adrenergic agemts. learning objectives understand the central and peripheral nervous systems, their...
Post on 02-Jan-2016
213 Views
Preview:
TRANSCRIPT
Adrenergic agemts
Learning Objectives
• Understand the central and peripheral nervous systems, their functions, and their relationship to drugs.
• Become aware of the role of neurotransmitters.
• Learn how adrenergic drugs affect body systems and where they work in the body.
Learning Objectives
• Define the action of neuromuscular blocking agents in reducing muscle activity.
• Distinguish between narcotic and nonnarcotic analgesia.
• Become familiar with the various types of agents for migraine headaches.
Divisions of the Nervous System
• Central Nervous System– Brain– Spinal cord
• Peripheral Nervous System– Nerves– Sense organs
Divisions of the Nervous System
• Central Nervous System
• Peripheral Nervous System
Divisions of the Nervous System
• Central Nervous System
• Peripheral Nervous System– Somatic Nervous System– Autonomic Nervous System
Divisions of the Nervous System
• Central Nervous System
• Peripheral Nervous System– Somatic Nervous System
Voluntary action: skeletal muscle contraction and movement
– Autonomic Nervous SystemInvoluntary activities: respiration, circulation, digestion, sweating
Autonomic Nervous System
Review
The nervous system has two components. What are they?
Review
The nervous system has two components. What are they?
Answer – Central nervous system (CNS)– Peripheral nervous system (PNS)
Major Neurotransmitters
• Acetylcholine
• GABA
• Dopamine
• Epinephrine
• Serotonin
Major Neurotransmitters
• Acetylcholine (ACh)– Smooth muscle, cardiac muscle, and
exocrine glands
– Anticholinergics block ACh receptors• GABA
• Dopamine
• Epinephrine
• Serotonin
Major Neurotransmitters
• Acetylcholine
• GABA (gamma-aminobutyric acid)
Regulates message delivery system of the brain
• Dopamine
• Epinephrine
• Serotonin
Major Neurotransmitters
• Acetylcholine
• GABA
• DopamineActs on the CNS and kidneys
• Epinephrine
• Serotonin
Major Neurotransmitters
• Acetylcholine• GABA• Dopamine
• Epinephrine– Acts on cardiac and bronchodilator
receptors– Known as Adrenaline
• Serotonin
Major Neurotransmitters
• Acetylcholine
• GABA
• Dopamine
• Epinephrine
• Serotonin– Acts on smooth muscle and gastric mucosa
(causes vasoconstriction)
– Emotional responses: depression, anxiety
Communication by Neurotransmitters
Neurotransmitters are released from one axon and received by another neuron’s dendrites.
Discussion
What are three important types of receptors in the study of drugs?
Discussion
What are three important types of adrenergic receptors in the study of drugs?
Answer – Alpha– Beta-1– Beta-2
Types of Receptors
• AlphaVasoconstriction, raise BP
• Beta-1Heart stimulation
• Beta-2Vasodilation and bronchodilation
Drugs Affecting TheAutonomic Nervous
SystemAdrenergic Agents and
Adrenergic-Blocking Agents
The Sympathetic Nervous System
in Relationship to the Entire Nervous System
Adrenergic Agents
• Drugs that stimulate the sympathetic nervous system (SNS)
Adrenergic Agents
Also known as
• adrenergic agonists or sympathomimetics
Adrenergic Agents
Mimic the effects of the SNS neurotransmitters:
• norepinephrine (NE) and epinephrine (EPI)
Adrenergic Receptors
• Located throughout the body
• Are receptors for the sympathetic neurotransmitters
Alpha-adrenergic receptors: respond to NE
Beta-adrenergic receptors: respond to EPI
Alpha-Adrenergic Receptors
• Divided into alpha1 and alpha2 receptors
• Differentiated by their location on nerves
Alpha1-Adrenergic Receptors
• Located on postsynaptic effector cells (the cell, muscle, or organ that the nerve stimulates)
Alpha2-Adrenergic Receptors
• Located on presynaptic nerve terminals (the nerve that stimulates the effector cells)
• Control the release of neurotransmitters
The predominant alpha-adrenergic agonist responses are:• Vasoconstriction and CNS stimulation
Beta-Adrenergic Receptors
All are located on postsynaptic effector cells• Beta1-adrenergic receptors—located primarily
in the heart
• Beta2-adrenergic receptors—located in smooth muscle of the bronchioles, arterioles, and visceral organs
The beta-adrenergic agonist response results in:
• Bronchial, GI, and uterine smooth muscle relaxation
• Glycogenolysis
• Cardiac stimulation
Dopaminergic Receptors• An additional adrenergic receptor• Stimulated by dopamine• Causes dilation of the following blood vessels,
resulting in INCREASED blood flow– Renal
– Mesenteric
– Coronary
– Cerebral
Adrenergic Receptor Responsesto Stimulation
LOCATION RECEPTOR RESPONSECardiovascular
Blood vessels alpha1 and beta2 Constriction /dilation
Cardiac muscle beta1 Increasedcontractility
AV Node beta1 Increased heart rate
SA Node beta1 Increased heart rate
Adrenergic Receptor Responsesto Stimulation
LOCATION RECEPTOR RESPONSEGastrointestinal
Muscle beta2 Decreased motility
Sphincters alpha1 Constriction
Adrenergic Receptor Responsesto Stimulation
LOCATION RECEPTOR RESPONSEGenitourinary
Bladder alpha1 Constrictionsphincter
Penis alpha1 Ejaculation
Uterus alpha1 and beta2 Contraction/relaxation
Adrenergic Receptor Responsesto Stimulation
LOCATION RECEPTOR RESPONSERespiratory
Bronchial beta2 Dilation/relaxationmuscles
Catecholamines
Substances that can produce a sympathomimetic response
Endogenous:• epinephrine, norepinephrine,dopamine
Synthetic:• isoproterenol, dobutamine, phenylephrine
Adrenergic Agents Mechanism of Action
Direct-acting sympathomimetic:• Binds directly to the receptor and causes a
physiologic response
Direct-Acting Sympathomimetics
Adrenergic Agents Mechanism of Action
Indirect-acting sympathomimetic:• Causes the release of catecholamine from the
storage sites (vesicles) in the nerve endings• The catecholamine then binds to the receptors and
causes a physiologic response
Indirect-Acting Sympathomimetics
Adrenergic Agents Mechanism of Action
Mixed-acting sympathomimetic:• Directly stimulates the receptor by binding
to it
AND• Indirectly stimulates the receptor by causing
the release of stored neurotransmitters from the vesicles in the nerve endings
Mixed-Acting Sympathomimetics
Drug Effects of Adrenergic Agents
Stimulation of alpha-adrenergic receptors on smooth muscles results in:
• Vasoconstriction of blood vessels• Relaxation of GI smooth muscles• Contraction of the uterus and bladder• Male ejaculation• Decreased insulin release• Contraction of the ciliary muscles of the eye
(dilated pupils)
Drug Effects of Adrenergic Agents
Stimulation of beta2-adrenergic receptors on the airways results in:
• Bronchodilation (relaxation of the bronchi)• Uterine relaxation• Glycogenolysis in the liver
Drug Effects of Adrenergic Agents
Stimulation of beta1-adrenergic receptors on the myocardium, AV node, and SA node results in CARDIAC STIMULATION:
• Increased force of contraction (positive inotropic effect)
• Increased heart rate (positive chronotropic effect)
• Increased conduction through the AV node (positive dromotropic effect)
Adrenergic Agents: Therapeutic Uses
• Anorexiants: adjuncts to diet in the short-term management of obesityExamples: benzphetamine
phenterminedextroamphetamineDexedrine
Adrenergic Agents: Therapeutic Uses
Bronchodilators: treatment of asthma and bronchitis
• Agents that stimulate beta2-adrenergic receptors of bronchial smooth muscles causing relaxationExamples:albuterol ephedrine epinephrineisoetharine isoproterenol levalbuterolmetaproterenol salmeterol terbutaline
• These agents may also affect uterine and vascular smooth muscles.
Adrenergic Agents: Therapeutic Uses
• Reduction of intraocular pressure and mydriasis (pupil dilation): treatment of open-angle glaucoma
Examples: epinephrine and dipivefrin
Adrenergic Agents: Therapeutic Uses
Nasal decongestant: • Intranasal (topical) application causes constriction
of dilated arterioles and reduction of nasal blood flow, thus decreasing congestion.
Examples:epinephrine ephedrine naphazoline
phenylephrinetetrahydrozoline
Adrenergic Agents: Therapeutic Uses
Ophthalmic • Topical application to the eye surface affects
the vasculature of the eye, stimulating alpha receptors on small arterioles, thus relieving conjunctival congestion.Examples: epinephrine naphazoline
phenylephrine tetrahydrozoline
Adrenergic Agents: Therapeutic Uses
Vasoactive sympathomimetics (pressors, inotropes), also called cardioselective sympathomimetics
• Used to support the heart during cardiac failure or shock.Examples:dobutamine dopamine ephedrine epinephrine fenoldopam isoproterenolmethoxamine norepinephrine phenylephrine
Adrenergic Agents: Side EffectsAlpha-Adrenergic Effects• CNS:
– headache, restlessness, excitement, insomnia, euphoria
• Cardiovascular:– palpitations (dysrhythmias), tachycardia,
vasoconstriction, hypertension
• Other:– anorexia, dry mouth, nausea, vomiting, taste changes
(rare)
Adrenergic Agents: Side EffectsBeta-Adrenergic Effects• CNS:
– mild tremors, headache, nervousness, dizziness
• Cardiovascular:– increased heart rate, palpitations (dysrhythmias),
fluctuations in BP
• Other:– sweating, nausea, vomiting, muscle cramps
Adrenergic Agents: Interactions• Anesthetic agents
• Tricyclic antidepressants
• MAOIs
• Antihistamines
• Thyroid preparations
• Antihypertensives
• Will directly antagonize another adrenergic agent, resulting in reduced effects
Adrenergic Agents: Nursing Implications
• Assess for allergies and history of hypertension, cardiac dysrhythmias, or other cardiovascular disease.
• Assess renal, hepatic, and cardiac function before treatment.
• Perform baseline assessment of vital signs, peripheral pulses, skin color, temperature, and capillary refill. Include postural blood pressure and pulse.
• Follow administration guidelines carefully.
Adrenergic Agents: Nursing Implications
IV administration:• Check IV site often for infiltration• Use clear IV solutions• Use an infusion device/IV pump• Infuse agent slowly to avoid dangerous
cardiovascular effects• Monitor cardiac rhythm
Adrenergic Agents: Nursing Implications
With chronic lung disease:
• Instruct patients to avoid factors that exacerbate their condition.
• Encourage fluid intake (up to 3000 mL per day) if permitted.
• Educate about proper dosing and equipment care.
Salmeterol is indicated for PREVENTION of bronchospasms, not management
of acute symptoms.
Adrenergic Agents: Nursing Implications
• Overuse of nasal decongestants may cause rebound nasal congestion or ulcerations.
• Avoid OTC or other medications because of possible interactions.
• Administering two adrenergic agents together may precipitate severe cardiovascular effects such as tachycardia or hypertension.
• Inform patients taking inhaled isoproterenol that their sputum or saliva may turn pink.
Adrenergic Agents: Nursing Implications
Monitor for therapeutic effects (cardiovascular uses):
• Decreased edema• Increased urinary output• Return to normal vital signs• Improved skin color and temperature• Increased LOC
Adrenergic Agents: Nursing Implications
Monitor for therapeutic effects (asthma):• Return to normal respiratory rate• Improved breath sounds, fewer rales• Increased air exchange• Decreased cough• Less dyspnea• Improved blood gases• Increased activity tolerance
Adrenergic-Blocking Agents
• Bind to adrenergic receptors, but inhibit or block stimulation of the sympathetic nervous system (SNS)
Adrenergic Blocking Agents
• Have the opposite effect of adrenergic agents
• Also known as– adrenergic antagonists or sympatholytics
Adrenergic Blocking Agents
• Sympatholytics inhibit—or LYSE—sympathetic neurotransmitters
(norepinephrine and epinephrine)
Adrenergic Blocking Agents
Classified by the type of adrenergic receptor they block
• Alpha1 and alpha2 receptors
• Beta1 and beta2 receptors
Alpha-Blocker Mechanisms
Adrenergic-Blocking Agents: Drug Effects and Therapeutic
UsesErgot Alkaloids (Alpha-Blockers)• Constrict dilated arteries going to the brain
(carotid arteries)• Used to treat vascular headaches (migraines)• Stimulate uterine contractions by inducing
vasoconstriction• Used to control postpartum bleeding
Adrenergic-Blocking Agents: Drug Effects and Therapeutic
UsesAlpha-Blockers• Cause both arterial and venous dilation, reducing
peripheral vascular resistance and BP• Used to treat hypertension• Effect on receptors on prostate gland and bladder
decreased resistance to urinary outflow, thus reducing urinary obstruction and relieving effects of BPH
Adrenergic-Blocking Agents: Drug Effects and Therapeutic
UsesAlpha-Blockers• Phentolamine
– Quickly reverses the potent vasoconstrictive effects of extravasated vasopressors such as norepinephrine or epinephrine.
– Restores blood flow and prevents tissue necrosis.
Adrenergic-Blocking Agents: Side Effects
Alpha BlockersBody System Side/Adverse EffectsCardiovascular Palpitations, orthostatic
hypotension, tachycardia, edema, dysrhythmias,
chest pain
CNS Dizziness, headache, drowsiness,anxiety, depression, vertigo,weakness, numbness, fatigue
Adrenergic-Blocking Agents: Side Effects
Alpha Blockers
Body System Side/Adverse EffectsGastrointestinal Nausea, vomiting, diarrhea,
constipation, abdominal pain
Other Incontinence, nose bleeding,tinnitus, dry mouth, pharyngitis,rhinitis
Beta Blockers
• Block stimulation of beta receptors in the SNS
• Compete with norepinephrine and epinephrine
• Selective and nonselective beta blockers
Beta Receptors
Beta1 Receptors• Located primarily on the heart• Beta blockers selective for these receptors
are called cardioselective beta blockers
Beta Receptors
Beta2 Receptors
• Located primarily on smooth muscles of bronchioles and blood vessels
Nonspecific Beta Blockers
• Beta blockers that block both beta1 and beta2 receptors
Salbutamol (ventolin)
selective b2-adrenomimetic of direct action
Administration • inhalations during attacks of bronchial asthma and bronchial spasms of other etiology, • передчасних child delivery, бурхливій child delivery
Beta Blockers: Mechanism of Action
Cardioselective (Beta1)• Decreases heart rate• Prolongs SA node recovery• Slows conduction rate through the AV node• Decreases myocardial contractility, thus
decreasing myocardial oxygen demand
Beta Blockers: Mechanism of Action
Nonspecific (Beta1 and Beta2)• Effects on heart: Same as cardioselective• Bronchioles: Constriction, resulting in
narrowing of airways and shortness of breath
• Blood vessels: Vasoconstriction
Beta Blockers: Therapeutic Uses
• Anti-angina: decreases demand formyocardial oxygen
• Cardioprotective: inhibits stimulation bycirculating
catecholamines
• Class II antidysrhythmic
Terbutalin (brikanil) and phenoterol (berotek, partusisten)
are stimulants of mostly 2-adrenal receptors. They posses broncholytic and tokolytic activity
Beta Blockers: Therapeutic Uses
• Antihypertensive
• Treatment of migraine headaches
• Glaucoma (topical use)
Beta Blockers: Side Effects
Body System Side/Adverse EffectsBlood Agranulocytosis,
thrombocytopenia
Cardiovascular AV block, bradycardia, congestiveheart failure, peripheral vascularinsufficiency
CNS Dizziness, mental depression,lethargy, hallucinations
Adrenergic-Blocking Agents: Side Effects
Beta Blockers
Body System Side/Adverse EffectsGastrointestinal Nausea, dry mouth, vomiting,
diarrhea, cramps, ischemic colitis
Other Impotence, rash, alopecia,bronchospasms
Adrenergic Blocking Agents: Nursing Implications
• Assess for allergies and history of COPD, hypotension, cardiac dysrhythmias, bradycardia, CHF, or other cardiovascular problems
Any preexisting condition that might be exacerbated by the use of these agents might
be a CONTRAINDICATION to their use.
Adrenergic Blocking Agents: Nursing Implications
• Remember that alpha blockers may precipitate hypotension.
• Remember that beta blockers may precipitate bradycardia, hypotension, heart block, CHF, and bronchoconstriction.
Adrenergic Blocking Agents: Nursing Implications
• Avoid OTC medications because of possible interactions.
• Possible drug interactions may occur with:– Antacids (aluminum hydroxide type)– Antimuscarinics/anticholinergics– Diuretics and cardiovascular drugs– Neuromuscular blocking agents– Oral hypoglycemic agents
Adrenergic Blocking Agents: Nursing Implications
• Encourage patients to take medications as prescribed.
• These medications should never be stopped abruptly.
• Report constipation or the development of any urinary hesitancy or bladder distention.
Adrenergic Blocking Agents: Nursing Implications
• Teach patients to change positions slowly to prevent or minimize postural hypotension.
• Avoid caffeine (excessive irritability).• Avoid alcohol ingestion and hazardous
activities until blood levels become stable.• Patients should notify their physician if
palpitations, dyspnea, nausea, or vomiting occur.
Beta Blocking Agents: Nursing Implications
• Rebound hypertension or chest pain may occur if this medication is discontinued abruptly.
• Patients should notify their physician if they become ill and unable to take medication.
• Inform patients that they may notice a decrease in their tolerance for exercise; dizziness and fainting may occur with increased activity. Notify the physician if these problems occur.
Beta Blocking Agents: Nursing Implications
Patients should report the following to their physician:
• Weight gain of more than 2 pounds (1 kg) within a week
• Edema of the feet or ankles• Shortness of breath• Excessive fatigue or weakness• Syncope or dizziness
Adrenergic Blocking Agents: Nursing Implications
Monitor for side effects, including:Hypotension Fatigue
Tachycardia (alpha blockers) Lethargy
Bradycardia Depression
Heart block Insomnia
CHF Vivid nightmares
Increased airway resistance
Adrenergic Blocking Agents: Nursing Implications
Monitor for therapeutic effects• Decreased chest pain in patients with angina• Return to normal BP and P• Other specific effects, depending on the use
Adrenomimetics а) adrenomimetics of direct action
б) adrenomimetics of indirect action or sympathomimetics
Adrenoblockers or adrenolytics
Sympatholytics
І. Adrenomimetics 1.- і -adrenomimetics (adrenalin hydrochloride,
noradrenalin hydrotartrate)2. dopamine-, -, -adrenomimetics (dopamine)3. -adrenomimetics (mesatone, naftizin, galazoline)4. -adrenomimetics (isadrine, salbutamol, phenoterol,
terbutalin, dobutamine)ІІ. Sympathomimetics (ephedrine hydrochloride)ІІІ. Adrenoblockers 1. -adrenoblockers (phentolamine, tropaphen, prasosine,
pyroxan)2. -adrenoblockers (anaprilin, athenolol, talinolol,
acebutolol)3. - і -adrenoblockers (labetalol)ІІІ. Sympatholytics (reserpine, octadine)
Adrenomimetcs
Adrenalin (epinephrine) is a hormone of medullar layer of adrenal glands which is used in a form of a
remedy
adrenaline hydrochloride
It is an adrenomimetic which stimulates 1,- 2- and 1,- 2-adrenoreceptors
Administration sudden stoppage of heart, for example, during surgical
narcosis electric trauma
shock and collapse conditions bronchial spasm
hypoglycemic coma treatment of open-angle glaucoma
Noradrenalin hydrotartrate (norepinephrine)
Is an adrenomimetic of direct action which stimulates 1-, 2- and 1-adrenal receptors
Administration in cases of acute decreasing of blood pressure -
shock and collapse conditions, surgeries, traumasThe drug is absolutely contraindicated for
subcutaneous and intramuscular introductions
Dopamine
Drug of choice for treatment of
shock and collapse of different etiology, including cardiogenic
and hemorrhagic
Mesaton (phenilefrin)Is a synthetic a1-adrenomimetic drug of direct action
Administration • acute hypotensive conditions,• prophylaxis of decreasing of blood pressure in case of infectious diseases, poisonings,• decreasing of blood pressure during narcosis with fluorothan and cyclopropan• nose drops in case of rhinits
Naphtisin
Xylometazolinare a2-adrenomimetics of direct action
Usage for rhinitis in a form of nose drops – 1-2
drops 2-3 times a day
It is not recommended to use the drug in case of chronic cold
Isadrin (isoprenalin, novodrin, euspiran)
– is a synthetic catecholamine, which is a strong stimulant of b1- і b2-adrenal receptors
Administration • bradycardia, atrio-ventricular blockade • bronchial spasm • complex therapy of some kinds of shock (if the patient doesn’t
have hypovolemia)Side effects
• nausea, hands tremor, dryness in mouth,• in patients with ischemic heart disease – attack of stenocardia,• heavy cardiac tachyarrhythmias, even fibrillation of ventricles
Salbutamol (ventolin)
selective b2-adrenomimetic of direct action
Administration • inhalations during attacks of bronchial asthma and bronchial spasms of other etiology, • передчасних child delivery, бурхливій child delivery
Terbutalin (brikanil) and phenoterol (berotek, partusisten)
are stimulants of mostly 2-adrenal receptors. They posses broncholytic and tokolytic activity
Dobutamin Is a synthetic 1-adrenomimetic
Cardiotonic effects of dobutamin is 5 times stronger than action of dopamine
Administrationsome forms of acute and chronic cardiac
insufficiency intravenous dropping infusion with the speed
of 2,5-10 mcg / (kg.min)
Sympathomimetics
Ephedrine hydrochloride (Ephedrini hydrochloridum)
It is an alkaloid of plants of Ephedra family, which has indirect a-, b-adrenomimetic (sympathomimetic) action
Administration • collapse conditions, for prophylaxis of decreasing of blood pressure before spinal anesthesia, infectious diseases
• treatment of rhinitis (2 %, 3 % solution to drop into nose).
• prophylaxis and elimination of bronchial spasm (inhalations 0,5 %-1 % solutions of drug)
SIDE EFFECTS• неспокій, excitement, tremor, inconsiderable euphoria, insomnia, seizures
• drug addiction
• tachyphylaxy
Adrenoblockers
Alfa-adrenoblockers
Phentolamine, tropaphenare synthetic a1, 2-аdrenoblockers
administration• diagnostics and symptomatic treatment of feochromocytoma• disturbances of peripheral blood circulation in case of endarteritis, Reino’s disease, trophic ulcers, decubitus• complex treatment of hypertensive crises, acute cardiac insufficiency• complex therapy of hypovolemic and cardiogenic shock
Prasosin
Selective a1- adrenoblocker
Administration • treatment of essential hypertension• stabile cardiac insufficiency
Side effects“phenomenon of first dose”: sudden decreasing of blood pressure and even development of orthostatic collapse after first administrations of the drugProphylaxis: administration of half-dose before sleep
Beta-adrenoblockers
Anaprilin Is a selective b1- і b2-adrenoblocker
Administration • ischemic heart disease
• essential hypertension
• cardiac tachyarrhythmias
• acute myocardium infarction
Talinolol or cordanum
is a cardioselective
b-adrenoblocker
Administration• disorders of cardiac rhythm (extrasystolies, paroxysmal tachycardia, fibrillation and scintillation of atria)
• stenocardia
• arterial hypetension
.
Atenolol (tenormin)cardioselelctive -adrenoblocker of long action
Indications for administration• ischemic heart disease • essential hypertension
• cardiac arrhythmias• acute myocardium infarction
Acebutolol (sectral)1-adrenoblocker with internal
sympathomimetic activity
Indications• disorders of cardiac rhythm (tachyarrhythmias)
• hypertension
• ischemic heart disease
Labetolol
-, -adrenoblocker. The drug blocks 1, 2, 1 and 2-adrenoreceptors
Administration • treatment of patients with essential hypertension
• hypertensive crisis
Contraindications Atrio-ventricular blockade,
cardiac insufficiency
Sympatholytics
Reserpin is a sum of раувольфії (plant) alkaloids. Maximal hypotensive action develops after 5-7 days of regular administration of the drug. After the treatment coarse effect can still stay for two weeks.
Administration treatment of different forms of essential hypertension (combined drugs trirezid, cristepin, adelfan, brinerdin)
Side effects• manifestations of parkinsonism• в’ялість, somnolence, depression,• bradycardia• increasing of motor and secretory activity of gastro-intestinal tract, • acute attacks of ulcer disease, diarrhea• swelling of nose mucous membrane with complication of nose breathing
Octadin Is a sympatholytic with strong hypotensive effect. During administration of the drug decreasing of blood pressure develops gradually, after 2-3 days. After quitting of drug administration the effect still stays for 2 weeks.
Administration heavy forms of arterial hypertension
Side effects general weakness, nausea, vomiting, swelling of nose mucous membrane, diarrhea, storing of liquid in the organism, orthostatic collapse.
Thanks for attention!
top related