Transcript Slide 1

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
Complications that may occur include, but are not limited to:

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Cardiac arrhythmias
Cardiac arrest
Hypotension
Laryngospasm
Bronchospasm
Vomiting and aspiration
Respiratory failure

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
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Respiratory obstruction (from
tongue relaxation, excessive
mucus, edema of the larynx)
Shock
Cerebral accidents (from
arteriosclerotic plaque)
Convulsions or delirium
Renal complications
Inhalation Agents
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 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 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.
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 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 electrosurgical or laser energy.
Review Questions
Inhalation Agents
1. Most complications related to the use of
inhalation agents only occur during
emergence from anesthesia.
1. True
2. False
2. Inhalation agents know to trigger a MH crisis
are
1. Desflurane, nitrous oxide, and halothane
2. Nitrous oxide, halothane, and sevoflurane
3. Desflurane, ethrane, and sevoflurane
4. 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
Medications (Narcotics, Analgesics)
(CNS)
 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.
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.
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. True
2. False
2.
A CNS antagonist agent is routinely
administered to ensure a quick reversal of
narcotic and analgesics medications after MAC
procedures.
1. True
2. 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:
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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:
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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 neuromuscular 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 neuromuscular 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)
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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
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Used to facilitate intubation
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Used as a general anesthesia adjunct to induce
skeletal muscle relaxation
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Decrease muscle contractions during orthopedic
manipulations
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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. True
2. False
2.
Some muscle relaxants used can lower the
patient’s body temperature by inhibiting the
release of the neurotransmitter acetylcholine
(ACh).
1. True
2. 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 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
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
Review Questions –
Cholinergics/Anticholinergics
1.
Most cholinergic agents:
1. Are metabolized by the liver and excreted by the
kidney
2. Promote the destruction of ACh and improve
impulse transmission at the myoneural junction
3. Should only be administered with epinephrine
on hand
4. 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. True
2. 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.
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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.
2.
True
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 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 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 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
Local Anesthetics

Intermediate-Duration
Local Anesthetics are
used for:
 Caudal or epidural block
 Long-Duration Local
Anesthetics are used for:

Local infiltration

Retrobulbar, caudal
block
 Lumbar block
 Retrobulbar block
 Peripheral nerve 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.
2.
3.
4.
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
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.
2.
3.
4.
1.
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.
1.
2.
True
False
Answer Key –
Antiemetics/Antiulcer agents
1.
Correct answer #2:
Smokers; nonsmokers have a greater
incidence of PONV.
2.
False
Antacids 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 Kdependent 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 with
brief descriptions:

Avetine (microfibrillar collagen)
 Reduces capillary bleeding through hemostasis
 Applied directly to the bleeding site in a drypowdered 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 antiinflammatory agents, steroids, and salicylates.
1. True
2. 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 agents
2. Reduce capillary bleeding through hemostasis
3. Are applied directly to the affected site
4. 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 antiinfective 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 grampositive 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. True
2. False
Answer Key –
Anti-infective Agents
1. 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.
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 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.
1. True
2. 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. True
2. 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 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.
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. True
2. False
2. Fluorescein is used to identify corneal
and retinal disorders by way of
intravenous injection.
1. True
2. False
Answer Key –
Ophthalmic Medications
1.
2.
False
Viscoelastics provide lubrication and
support to the eye. Viscoadherents
provide a cushion effect during
placement of an external lens onto the
eye.
False
Fluorescein is used intravenously to
diagnose retinal disorders and topically
as a strip to stain the cornea to identify
injury.
Bibliography
American 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/B5DBDF1220C3-4537-948C098DAB0777E3.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).