Common Perioperative Medications

1
Common Perioperative Medications

• An Independent Self-study Program
• Safe Medication Administration Tool Kit

2
Introductory Note

• The intent of this independent self-study module
  is to provide the participant with a review of
  the medication categories commonly used in the
  perioperative setting.
• The complexity of this subject prohibits a
  thorough overview in this module of all
  individual medications use in perioperative
  patient care.

3
Objectives

• Discuss the categories of perioperative
  medications
• Review applications for perioperative medications
  
• Identify perioperative medication interactions,
  desired outcomes, adverse reactions, and special
  considerations

4
Table of Contents

• 
  Slide No.
• Inhalation Agents ..................
  ...6
• Central Nervous System Agents ..........
  ..20
• Muscle Relaxant Agents ...............
  .26
• Cholinergic Agents /Anticholinergic
  Agents..........35
• Adrenergic Agents..............41
• Local Anesthetic Agents ............4
  5

5
Table of Contents

• 
  
  Slide No.
• Antiemetic Agents /Antiulcer Agents.
  51
• Anticoagulant /Hemostatic Agents
  ...56
• Antidiabetic Agents ..... 63
• Anti-infective Agents ...69
• Emergency Medications ......84
• Ophthalmic Medications ...... 91
• References ... 98

6
Inhalation Agents

• Although used for many years, it is still not
  fully understood how inhalation agents dull the
  pain centers of the brain.
• Inhalation agents are
• Administered by a licensed anesthesia
  provider.
• Used during general anesthesia (GA).
• Used to provide a controllable state of pain
  free, deep
• amnesic sedation.
• Selected relative to a patients physical
  health, current
• medications, and surgical procedure.

7
Inhalation Agents

• Agents are delivered in the form of anesthetic
  gas or volatile anesthetic liquid via anesthesia
  machine and breathing circuit.
• During administration, the agent moves from the
  anesthesia machine into the patients alveoli
• From the alveoli into the arterial blood
• From the arterial blood it flows to the brain
• The brain becomes saturated with the agent
  forming an equilibrium with the alveolar and
  arterial concentrations.

8
Inhalation Agents

• When termination of the anesthetic agent occurs
  
• The saturation levels of the agent decline
  initially
• Followed by a reduction in the arterial blood
• And a release from the alveoli and lungs, with a
  final elimination into the atmosphere.
• Most complications from inhalation agents occur
  during induction or emergence from anesthesia.

9
Inhalation Agents
Complications that may occur include, but are not
limited to

• Cardiac arrhythmias
• Cardiac arrest
• Hypotension
• Laryngospasm
• Bronchospasm
• Vomiting and aspiration
• Respiratory failure

• Respiratory obstruction (from
• tongue relaxation, excessive
• mucus, edema of the larynx)
• Shock
• Cerebral accidents (from
• arteriosclerotic plaque)
• Convulsions or delirium
• Renal complications

10
Inhalation Agents

• Inhalation agents are depressant medications and
  they affect the hypothalamus, disrupting the
  regulation of the bodys temperature.
• Closely monitor the patient for hypothermia or
  hyperthermia during the recovery phase.
• Sodium retention with potassium loss may occur
  because of the agents effect on the pituitary
  and adrenocortical systems.

11
Inhalation Agents

• Inhalation agents are divided into two
  categories
• Volatile Chemicals when in the liquid state at
  room temperature, have a boiling point of 200oC
  (halogenated hydrocarbons such as halothane and
  ethers such as enflurane).
• Volatile agents can trigger a Malignant
  Hyperthermia (MH) crisis.
• Gaseous Agents that are in the gaseous state at
  room temperature (nitrous oxide).
• These agents are commonly used in general
  anesthesia today

12
Volatile Agents

• Enflurane (Ethrane) A halogenated ether,
  nonflammable,
• and very
  rapid-acting.
• Provides a small amount of muscle relaxation and
  greatly potentiates nondepolarizing skeletal
  muscle relaxants, such as curare.
• Causes cerebral vasodilatation if the patient has
  normal blood pressure. Will reduce cerebral blood
  flow if the patient is hypertensive. Depresses
  arterial blood flow, stroke volume, and systemic
  vascular resistance. May increase the heart rate.
  Enflurane is a potent respiratory depressant.
• The patient regains consciousness quickly and
  usually has no residual analgesia.
• Contraindicated in seizure disorders, diabetes
  mellitus, pregnancy, or with the administration
  of catecholamines.

13
Volatile Agents

• Halothane (Fluothane) A modern inhalation
  anesthetic
• that
  is a saturated hydrocarbon.
• Very rapid-acting and easily controlled so the
  depth of anesthesia can be predictably changed.
• Very potent agent that must be delivered using
  finely calibrated vaporizers. Small amounts are
  absorbed by the brain tissue so recovery to
  consciousness is rapid.
• Sensitizes the heart to catecholamines so
  epinephrine should be administered cautiously in
  PACU, because serious arrhythmias can occur.
• Peripheral vasodilator therefore, blood volume
  must be maintained within normal limits.
• If a narcotic is to be given, the synergistic
  effect with halothane may cause respiratory
  depression.

14
Volatile Agents

• Isoflurane (Forane) A halogenated methyl ethyl
  ether that
• produces a
  dose related depression
• of the
  CNS.
• Reduces systemic arterial blood pressure and
  total peripheral resistance. Heart rate usually
  increases during isoflurane administration.
• Produces respiratory depression and skeletal
  muscle relaxation depending on dosage.
• Potentiates the action of nondepolarizing muscle
  relaxants. Recovery phase is rapid.
• Does not sensitize the heart to catecholamines.

15
Volatile Agents

• Sevoflurane A modern inhalation anesthetic that
  is
• extremely rapid-acting.
• Rapid recovery necessitates pain control with
  analgesic medications immediately
  postoperatively.
• Decreases blood pressure, causes respiratory
  depression, and does not sensitize the heart to
  catecholamines.
• Enhances the action of skeletal muscle relaxants,
  but usually is not a concern since the agent is
  rapidly eliminated.

16
Volatile Agents

• Desflurane (Suprane) A modern agent that is a
  fluorinated
• ether
  similar to isoflurane
• Extremely rapid-acting necessitating the use of
  pain control medications.
• Causes a decrease in blood pressure and cardiac
  output, depending on the dosage used.
• The pungent odor causes respiratory irritation,
  coughing, and laryngospasm therefore, not
  recommended as an inhalation induction agent.
  Causes respiratory depression.
• Eliminated by the respiratory system without
  negative effect to the kidney or liver.

17
Gaseous Agents

• Nitrous oxide Inorganic gas marketed in blue
  steel
• cylinders
• Supports combustion but is not explosive.
• Nontoxic and nonirritating but can cause
  postoperative nausea and vomiting.
• Can be administered alone or in combinations with
  other agents.
• When administered with a volatile inhalation
  anesthetic, such as halothane, nitrous oxide acts
  as a carrier and analgesic.
• Nitrous oxide is flammable and should not be used
  during upper airway procedures that involve
  electro-surgical or laser energy.

18
Review Questions ? Inhalation
Agents

1. Most complications related to the use of
   inhalation agents only occur during emergence
   from anesthesia.
2. True
3. False
4. Inhalation agents know to trigger a MH crisis are
5. Desflurane, nitrous oxide, and halothane
6. Nitrous oxide, halothane, and sevoflurane
7. Desflurane, ethrane, and sevoflurane
8. Isoflurane, halothane, and nitrous oxide

19
Answer Key Inhalation Agents

• False
• Most complications from inhalation
  agents occur during induction and emergence from
  anesthesia.
• 2. Correct answer 3
• Volatile inhalation agents known to
  trigger a MH crisis include enflurane
  (ethrane), halothane (fluothane), isoflurane
  (forane), sevoflurane, and desflurane (suprane).
  Nitrous oxide is a gaseous agent and does not
  trigger MH.

20
Central Nervous System (CNS) Medications
(Narcotics, Analgesics)

• Often used for monitored anesthesia care (MAC),
  
• moderate sedation/analgesia and pain relief.
• Most often administered through the intravenous
  injection
• route providing a rapid onset of action.
• Agents are titrated to patient needs using the
  lowest dose
• required.
• If a narcotic or analgesic medication is
  administered inappropriately, adverse reactions
  can occur, from a drop in blood pressure to
  respiratory or cardiac arrest.
• Narcotic and analgesic antagonists must be
  readily
• available for use.

21
Central Nervous System (CNS) Medications
(Narcotics, Analgesics)

• Antagonists (ie, naloxone, flumazenil) should
  only be given if the patient shows signs of
  respiratory depression or prolonged sedation.
• When antagonists are administered routinely,
  patients may present with a recurrence of
  respiratory depression as the effects of the
  antagonist subside.
• With larger doses of an antagonist is given to
  reverse an opioid, pain, hypertension,
  tachycardia, and pulmonary edema may occur.

22
Non-Opioid Medications

• The following CNS agents are commonly use in
  surgery
• Barbiturates Derivatives of barbituric acid
  that act
• as a sedative or
  hypnotic.
• Nonbarbiturates Rapid-acting agents used for
• induction with no
  cumulative effect.
• Tranquilizers
• Benzodiazepines - Used to enhance anesthesia,
  opiates, and barbiturates when used in
  combination can enhance the hypnotic action of
  other benzodiazepines

23
Opioids and Other Analgesics

• Tranquilizers (continued)
• Butyrophenones Produces a profound state of
  calmness and immobility, allowing the patient to
  be pain-free.
• Benzodiazepine Antagonists
• Reverse the CNS effects of benzodiazepines such
  as sedation and amnesia.
• Narcotic antagonists
• Used to combat the effects of narcotics

24
Review Questions CNS Agents

• Some anti-inflammatory agents are used to treat
  mild to moderate pain in the post surgical
  patient.
• True
• False
• A CNS antagonist agent is routinely administered
  to ensure a quick reversal of narcotic and
  analgesics medications after MAC procedures.
• True
• False

25
Answer Key CNS Agents

• True
• Both anti-inflammatory and nonsteroidal
  medications are used to treat mild to moderate
  pain and as antipyretic agents.
• 2. False
• Routine use of CNS antagonist agents can
  cause
• rebound respiratory depression as the
  antagonist subsides. This places the patient at
  great risk if post procedure monitoring is
  curtailed too soon.

26
Muscle Relaxants

• Muscle relaxants are chemotherapeutic agents that
  
• decrease muscle fiber contractility.
• Muscle relaxants are used in the perioperative
  setting for
• Facilitation of endotracheal intubation
• Procedures requiring muscle relaxation
• Relaxation of extraocular muscles in ophthalmic
  surgery
• Termination of laryngospasm and elimination of
  chest wall rigidity (which may occur after rapid
  administration of a potent narcotic)
• Facilitation of mechanical ventilation by
  paralyzing respiratory muscles.

27
Muscle Relaxants

• Factors to be considered when administering
• neuromuscular blocking agents
• Dehydration increases patient sensitive to agents
• Sodium deficiencies prolong neuromuscular blocks
• Potassium deficiencies increase the agents
  blocking action requiring larger amounts to be
  used
• Calcium depletions prolong the effects of
  nondepolarizing neuromuscular blocking agents and
  conversely potentiate the effect of depolarizing
  agents
• Magnesium excesses enhance the effects of the
  nondepolarizing neuromuscular block and will
  potentiate the action of a depolarizing
  neuromuscular blocking agent

28
Muscle Relaxants

• Factors to be considered when administering
  neuro-
• muscular blocking agents
• pH and carbon dioxide
• Acidosis, with an elevated carbon dioxide
  tension, intensifies the action of a
  neuromuscular blocking agents (ie,
  nondepolarizing)
• Alkalosis usually decreases the effect
• Acidotic states diminish the action of
  depolarizing agents
• Antibiotics
• Certain antibiotics (ie, aminoglycosides) can
  potentiate neuromuscular blocking actions by
  inhibiting the release of the neurotransmitter
  acetylcholine (ACh).

29
Muscle Relaxants

• Factors to be considered when administering
  neuro-
• muscular blocking agents
• Cardiac antidysrhythmic medications
• Can potentiate the action of muscle relaxants
• Temperature
• Low body temperature can potentiate the action of
  some depolarizing muscle relaxants
  (eg, Succinylcholine), or antagonize
  the action of some nondepolarizing agents
  (Curare)
• Inhalation anesthetics
• Will potentiate the action of muscle relaxants

30
Muscle Relaxants

• Nursing considerations during the postanesthesia
  care
• period
• The return of muscle movement will occur in the
• reverse order of muscle relaxation that occurred
• during administration.
• Small, rapidly moving muscles, ie, fingers and
  eyes, are affected first with the long muscles of
  the limbs and trunk affected next
• During recovery, the long muscles will return to
  normal more quickly than the small, rapidly
  moving muscles

31
Types of Muscle Relaxants

• Nondepolarizing Neuromuscular Blocking Agents
• act by blocking ACh to prevent activation of the
  muscle
• Used to facilitate intubation
• Used as a general anesthesia adjunct to induce
  skeletal muscle relaxation
• Decrease muscle contractions during orthopedic
  manipulations
• Long-acting agents may be used to facilitate
  endotracheal intubation or for skeletal muscle
  relaxation during general anesthesia

32
Types of Muscle Relaxants

• Depolarizing Neuromuscular Blocking Agents
• Compete with ACh, causing depolarization and
  blockage
• of the neuromuscular impulse.
• Succinylcholine (Anectine) Initially excites
  skeletal muscles by combining with cholinergic
  receptors (ACh) and prevents muscle contraction
  by interfering with the response of ACh.
• Facilitates endotracheal tube intubation
• Relaxes skeletal muscles during orthopedic
  manipulations
• Known MH-triggering agent

33
Review Questions Muscle Relaxants

• Calcium depletions potentiate the effects of
  nondepolarizing neuromuscular blocking agents and
  conversely prolong the effect of depolarizing
  agents.
• True
• False
• Some muscle relaxants used can lower the
  patients body temperature by inhibiting the
  release of the neurotransmitter acetylcholine
  (ACh).
• True
• False

34
Answer Key Muscle Relaxants

• False
• The opposite is true calcium
  depletions prolong the effects of nondepolarizing
  neuromuscular blocking agents and conversely
  potentiate the effect of depolarizing agents.
• 2. False
• Muscle relaxants do not lower body
  temperature. Low body temperatures can
  potentiate the action of some depolarizing muscle
  relaxants or antagonize some nondepolarizing
  agents.

35
Cholinergic Agents

• Cholinergics are reversal agents used for the
  restoration of neuromuscular transmission after
  the administration of a nondepolarizing
  neuromuscular blocking agent.
• Work by preventing the destruction of ACh that
  assists in the transmission of impulses across
  the myoneural junction.
• Most cholinergics are metabolized by the liver
  and excreted in the urine.
• Should only be administered with atropine sulfate
  available, in case of a cholinergic crisis.

36
Types of Cholinergic Agents

• Neostigmine (Prostigmin)
• Acetylcholinesterase inhibitor
• Leads to an increase in ACh concentration at the
  myoneural junction aiding in the trans-mission of
  impulses across the myoneural junction
• Edrophonium chloride (Reversol/Tensilon)
• Inhibits the destruction of ACh
• Used to reverse effects of neuromuscular blockage

37
Anticholinergic Agents

• Cholinergic blockers inhibit, block, or compete
• With the action of ACh at receptor sites in the
• autonomic nervous system inhibiting the
• neuromuscular transmission across the juncture
  site.
• Used to minimize secretions before surgery and to
  decrease GI, biliary, and urinary tract motility
• Common side effects
• Dryness of the mouth
• Constipation

38
Types of Anticholinergic Agents

• Atropine sulfate
• Blocks the action of ACh on cholinergic
  receptors in smooth muscle, cardiac muscle,
  exocrine glands, urinary bladder, and the AV and
  SA nodes in the heart
• Used as a preoperative medication to diminish
  secretions and block cardiac vagal reflexes
• Glycopyrrolate (Robinul)
• Inhibits the action of ACh at the
  receptor sites of the autonomic nervous system
  (responsible for gastric acid secretion and
  control)
• Used preoperatively to diminish secretions and
  block cardiac vagal reflexes

39
Review Questions
Cholinergics/Anticholinergics

• Most cholinergic agents
• Are metabolized by the liver and excreted by the
  kidney
• Promote the destruction of ACh and improve
  impulse transmission at the myoneural junction
• Should only be administered with epinephrine on
  hand
• Are used to enhance neuromuscular blockage during
  intubation
• 2. Anticholinergics are used preoperatively to
  minimize
• gastric secretions and reduce GI, biliary,
  and urinary
• tract mobility.
• True
• False

40
Answer Key Cholinergics/Anticholin
ergics

• Correct Answer 1
• Most cholinergics are metabolized by the
  liver and excreted in the urine.
• 2. True
• Anticholinergics block, inhibit, or
  compete with ACh at receptor sites reducing
  impulse transmission across the neuromuscular
  junction and reducing motility of GI, biliary,
  and urinary tract musculature.

41
Adrenergics (sympathomimetics)

• Adrenergic medications affect the sympathetic
  nerve fibers
• of the autonomic nervous system using epinephrine
  or
• epinephrine-like substances as neurotransmitters.
  
• These agents affect involuntary vital functions,
  such as cardiac muscles, smooth muscles, and
  glandular functioning
• Occupy receptor sites of the sympathetic nervous
  system or increase the release of the
  neurotransmitter to stimulate organs and
  structures
• Action and target sites of various adrenergics
  can cause
• Bronchodilation, cardiac stimulation,
  prolongation of local anesthesia, and
  vasoconstriction

42
Adrenergics (sympathomimetics)

• Adverse effects vary and include, but are not
  limited to, nervousness, headache, nausea,
  vomiting, anxiety, dilated pupils, insomnia,
  dyspnea, and palpitations
• Most popular adrenergics
• Epinephrine (Adrenalin) Used in the treatment
  of bronchospasm, shock, and anaphylaxis to
  prolong the effects of a local anesthetic, to
  restore cardiac rhythm during a cardiac arrest
• Phenylephrine hydrochloride (Neosynephrine)
  Used to treat hypotension during spinal
  anesthesia, for prolonging the effects of spinal
  anesthesia, and as a vasoconstrictor for regional
  anesthesia

43
Review Questions Adrenergic
Agents

• Adrenergic agents affect the receptor sites of
  the involuntary muscle groups of the heart,
  smooth muscles, and glandular systems.
• True
• False

44
Answer Key Adrenergic Agents

• True
• Adrenergic agents affect the sympathetic
  nerve fibers of the autonomic nervous system that
  use epinephrine or epinephrine-like substances as
  neurotransmitters. Target responses include
  bronchodilation, cardiac stimulation, and
  vasoconstriction.

45
Local Anesthetics

• Local anesthetics are administered through
  infiltration
• or topical application when a selected area/body
  part
• is to be anesthetized.
• When an anesthesia provider is not required, a RN
  monitors the patient
• Used for minor procedures, when a patients
  physical condition cannot withstand other forms
  of anesthesia, or when the patients cooperation
  is necessary during a procedure
• Produce a loss of sensation in an area of the
  body by blocking the transmission of nerve
  impulses

46
Local Anesthetics

• Adverse side effects
• May escalate to lethal anaphylaxis, respiratory
  or cardiac arrest
• Effects are dependent on
• the patients hypersensitivity to the agent
• the rate of medication administered
• the vascularity of the injection site
• the action of the medication
• the presence of epinephrine
• Epinephrine affects medication absorption and is
  sometimes used to constrict the blood vessels in
  the surgical area to prolong the effects of the
  local agent

47
Local Anesthetics

• Local anesthesia edications
• can be used for local
• infiltration or regional
• anesthesia according to the
• length of duration.
• Short-Duration Local
• Anesthetics are used for
• Spinal anesthesia
• Epidurals
• Peripheral nerve block

• Local Anesthetics are
• used for
• Local infiltration
• Vasoconstriction of
• mucous membranes,
• in oral, nasal, and
• laryngeal cavities
• Lumbar blocks

48
Local Anesthetics

• Intermediate-Duration Local Anesthetics are used
  for
• Caudal or epidural block
• Lumbar block
• Retrobulbar block
• Peripheral nerve block

• Long-Duration Local Anesthetics are used for
• Local infiltration
• Retrobulbar, caudal
• block
• Lumbar block
• Peripheral nerve block
• Subarachnoid block
• Transtracheal anesthesia
• Low spinal anesthesia

49
Review Questions Local
Anesthetics

• A 20 year old patient with a history of Raynauds
  Disease is scheduled for excision of a lesion on
  the right long (middle) finger under local
  anesthesia. As the circulating RN you would be
  most concerned about
• A possible hypersensitivity to the local agent
• Using a local agent with epinephrine
• The rate of infiltration into the surgical site
• The presence of ischemia at the surgical site

50
Answer Key Local Anesthetics

• Correct answer 2
• Using a local agent with epinephrine will
  constrict the vasculature of the surgical site.
  A patient with Raynauds Disease is predisposed
  to ischemia. The addition of epinephrine to an
  ischemic surgical site will contribute to
  irreversible tissue death.

51
Antiemetics

• Antiemetic medications are administered to
  prevent
• or alleviate nausea and vomiting.
• Patients with a higher incidence of
  postanesthesia nausea and vomiting (PONV)
  include
• Female
• Nonsmokers
• Users of postoperative opioids
• Previous history of nausea and vomiting or motion
  sickness

52
Antiemetics

• Treatment for PONV in the postanesthesia care
  unit (PACU) is prophylaxis and/or therapy using
  selective antiemetic medications combined with
  supplemental oxygen.
• A popular antiemetic used in the perioperative
  setting is metoclopramide hydrochloride (Reglan).
  This gastrointestinal (GI) stimulant acts by
  increasing sensitivity to ACh resulting in
  increased upper GI tract motility and relaxation
  of the pyloric sphincter and duodenal bulb.

53
Antiulcer Medications

• Antiulcer medications are H2-histamine receptor
  antagonists.
• By inhibiting histamine at the H2 receptor site
  of gastric parietal cells responsible for the
  secretion of hydrochloric acid, gastric
  secretions are limited.
• Used for the treatment of duodenal and gastric
  ulcers and gastroesophageal reflux syndrome .
• Antacids may interfere with the absorption of
  selected antiulcer medications.

54
Review Questions Antiemetics /
Antiulcer Agents

• Patients with a higher incidence of PONV include
  (select the incorrect answer)
• Females
• Smokers
• Users of postoperative opioids
• Previous history of PONV or motion sickness
• Reglan (metoclopramide hydrochloride) will
  interfere with the absorption of selected
  antiulcer medications.
• True
• False

55
Answer Key Antiemetics/Antiulcer
agents

• Correct answer 2
• Smokers nonsmokers have a greater incidence of
  PONV.
• 2. False
• Antacids may interfere with the absorption of
  selected antiulcer medications.

56
Anticoagulants

• Anticoagulants delay or prevent the formation of
  blood clots by
• Depressing the hepatic synthesis of vitamin
  K-dependent clotting factors II, VII, IX, and X
• or by
• Enhancing the inhibitory effects of antithrombin
  III, preventing the conversion of fibrinogen to
  fibrin and prothrombin to thrombin
• Useful during open-heart surgery, with myocardial
  infarction and pulmonary embolism, and to prevent
  deep vein thrombosis formation

57
Anticoagulants

• Effects can be potentiated by use of steroids,
  salicylates, and nonsteroidal anti-inflammatory
  agents
• To maintain steady blood levels, anticoagulants
  should be administered at the same time each day
• Serious adverse reaction is hemorrhage
• Common side effects include diarrhea, fever, and
  rash
• Patients on anticoagulant therapy must stop
  treatment prior to surgery.

58
Heparin Antagonists

• Heparin antagonists bind with heparin making it
  ineffective by forming a physiologically inert
  complex.
• Administered to reverse the effects of heparin
  therapy or in the event of heparin overdose.
• The therapeutic response of heparin reversal must
  be carefully assessed and monitored to closely
  evaluate desired effects of treatment.

59
Hemostatic Agents

• Used to control bleeding during surgery by
  affecting the various blood clotting agents.
• Preparations available include collagens,
  gelatins, cellulose products, and thrombin
  agents.
• The most popular hemostatic agents are listed
  with
• brief descriptions
• Avetine (microfibrillar collagen)
• Reduces capillary bleeding through hemostasis
• Applied directly to the bleeding site in a
  dry-powdered form or compressed sheet

60
Hemostatic Agents

• Gelfoam (absorbable gelatin sponge)
• Reduces capillary bleeding through hemostasis
• Placed directly on the bleeding surface
• May be soaked in topical thrombin to enhance
  absorption and hemostatic action
• Gelfoam does not have to be removed
• Surgicel (oxidized cellulose)
• Reduces capillary bleeding through hemostasis
• Placed topically on the bleeding area to absorb
  the blood and decrease bleeding
• Removed after hemostasis has been achieved
• Topical thrombin
• Reduces capillary bleeding through hemostasis
• Needs to be reconstituted before use

61
Review Questions
Anticoagulant / Hemostatic
Agents

• The effects of anticoagulant agents can be
  potentiated by the use of nonsteroidal
  anti-inflammatory agents, steroids, and
  salicylates.
• True
• False
• 2. Select the statement that is NOT true for
  all hemostatic agents
• Are used to control bleeding during surgery by
  affecting various clotting agents
• Reduce capillary bleeding through hemostasis
• Are applied directly to the affected site
• Do not need to be removed

62
Answer Key
Anticoagulants/Hemostatic
Agents

• True
• Steroids, salicylates, and nonsteroidal
  anti-inflammatory medications can potentiate
  anticoagulant agents.
• 2. Correct answer 4
• Surgical (oxidized cellulose) needs to be
  removed after the desired affect is achieved.

63
Antidiabetic Medications

• Used to treat diabetes mellitus types I and II
  and ketoacidosis by stabilizing the bodys
  metabolism of sugars and carbohydrates.
• Antidiabetic medications can be divided into two
  classifications
• Insulins A pharmacologic preparation of the
  hormone insulin that lowers blood glucose levels
  and helps regulate processes necessary for the
  metabolism of fats, carbohydrates, and proteins
• Oral antidiabetics Cause the functioning
  pancreatic beta cells of the Islets of Langerhans
  to release insulin and improve the effect of
  endogenous and exogenous insulin.

64
Antidiabetic Medications

• Most replacement insulin is given through
  subcutaneous injection closely following
  individualized patient dosage schedules.
• Injection sites should be rotated and the site
  documented in the patient record
• Injection sites include the abdomen, upper arm,
  thighs, upper back, and buttocks
• Adverse reactions to insulin injections include
  allergic responses, and, rarely, anaphylaxis.
• May be administered by the intravenous route.

65
Antidiabetic Medications

• Oral agents are used for
• Stable adult-onset diabetes mellitus type II.
• Should be avoided for brittle diabetes or
  juvenile diabetes, diabetic ketoacidosis, or
  severe renal or hepatic disease.
• Adverse reactions include blood dyscrasias and
  hepatotoxicity.
• Common side effect for all antidiabetic
  medications is hypoglycemia.

66
Antidiabetic Medications

• The onset of action, peak activity, and duration
  of antidiabetic medications vary extensively
  among the different agents.
• Blood and urine specimens can be obtained to
  determine the effectiveness of diabetes control.
• The perioperative nurse should determine the
  agent used and when the last dose was taken prior
  to surgery.
• Preoperative patient instruction should include a
  review of the dosaging schedule specific to the
  day of surgery.

67
Review Questions Antidiabetic
Agents

• Surgical interventions cause psychological and
  physical stress responses in the diabetic
  patient. As the preoperative RN you would
  instruct the patient to (select the most
  appropriate answer)
• Hold all antidiabetic medications until after
  surgery.
• Identify the subcutaneous injection site used on
  the day of surgery.
• Check his/her urine prior to arriving to the
  hospital.
• Follow the dosaging schedule prescribed for the
  day of surgery.

68
Answer Key Antidiabetic Agents

• Correct answer 4
• Preoperative patient instructions should always
  include the antidiabetic dosaging schedule
  specific to the day of surgery. This may include
  instruction to medicate or hold antidiabetic
  agents and whether to include a light meal prior
  to arrival for surgery.

69
Anti-Infective Medications

• The terms anti-infective, antimicrobial,
  antibacterial,
• and antibiotic are used to describe medications
  in the
• treatment of infection.
• Anti-infective A broad term pertaining to an
  agent that prevents or treats infective organisms
  ideally without harm or untoward effects to the
  infected person.
• Antimicrobial An agent that kills or stops the
  growth or replication of an infective
  microorganism.
• Antibacterial An agent that kills or inhibits
  the growth or replication of a bacterial
  substance.

70
Anti-Infective Medications

• Antibiotic An antimicrobial substance made from
  a naturally occurring product of a microorganism,
  or from a chemically modified derivative of this
  naturally occurring substance, to treat
  infections.
• Usually given for the antibacterial properties,
  but some are also active against fungi.
• Antibiotics are not effective against viral
  infections, but antiviral agents, made from all
  synthetic ingredients, are available to treat
  viral infections.
• Work by inhibiting the bacterial cell wall
  synthesis (ie, penicillins, cephalosporins).

71
Anti-Infective Medications

• Work by (continued)
• Altering permeability of the cell membrane (ie,
  polymyxin B, nystatin).
• Inhibiting microbial DNA translation and
  transcription (ie, erythromycin, tetracycline,
  streptomycin).
• Inhibiting essential metabolite synthesis (ie,
  sulfonamides, paraaminosalicylic acid).
• Unwanted side effects include, but are not
  limited to
• Allergic reactions

72
Anti-Infective Medications

• Unwanted side effects (continued)
• May disturb the bodys normal flora, causing an
  overgrowth of other organisms (seen as diarrhea,
  severe colitis, oral or vaginal yeast infections,
  etc.)
• The emerging resistance to antibacterial agents
• Toxicity to body organs and tissues (eg,
  nephrotoxic, ototoxic)
• Gastrointestinal irritation and dysfunction
• Fetal deformity, demise

73
Anti-Infective Medications

• Unwanted side effects (continued)
• photosensitivity
• rash or dermatitis
• blood dyscrasias
• The most common side effects are nausea,
  vomiting, and diarrhea.
• Adverse reactions can include bone marrow
• depression and anaphylaxis.

74
Anti-Infective Medications

• The onset, peak action, and duration of the
  anti-infective medications vary significantly
  from medication to medication, but most agents
  are metabolized in the liver and excreted in the
  urine, bile, and feces.
• There are hundreds of different antibiotics
  available with new agents being introduced
  regularly. Perioperative nurses should have a
  basic understanding of the general principles and
  the main groups of antibiotic agents.

75
Anti-Infective Medications

• The spectrum of an antibiotic agent refers to the
  range
• of effectiveness and its capability to kill
  microorganisms.
• A broad spectrum antibiotic has the ability to
  kill a wide
• range of species, while a narrow spectrum agent
  kills a
• limited range of microbes.
• A broad spectrum antibiotic is often used when
  the invading microorganism has not been
  identified.
• Broad spectrum agents also kill large quantities
  of normal bacterial flora.
• After identifying the invading organism,
  treatment changes to a narrow spectrum agent.

76
Anti-Infective Medications

• Potency refers to the concentration of the
  antimicrobial agent, which is required to kill a
  microorganism or inhibit its growth.
• Minimum inhibitory concentration (MIC) describes
  the lowest concentration of an antimicrobial
  agent that will completely inhibit the growth of
  an infective microorganism.
• Minimal bactericidal concentration (MBC) refers
  to the lowest concentration of an agent to
  effectively kill the invading microorganism.

77
Anti-Infective Medications

• Synergy and antagonism are often used to describe
  antibacterial agents.
• When two antibiotics work better together than
  alone, the medications are synergistic.
• If antibiotics work better alone than when used
  together, the medications are antagonistic.
• Antibiotics prescribed for prophylaxis are
  intended to protect the patient from unwanted
  infection. This may be due to the type of
  surgery or the patients state of physical
  wellness at the time of surgical intervention.

78
Anti-Infective Medications

• Prophylaxis treatment saturates the tissue with
  antibiotics and minimizes the patients risk for
  infection.
• The timing of antibiotic administration
  preoperatively is extremely important if the
  medication is to be effective.
• Depending on the type of prophylactic medication,
  it should be infused within 60 minutes prior to
  the surgical incision.
• Exceptions include medications requiring an
  extended infusion time prior to the surgical
  incision.

79
Anti-Infective Medications

• Prophylactic medications are infused before a
  tourniquet is inflated.
• The antibiotic chosen should be based on the type
  of bacteria most likely to cause an infection for
  each procedure.
• Prophylactic antibiotic administration is not
  appropriate for all surgeries, but has
  significantly impacted outcomes for abdominal,
  urological, and gynecological procedures.
• The following anti-infective medications are
  often used in the perioperative setting

80
Anti-Infective Medications

• Aminoglycosides Composed of amino sugars in a
  glycoside linkage interfere with the synthesis
  of the bacterial proteins used frequently to
  treat infections caused by gram-negative
  organisms.
• Cephalosporins Inhibit bacterial cell wall
  synthesis derived from the soil fungus
  Cephalosporium or produced semisynthetically
  used to treat infections caused by a wide range
  of gram-positive and gram-negative organisms.
• Sulfonamides Synthetic, bacteriostatic (not
  bacteriocidal) medication that is effective in
  treating many gram-negative and gram-positive
  infections works by inhibiting essential
  metabolite synthesis.

81
Anti-Infective Medications

• Penicillins derived from species of the fungus
  Penicillium or manufactured semisynthetically
  inhibit bacterial cell wall synthesis can be
  inactivated by the enzyme penicillinase produced
  by strains of staphylococci broad-spectrum
  penicillins are effective against gram-negative
  organisms penicillin therapy can cause
  hypersensitivity reactions.
• Miscellaneous Anti-Infectives often new
  generation agents falling outside of previous
  categories of anti-infective medications. Agents
  act to suppresses protein synthesis or inhibit
  bacterial cell wall synthesis.

82
Review Questions Anti-infective
Agents

• Surgical prophylactic antibiotic treatment
  (select the correct answer)
• is proven useful in all surgical situations.
• must be administered 30 minutes to 2 hours prior
  to surgery for maximum effectiveness.
• is only effective when administered before
  inflation of the surgical tourniquet.
• uses a broad spectrum antibiotic.
• 2. New generations of antibiotics are available
  to treat both bacterial and viral infections.
• True
• False

83
Answer Key Anti-infective Agents

• Correct answer 3
• Prophylactic anti-infective agents are selected
  according to the bacteria most likely encountered
  during surgery, are administered 30 minutes to 1
  hour prior to incision, and have not been
  validated for all surgical interventions.
• 2. False
• Antibiotics treat bacterial infections and
• synthetic antiviral agents are available
  to
• treat viral infections.

84
Emergency Medications

• The perioperative nurse should be attentive to
  the medications on the emergency cart in the
  perioperative setting.
• Emergency medications should be regularly checked
• For predetermined emergency medications on hand
• The medication expiration date
• The correct count of each emergency medication
• The correct concentration or dosage for each
  medication
• Medications should be arranged on the cart to
  permit quick and easy access during emergency
  situations.

85
Emergency Medications Categories

• Emergency medications found on the crash cart
  include
• Antidysrhythmics
• Electrolyte replacements and calcium channel
  blocking agents
• Glucose
• Used to promote adequate utilization of amino
  acids, while preventing ketosis and protein or
  nitrogen loss
• Anxiolytics, hypnotics, and sedatives
• Anticonvulsant, neuromuscular, and skeletal
  muscle relaxant agents

86
Emergency Medication Categories

• Emergency medications found on the crash
• cart include (continued)
• Cardiotonics and stimulants
• Adrenergic agents
• Diruretics
• Antihypertensives
• Anticoagulants
• Opioid antagonists

87
Emergency Medication Categories

• Dantrolene Sulfate A skeletal muscle relaxant
  that slows catabolism in malignant
  hyperthermia (MH)
• Decreases the release of calcium from the storage
  sites in muscle.
• Can be used with non-depolarizing relaxants and
  will not interfere with reversal of muscle
  relaxants.
• May cause significant muscle weakness in patients
  with pre-existing muscle disease.
• Phlebitis often follows administration of
  dantrolene, and therefore should be infused
  through the largest possible vein .

88
Emergency Medication Categories

• Dantrolene Sulfate (continued)
• When used with non-depolarizing muscle relaxants,
  evaluate the return of muscle strength prior to
  extubation.
• May produce life-threatening hyperkalemia and
  myocardial depression when used with calcium
  channel blockers.
• Once successfully treated with intravenous
  dantrolene, the patient may be switched to oral
  dantrolene for several days.

89
Review Questions Emergency
Medications

• 1. Dantrolene Sulfate is used to slow catabolism
  in MH. It is critical to evaluate the return of
  muscle strength prior to patient extubation when
  non-depolarizing muscle relaxants are used.
• True
• False
• 2. The emergency medication cart should be
  checked for desired types of emergency
  medications, medication expiration dates,
  concentrations/dosages for each medication and
  the needed inventory for each emergency
  medication.
• True
• False

90
Answer Key Emergency Medications

• True
• Dantrolene can worsen muscle weakness in
  patients with muscle disease. If used in
  combination with non-depolarizing agents, it is
  imperative to assess the patients muscle
  strength prior to extubation.
• 2. True
• The perioperative nurse should be familiar
  with each medication on the emergency cart
  including drug type, quantity, expiration date
  and necessary concentration of each emergency
  medication.

91
Ophthalmic Medications

• Ophthalmology medications are used widely in the
• perioperative environment and must be
  administered
• appropriately to avoid unwanted, adverse
  reactions.
• An understanding of the uses, preparations,
  dosages, side effects, and contraindications will
  ensure patient safety and comfort as many
  ophthalmology surgeries are now performed using
  local or regional anesthesia.

92
Ophthalmic Medications

• Miotics Cause constriction of the pupil and
  reduction of the intraocular pressure during
  glaucoma procedures and during other surgeries
  when the intraocular pressure must be lowered.
• Cycloplegics For paralysis of ciliary muscles,
  anticholinergic medications.
• Mydriatics Used to dilate the pupil and
  paralyze the ocular muscles of accommodation.
• Enzymatics Used during cataract surgery to
  dissolve the zonule fibers of the ciliary body
  attached to the lens.

93
Ophthalmic Medications

• Topical Anesthetics Applied topically to reduce
  the pain sensation in or on the eye.
• Injectable Anesthetics Used to reduce pain
  sensation in the eye.
• Anti-infectives Used to control infections of
  the eye.
• Anti-inflammatories Used to decrease
  inflammation of the eye.
• Viscoelastics Provide lubrication or support
  for the eye.

94
Ophthalmic Medications

• Viscoadherents Provide a cushion effect to
  minimize trauma when applying an external lens on
  the surface of the eye.
• Irrigants Provide moisture to eye surfaces can
  be used as an irrigant during surgical eye
  procedures.
• Miscellaneous Ophthalmology Medications
• Timolol maleate (Timoptic) Used for the
  treatment of increased intraocular pressure.

95
Ophthalmic Medications

• Miscellaneous Medications (continued)
• Fluorescein Used for angiography though
  intravenous injection to diagnose retinal
  disorders used topically as fluorescein strip to
  temporarily stain the cornea to note denuded
  epithelium.
• Acetazolamide sodium (Diamox) Given
  intravenously to decrease the secretion of
  aqueous humor and decrease the intraocular
  pressure.

96
Review Questions Ophthalmic
Medications

• Viscoelastic medications provide a cushion effect
  to minimize ocular trauma when applying an
  external lens to the eye surface.
• True
• False
• Fluorescein is used to identify corneal and
  retinal disorders by way of intravenous
  injection.
• True
• False

97
Answer Key Ophthalmic Medications

• False
• Viscoelastics provide lubrication and
  support to the eye. Viscoadherents provide a
  cushion effect during placement of an external
  lens onto the eye.
• 2. False
• Fluorescein is used intravenously to
  diagnose retinal disorders and topically as a
  strip to stain the cornea to identify injury.

98
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