Common Perioperative Medications

An Independent Self-study Program

Safe Medication Administration Tool Kit

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.

Objectives

Discuss the categories of perioperative medications

Review applications for perioperative medications

Identify perioperative medication interactions, desired outcomes, adverse

reactions, and special considerations

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 …………….....………….……..….…...45

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

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 patient’s physical health, current medications, and surgical procedure.

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 patient’s 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.

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.

Inhalation Agents

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

Complications that may occur include, but are not limited to:

Inhalation agents are depressant medications and they affect the hypothalamus, disrupting the regulation of the body’s temperature.

Closely monitor the patient for hypothermia or hyperthermia during the recovery phase.

Sodium retention with potassium loss may occur because of the agent’s effect on the pituitary and adrenocortical systems.

Inhalation Agents

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:

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.

Volatile AgentsHalothane (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.

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.

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.

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.

Gaseous AgentsNitrous 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.

Review Questions Inhalation Agents

1. Most complications related to the use of inhalation agents only occur during emergence from anesthesia.1. True2. False

2. Inhalation agents know to trigger a MH crisis are1. Desflurane, nitrous oxide, and halothane2. Nitrous oxide, halothane, and sevoflurane 3. Desflurane, ethrane, and sevoflurane4. Isoflurane, halothane, and nitrous oxide

Answer Key – Inhalation Agents

1. 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.

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.

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.

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

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

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

Review Questions – CNS Agents

1. Some anti-inflammatory agents are used to treat mild to moderate pain in the post surgical patient.

1. True2. False

2. A CNS antagonist agent is routinely administered to ensure a quick reversal of narcotic and analgesics medications after MAC procedures.

1. True2. False

Answer Key – CNS Agents

1. 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.

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.

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 agent’s 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

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).

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

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

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

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

Review Questions – Muscle Relaxants

1. Calcium depletions potentiate the effects of nondepolarizing neuromuscular blocking agents and conversely prolong the effect of depolarizing agents.

1. True2. False

2. Some muscle relaxants used can lower the patient’s body temperature by inhibiting the release of the neurotransmitter acetylcholine (ACh).

1. True2. False

Answer Key – Muscle Relaxants

1. 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.

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.

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

Anticholinergic Agents

Cholinergic blockers inhibit, block, or compete With the action of ACh at receptor sites in theautonomic 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

Types of Anticholinergic AgentsAtropine 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

Review Questions – Cholinergics/Anticholinergics

1. Most cholinergic agents:1. Are metabolized by the liver and excreted by the

kidney2. Promote the destruction of ACh and improve

impulse transmission at the myoneural junction3. Should only be administered with epinephrine on

hand4. 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.

1. True2. False

Answer Key – Cholinergics/Anticholinergics

1. 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.

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

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

Review Questions – Adrenergic Agents

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

1. True2. False

Answer Key – Adrenergic Agents

1. 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.

Local Anesthetics Local anesthetics are administered through infiltrationor topical application when a selected area/body partis to be anesthetized. When an anesthesia provider is not required, a RN monitors

the patient

Used for minor procedures, when a patient’s physical condition cannot withstand other forms of anesthesia, or when the patient’s cooperation is necessary during a procedure

Produce a loss of sensation in an area of the body by blocking the transmission of nerve impulses

Local Anesthetics Adverse side effects

May escalate to lethal anaphylaxis, respiratory or cardiac arrest

Effects are dependent on: the patient’s 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

Local Anesthetics Local anesthesia edicationscan be used for local infiltration or regionalanesthesia 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

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

Review Questions – Local Anesthetics

1. A 20 year old patient with a history of Raynaud’s 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:

1. A possible hypersensitivity to the local agent2. Using a local agent with epinephrine3. The rate of infiltration into the surgical site4. The presence of ischemia at the surgical site

Answer Key – Local Anesthetics

1. Correct answer #2

Using a local agent with epinephrine will constrict the vasculature of the surgical site. A patient with Raynaud’s Disease is predisposed to ischemia. The addition of epinephrine to an ischemic surgical site will contribute to irreversible tissue death.

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

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.

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.

Review Questions – Antiemetics / Antiulcer Agents

1. Patients with a higher incidence of PONV include (select the incorrect answer):

1. Females2. Smokers3. Users of postoperative opioids4. Previous history of PONV or motion sickness

1. Reglan (metoclopramide hydrochloride) will interfere with the absorption of selected antiulcer medications.

1. True2. False

Answer Key – Antiemetics/Antiulcer agents

1. Correct answer #2: Smokers; nonsmokers have a greater incidence of PONV.

2. FalseAntacids may interfere with the absorption of selected antiulcer medications.

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

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.

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.

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 withbrief descriptions:

Avetine (microfibrillar collagen) Reduces capillary bleeding through hemostasis Applied directly to the bleeding site in a dry-powdered

form or compressed sheet

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

Review Questions – Anticoagulant / Hemostatic Agents

1. The effects of anticoagulant agents can be potentiated by the use of nonsteroidal anti-inflammatory agents, steroids, and salicylates.1. True2. False

2. Select the statement that is NOT true for all hemostatic agents:1. Are used to control bleeding during surgery by

affecting various clotting agents2. Reduce capillary bleeding through hemostasis3. Are applied directly to the affected site4. Do not need to be removed

Answer Key – Anticoagulants/Hemostatic Agents

1. 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.

Antidiabetic Medications Used to treat diabetes mellitus types I and II and ketoacidosis

by stabilizing the body’s 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.

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.

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.

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.

Review Questions – Antidiabetic Agents

1. 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):

1. Hold all antidiabetic medications until after surgery.

2. Identify the subcutaneous injection site used on the day of surgery.

3. Check his/her urine prior to arriving to the hospital.

4. Follow the dosaging schedule prescribed for the day of surgery.

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.

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.

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).

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

Anti-Infective Medications

Unwanted side effects (continued)

May disturb the body’s 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

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.

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.

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.

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.

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 patient’s state of physical wellness at the time of surgical intervention.

Anti-Infective Medications

Prophylaxis treatment saturates the tissue with antibiotics and minimizes the patient’s 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.

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:

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.

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.

Review Questions – Anti-infective Agents

1. Surgical prophylactic antibiotic treatment (select the correct answer)

1. is proven useful in all surgical situations.2. must be administered 30 minutes to 2 hours prior to

surgery for maximum effectiveness.3. is only effective when administered before inflation

of the surgical tourniquet.4. uses a broad spectrum antibiotic.

2. New generations of antibiotics are available to treat both bacterial and viral infections.

1. True2. False

Answer Key – Anti-infective Agents

1. Correct answer #3Prophylactic 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.

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.

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

Emergency Medication Categories

Emergency medications found on the crash cart include (continued):

Cardiotonics and stimulants

Adrenergic agents

Diruretics

Antihypertensives

Anticoagulants

Opioid antagonists

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 .

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.

Review Questions – Emergency Medications1. 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.

1. True2. 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.

1. True2. False

Answer Key – Emergency Medications

1. 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 patient’s 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.

Ophthalmic Medications

Ophthalmology medications are used widely in the perioperative environment and must be administeredappropriately 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.

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.

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.

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.

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.

Review Questions – Ophthalmic Medications

1. Viscoelastic medications provide a cushion effect to minimize ocular trauma when applying an external lens to the eye surface.

1. True2. False

2. Fluorescein is used to identify corneal and retinal disorders by way of intravenous injection.

1. True2. False

Answer Key – Ophthalmic Medications

1. 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.

BibliographyAmerican Health Consultants, “Fight infection before it develops,” Same Day Surgery,

(November 2002).

AORN, “AORN Guidance Statement: Safe Medication Practices in Perioperative Practice Settings,” AORN Standards ,Recommended Practices, and Guidelines (Denver, CO: AORN, 2004).

AORN, “Standards: Patient Outcomes,” Standards, Recommended Practices, and Guidelines (Denver, CO: AORN, 2004).

MHAUS, “Drugs, Equipment, and Dantrolene - Managing MH”, online broacher, http://mhaus.org/index.cfm/fuseaction/OnlineBrochures.Display/BrochurePK/B5DBDF12-20C3-4537-948C098DAB0777E3.cfm\, accessed 20 February 2005.

Mosby’s Nursing Drug Reference (St. Louis, MO: Mosby, 2003).

Nursing 2004 Drug Handbook 24th ed (Philadelphia, PA: Lippincott Williams & Wilkins, 2004)

USP, Medication Information for the Health Care Professional, 20th ed (Englewood, CA: Micromedex, 2000).

D Watson, Conscious Sedation/Analgesia, (St. Louis, MO: Mosby, 1998).