary regimen and school attendance; us that all members were willing to donate or in antagonism, aggressiveness or immediately. When we imposed our orderself-punishing behaviour such as refusly decision-making process the situation ing food or medication. changed. One older sibling declined be¬ A host of associated organic fac¬ cause of persistent open feelings of resentment for the patient. Another older secondary gratifications, was gradually re¬ tors,22 such as azotemia, anemia, elec¬ placed by the characteristic adolescent trolyte disturbances, hypertension and sibling considered his professional sports striving for independence. Clarice's mother career in jeopardy were he to have a such as steroids, affect the accepted this maturation almost with re¬ medications nephrectomy. A third member of the fam¬ lief. cerebral function directly. patient's the basic of family dynaily had, in our opinion, insufficient mental mics Recognition and and in behavioural persistence consistency Every abnormality has capacity to understand the nature and con¬ dealing with them were the chief factors to be evaluated in light of these many sequences of donating a kidney. in maintaining family integration. factors. We have treated a total of We have been repeatedly surprised five psychotic episodes over the past 7 A family requiring interhospital liaison at the changes in attitude in a family years. Fortunately they were brief. Two organization: Simon, a episodes when a child has undergone dialysis and community are described below, without American Indian boy, lives in and received a transplant that has a10-year-old northland Indian community 1 hour elaboration on the psychiatric treat¬ tiny failed. Though both child and family by bush plane from the nearest hospital. ment, to illustrate the complex inter¬ once earnestly desired a kidney, they Simon has Alport's syndrome with asso¬ action of the many possible factors now want a period of relief from the ciated deafness. The northern hospital has leading to such psychotic conditions. ways
forward
CMA JOURNAL/NOVEMBER 22, 1975/VOL. 113 961
In a previously well adjusted 16-year-old boy with a high anxiety level and an active fantasy life, delirium developed when he was critically ill with complications following transplant rejection and transplant nephrectomy. For several days he was confused, disoriented, restless, fearful and had lapses of memory. This toxic delirium eventually subsided after surgical drainage of an abdominal abscess. On a different occasion he had two brief episodes of extreme mental anguish and hallucinations. Besides having kidney disease he was now convinced he had become insane. It was disturbing and puzzling to the staff but the psychiatrist was able to diagnose this state as induced by ketamine hydrochloride,23 given for anesthesia at the time of renal biopsy. A 16-year-old girl came to us in terminal renal failure from a foreign country. She was critically ill and required immediate peritoneal dialysis. Culture shock and a complete language barrier made her feel totally lost. She became mildly psychotic for about 10 days. Disorientation seemed minimal but she began to cling to people by using hypochondriacal complaints. She sometimes confused the identity of her relatives. This delusional episode seemed more functional than organic. Such psychotic episodes can be accentuated, perhaps produced or prevented by the general hospital atmosphere as expressed in the psychological awareness of the staff and their skill in relationships, and in the psychological preparation for procedures. Despite efforts to provide care of good quality, it is realistic to expect that the stress of dialysis and transplantation in children will produce psychiatric disturbances, both functional and organic, from time to time.
Patient and family group meetings
for D-T patients is a demanding task, extending far beyond the confines of direct patient care. Whole families must be helped, a large team must be oriented to psychological issues, and mental health concepts must be integrated into overall policy planning. This can only be achieved with a program director who appreciates the importance of the juxtaposition of mental and physical health care. References 1. ABRAM HS: Psychological dilemmas of medical progress. Psychiatr Med 3: 51, 1972 2. ARBUS GS, SNIDERMAN S: Oxalosis with peripheral gangrene. Arch Pathol 97: 107, 1974 3. GRUSHKIN CM, KORSCH B, FINE RN: Hemodialysis in small children. JAMA 221: 869, 1972 4. KNAN
CH,
AHMADIAN
SY:
7. GRUSHKIN CM, KoRscH BM, FINE RN: The
outlook for adolescents with chronic renal failure. Pediatr Clin North Am 20: 953, 1973
8. STEINHAUER
PD,
MUSHIN
DN,
RAE-GRANT
Q: Psychological aspects of chronic illness. Pedjair Clin North Am 21: 825, 1974 9. KAPLAN DE-NOUR A, CZACZKE5 JW, LILos P: A study of chronic hemodialysis teams differences in opinions and expectations. J Chronic Dis 25: 441, 1972 10. KoRscH BM, NEGRETE VF, GARDNER JE, et
11.
12. 13. 14.
The mental health team meets with patients and parents in a number of group situations. Patient groups, such as adolescents, have been formed to discuss how teenage concerns such as dating, physical appearance, independence and vocational choice are affected by D-T treatment. From time to time parents meet in a formal group with the program director and mental health team to update their knowledge and help them come to grips with the stress of dialysis-transplantation. We believe it is important that both parents attend these meetings to encourage the development of mutual support. We come to know the patient's siblings through home visits, informal contacts and family group sessions. Often we treat the whole family in order to maintain and support total family stability.
22.
ConcIusioM
23.
Comprehensive mental health care
AU, HERNDON
Social and emotional adaptations of children with transplanted kidneys and chronic hemodialysis. Am J Psychiatry 127: 1194, 1971 5. LEraaviw P, NOBERT A, CROMBEZ JC: Psychological and psychopathological reactions in relation to chronic hemodialysis. Can Psychiatr Assoc / 17: 55-9, 1972 6. RAIMBAULT G: Psychological aspects of chronic renal failure and hemodialysis. Wephron 11: 252, 1973
15.
16.
17.
18. 19. 20. 21.
al: Kidney transplantation in children: psychosocial follow-up study on child and family. J Pedlair 83: 399, 1973 MATrHEWS DE: The psychological preparation of children for dialysis and transplantation. Paper presented at annual meeting of Canadian Society of Extracorporeal Circulation Technicians, Toronto, Sept 21, 1974 BERNSTEIN DM: After transplantation - the child's emotional reactions. Am J Psychiatr 127: 1189, 1971 A child on dialysis (E). Dial Transpi 2: 22, 1973 VANLEEUWEN JJ: Dialysis-transplantation. Ont Med Rev 41: 71, 1974 ABRAMS HS: The "unco-operative" hemodialysis patient: a psychiatrist's viewpoint and a patient's commentary, in Living or Dying; Adaptation to Hemodialysis, edited by LEvY NB, Springfield, IL, CC Thomas, 1974. pp 50-61 NORDAN R, OsTENDoiu' R, NAUGHTON JP: Return to the land of the living: an approach to the problem of chronic hemodialysis. Pediatrics 48: 939, 1971 SCHULTZ MT, McVICAR MI, KEMPH JP: Treatment of the emotional and cognitive deficits of the child receiving hemodialysis, in Living or Dying; Adaptation to Hemodialysis, op cit, pp 62-73 BASeR SH: The intrapsychic integration of a new organ. A clinical study of kidney transplantation. Psychoanal Q 42: 364, 1973 CASTELNUOVO-TEDESCO P: Organ transplant, body image, psychosis. Ibid, p 349 KEMPH JP, BERMANN EA, COPPOLILLO HP: Kidney transplant and shifts in family dynamics. Am J Psychiatry 125: 1485, 1969 BERNSTEIN DM, SIMMON RG: The adolescent kidney donor: the right to give. Am I Psychiatry 131: 1338, 1974 HAILSTONE JD: Psychiatric disturbance in chronic renal failure and its treatment by dialysis. Posigrad Med 1 47: 549, 1971 BRUMMIi-F WB, WHALEN JS: Pediatric experience with ketamine hydrochloride (Keta. lar), in Ketalar®, Parke, Davis and C Ltd, Montreal, 1971, pp 85-90 py
962 CMA JOURNAL/NOVEMBER 22, 1975/VOL. 113
Bricanyf (terbutaline sulfate)
tablets
ACTION: Bricanyl (terbutaline sulfate) produces bronchodilation by stimulation of the ., adrenergic receptors in bronchial smooth muscle, thereby causing relaxation of muacle fibres. This action is manifested by an increaae in pulmonary function as demonstrated by FEy, measurements. Bricanyl also produces a decrease in airway and pulmonary resistance. Following administration of Bricanyl tablets, a measurable change in flow rate is usually observed in 30 minutea, and improvement in pulmonary function occurs within 120-180 minutes. The maximum effect usually occurs within 120 - 180 minutes and significant bronchodilator activity has been observed to persist for 4-8 hours. INDICATIONS: Bricanyl (terbutaline sulfate) tablets are indicated as a bronchodilator for the symptomatic relief of bronchial asthma and for relief of reversible bronchospasm which may occur in association with bronchitis and emphysema. CONTRAINDICATIONS: Bricanyl (terbutaline sulfate) tablets are contraindicated when there is known hypersensitivity to sympathomimetic amines. Bricanyl like other sympathomimetic smines, should not be used in patients with tachysrrhythmias. WARNINGS: USAGE IN PREGNANCY: The safe use of Bricanyl (terbutaline sulfate) has not been established in human pregnancy. The use of the drug in pregnancy, lactation, or women of childbearing potential requires that the expected therapeutic benefit of the drug be weighed against its possible hazards to the mother or child. Animal reproductive studies have shown no adverse effects on fetal development. USAGE IN PEDIATRICS: Sricanyl (terbutaline sulfate) tablets are not presently recommended for children due to limited clinical data in pediatric patients. PRECAUTIONS: Bricanyl (terbutaline sulfate) should be used with caution in patients with diabetes, hypertension and hyperthyroidism. As with other sympathomimetic bronchodilator agents, Sricanyl tablets should be administered cautiously to cardiac patients, especially those with associated arrhythmias. In patients in whom the administration of Bricanyl tablets induces cardiac irregularities, the dose should be reduced or the administration of the drug suspended. The concomitant use of Bricsnyl tablets with other sympathomimetic agents is not recommended since their combined effect on the cardiovascular system may be deleterious to the patient. However, this does not preclude the use of an aerosol bronchodilator of the adrenergic stimulant type for relief of the acute bronchospasm in patients receiving chronic omi Bricanyl therapy. ADVERSE REACTIONS: Commonly observed side effects include nervousness and tremor. Other reported reactions include headache, increased heart rate, palpitations, ectopic bests, drowsiness, nausea, vomiting, sweating and dizziness. SYMPTOMS AND TREATMENT OF OVERDOSAGE: The symptoms of overdosage are similar to those described above under ADVERSE REACTIONS, and are attributable to excessive 8 adrenergic stimulation. To antagonize the effect of excessive JI stimulation, a fi- adrenergic blocking agent such as propranolol may be considered. DOSAGE AND ADMINISTRATION: The usual oral dose of Sricanyl (terbutaline sulfate) for adults is 5 mg administered at approximately six hour intervals three times daily, during the hours the patient is usually awake. In the event of excessive aide effects in individual patients, the dose may be reduced to 2.5 mg three times daily. A total dose of 15 mg should not be exceeded in a24 hour period. Sricanyl5 is not currently recommended for use in children. AVAILABILITY: Tablets containing 5 mg of Bricanyl are white in colour and carry a numerical inscription (i.e.5) which designates the milligram content of terbutaline sulfate. Bricanyl (terbutaline sulfate) 5 mg tablets are supplied in bottles of 100.
Astra Chemicals Ltd.
Pharmaceutical Division asiassuga, Ontario
Product
literature available on request.
