Pharmacology Lecture #2

Care and Handling of Medications and Solutions Medication Identification: Medications come in a variety of packaging Glass, Metal, and Plastic Common Types of Containers in the OR: Ampule Tubes Vial Paper Preloaded syringe Foils/plastic Glass breaks and is considered a sharp for

disposal purposes

Read Medication Labels and Check

Name (trade & generic)

Manufacturer Strength Amount Expiration

Route Lot number Handling/Storage

directions Classification (if

controlled substance)

Identification

Name, strength, amount, and expiration should be checked three times before use

1. When obtained

2. Prior to preparation or delivery to sterile field

3. After on the sterile field and prepared for use will be labeled by the surgical technologist

Labeling Medications

Medications are labeled according to institutional policy

Some labels come prepared sterile Blank labels are included in sterile packs

and can be written on with a sterile marker Steri-strips can be used as labels when none

are available and written on with a sterile marker

Syringes and med cups should be labeled

The Six Rights

Right Patient Right Drug Right Dosage/Amount Right Route Right Time and Frequency Right Labeling/Documentation (new as of 2007)

It is the responsibility of the circulator and surgical technologist to verify this information

MEDICATIONS

Antibiotics Ophthalmic agents Diagnostic Agents Local Anesthetics Diuretics Drugs Affecting Coagulation

Antimicrobials and Their Action

Inhibit synthesis of cell wall Interfere with synthesis of protein Alter the function of cell walls Prevent RNA or DNA production (cell

replication) Interfere with metabolism of cells

ANTIMICROBIALS MICROORGANISM

Antibiotics BacterialStaphlococcus Aureaus

Antifungals FungiRing worm, athletes foot,

yeast

Antivirals VirusesHerpes, Hepatitis C, HIV

Antiparasitics ParasitesMalaria, trichomoniasis

Antiprotozoals ProtozoaGiardia, dysentary

Medications Used in Surgery

Antibiotics Are given pre-operatively, intra-operatively,

and post-operatively for prevention of bacterial infection. They can be administered intravenously, intra-muscularly, orally, topically as an ointment, and in an irrigation form

In the OR the ST will handle antibiotics that will be mixed with normal saline for irrigation purposes

Antibiotics

Their action may be bacteriostatic (inhibitive of bacterial growth) or bactericidal (bacteria killing)

Are a type of antimicrobial

Types of Antibiotics

Aminoglycosides Cephalosporin's Macrolids Penicillin's Tetracycline's Each type has a variety of antibiotics in that

category

Aminoglycosides

A group of antibiotics (such as gentamicin, polymyxin) that inhibit bacterial protein synthesis and are particularly active against Gram-negative bacteria.

Often used in eye cases.

Cephalosporin's

one of several broad spectrum antibiotic substances obtained from fungi and related to penicillin (trade names Mefoxin and Keflex).

prescribed for bacterial infections of the respiratory tract, the middle ear, the bones, the skin, and the reproductive and urinary systems.

Macrolids

A group of antibiotics produced by various strains of Streptomyces.– eg, clarithromycin, azithromycin

used to treat infections such as respiratory tract and soft tissue infections.

Penicillin's

obtained from Penicillium molds Penicillin acts by destroying the cell wall of

bacteria. may be used to treat infections such as urinary tract

infections, septicemia, meningitis, intra-abdominal infection, gonorrhea, syphilis, pneumonia, respiratory infections, ear, nose and throat infections, skin and soft tissue infections.

Tetracycline's

derived from microorganisms of the genus Streptomyces and used broadly to treat infections.

A "broad-spectrum" antibiotic, is used to treat bacterial infections such as Rocky Mountain spotted fever, typhus fever, and tick fevers; upper respiratory infections; pneumonia; gonorrhea; amoebic infections; and urinary tract infections.

It is also used to help treat severe acne and to treat trachoma (a chronic eye infection) and conjunctivitis (pinkeye).

Tetracycline is often an alternative drug for people who are allergic to penicillin.

Ophthalmic Agents

Are multiple eye medications most given topically ST must know what each agent does to know in what order to

pass it to the surgeon Eye Anatomy: Conjunctiva Anterior chamber (aqueous humor) Iris/ciliary muscle Posterior chamber (aqueous humor) Pupil Lens Vitreous body (vitreous humor) Retina (rods & cones) Optic nerve

Eye Anatomy cont.

Types of Ophthalmic Agents

Enzymes Irrigating Viscoelastic Miotics Mydriatics Ointments & Lubricants Anti-inflammatories Dyes Anesthetics

Enzyme Agents

Speed up chemical reactions when mixed with anesthetic agents

Wydase (Hyaluronidase)

Irrigating Agents

Corneal moisture and operative site cleansing BSS - Balanced salt solution – most common

in our area A-K Rinse Blinx Irigate ST may need to irrigate as surgeon performs

eye procedures

Viscoelastic Agents

Thick, jelly-like substance injected into anterior chamber to maintain expansion of the chamber and prevent injury to surrounding structures and tissue

May be used as vitreous substitute as well Healon and Viscoat (Sodium Hyaluronate) Occucoat (hydroxypropyl mthylcellulose)

Miotic Agents

Constrict the pupil Post-cataract extraction to maintain

implanted lens position Laser iridectomy Pilocarpine

Mydriatic Agents

Paralytic agents used to dilate the pupil Atropine Neo-Synephrine

Ointments & Lubricants

Prevent damage to the cornea from drying during general anesthesia

Lacrilube or Duratears Prevent eye infections post-ophthalmic

surgery Erythromycin, Neosporin, Tobramycin,

Gentamycin Combination antibiotic/anti-inflammatory Maxitrol and Tobradex

Anti-inflammatory Agents

Steroids Suppress inflammatory response from

traumatic eye injury NSAIDs Decrease or minimize post-operative

inflammation

Dyes

Color or mark eye tissue Help locate abnormalities or foreign bodies Abnormal eye cells take up staining agents Rose bengal (commonly used in eye drops to stain damaged

conjunctival and corneal cells and thereby identify damage to the eye.)

Fluorescein sodium (Ful-Glo) (chemical dye used to identify and locate damage to the surface of the eye; useful in the management of diabetic retinopathy and macular degeneration)

Anesthetic Agents

Topical anesthesia for short ophthalmic surgical procedures

Tetracaine (Pontacaine) and Proparacaine OR Lengthy ophthalmic procedures get a “retrobulbar”

block (sensory and motor block) Lidocaine or Bupivicaine (Marcaine) May mix with Wydase to prolong effect or

Epinephrine to vasoconstrict tissue to prolong anesthetic effect

Diagnostic Agents

Includes: Contrast media Dyes Staining Agents

Contrast Media

Used in radiographic diagnostic tests to enhance visualization

Most contain iodine, a radiopaque compound

Being radiopaque it illuminates tumors, stones, blockages, veins, and arteries (where ever it is injected)

Types include: Omnipaque & Hypaque Often incorrectly referred to as dyes

Omnipaque used in vascular procedures Hypaque is used in operative

cholangeograms

Are others as well Are light sensitive and should be stored in

closed box or with something over them to protect them from light which alters the efficacy of the contrast

Dyes

Used for marking skin as well as detecting injury in the urinary tract

Types include: Methylene blue, Indigo carmine, and Gentian violet

Methylene Blue

Is a blue dye, usually diluted with normal saline, and injected into the bladder to determine leaks in the urinary tract when pelvic surgeries are being performed

May also be injected into the fallopian tubes or uterus

Indigo Carmine

Is a blue dye given IV to verify that bladder function and kidney function are intact

Needs to be stored out of the light as it is light sensitive

Gentian Violet

A purple dye primarily used to mark incision sites

Comes in a sterile marking pen which are included in most custom packs

These are what you will use to write on the labels of your medications on your sterile field

Staining Agents

Primarily used to identify cervical tissue that is abnormal

Types include Lugol’s Solution and Acetic Acid

Lugol’s solution has an iodine component that in normal tissue is absorbed by the cell, but in abnormal tissue it is not absorbed leaving the tissue white verses dark

The white tissue is identified as abnormal and biopsied

Staining Agents

Acetic Acid (vinegar) Used as staining agent if patient is iodine

sensitive or if lasers are being used Acetic Acid makes the abnormal tissue

appear whiter than normal tissue as well With laser surgery, dark stained tissue

(Lugol’s) will react less effectively with the laser

Local Anesthetics

Primarily used in short or minor operations May be used in conjunction with general or

regional anesthesia Delivered by injection directly to the operative site Will be prepared by the surgical technologist on

the sterile field and given to the surgeon prior to incision and prn during surgery

Many surgeons also will administer local to the wound edges prior to closure to prolong the onset of post-operative pain

Local Anesthetics

Lidocaine (.5%, 1%, 1.5%, 2%) Marcaine (Bupivicaine) .25%, .5%, .75% a. with epinephrine b. without epinephrine

Injection is with a control syringe with appropriate sized needle (27 or 25ga initial)

22ga post-incision MUST KEEP UP WITH AMOUNTS GIVEN!

CAN WRITE ON A TOWEL OR ON A GLOVE OR GOWN TAG!

Local Anesthetics

Cocaine Nasal surgery Vasoconstrictor and mucous membrane

anesthetic

Diuretics Given to prevent the kidneys from

reabsorbing Na+ and water Reabsorption of these can cause a variety of

patient complications including but not limited to edema (swelling), pulmonary edema (fluid in the lungs), and congestive heart failure (increased circulatory blood volume which results in the heart being overworked>enlarged heart chambers>defective heart valvular function)

Diuretics Continued

Surgical uses: Prevent complications previously

mentioned as well as reduce intraocular pressure and to reduce intracranial pressure

Types of Diuretics

Different types of diuretics have different mechanisms of action

Types include: Loop Diuretics Thiazide Diuretics Potassium Sparing Diuretics Carbonic Anhydrase Inhibitors Osmotic Diuretics

Loop Diuretics

diuretics that act on the ascending loop of Henle in the kidney.

They are primarily used in medicine to treat hypertension and edema often due to congestive heart failure or renal insufficiency.

Thiazide Diuretics

They work by inhibiting reabsorption of sodium (Na+) and chloride (Cl−) ions from the distal convoluted tubules in the kidneys.

Thiazides are often used to treat hypertension, although they are also used to treat congestive heart failure and symptomatic edema.

Potassium Sparing Diuretics

Potassium-sparing diuretics are commonly used to help reduce the amount of water in the body. Unlike some other diuretics, these medicines do not cause your body to lose potassium.

They are used as adjunctive therapy, together with other drugs, in the treatment of hypertension and management of congestive heart failure.

Carbonic Anhydrase Inhibitors

Often used for opthalmic purposes. The drug decreases fluid formation in the eye

resulting in lower intraocular pressure. The drug forces the kidneys to excrete bicarbonate,

the conjugate base of carbonic acid. By increasing the amount of bicarbonate excreted in the urine, the blood becomes more acidic.

Acidifying the blood stimulates ventilation, which increases the amount of oxygen in the blood.

Osmotic Diuretics

a type of diuretic that inhibits reabsorption of water and sodium.

An example is Mannitol. Mannitol can also be used to reduce

intracranial pressure.

Diuretics in the OR

Lasix Bumex Aldactone Mannitol These are given IV by the CRNA during

surgery

Drugs Affecting Coagulation Our blood contains components that either inhibit its

ability to clot or promote that ability

Anticoagulants inhibit clotting Coagulants promote clotting Normally, blood is maintained in its liquid form by the

abundance of anticoagulants in our bodies When our body experiences trauma, coagulants create

clot at the site of injury to prevent blood loss (ex. scab formation)

Anticoagulants

Prolong blood clotting Primarily used in cardiovascular procedures As an irrigant are diluted with normal saline to prevent

clotting at the operative site Prevent clot formation in the patient’s circulatory system

when given IV Most commonly used anticoagulant is heparin Drug used to reverse heparin when given IV is protamine Prevents heparin from bonding to the cell receptors it had

previously bonded with Protamine given alone (not in presence of heparin is an

anticoagulant) Primary concern with heparin use is bleeding

Coagulants

Are used to promote clotting of the blood Can be topical or IV Two types: 1)Hemostatics and 2)Systemic Coagulants Hemostatics are used topically Systemic Coagulants are used IV Hemostatics are widely used in surgical

procedures

Hemostatics

These products actually assist to form clot at the operative site

They come in a variety of forms: powders, sponges, solutions, films, and fiber-like material

They are not for injection, but for topical use only

May see some that are combined with others to make them more practical to use as well as to enhance their efficacy

Types of Hemostatics

Thrombin Comes in a powder that is mixed with

preservative free sterile normal saline May see it used to soak the sponge material the

next type for application to a surgical site Gelfoam Sponge like material Can be left in the patient as it absorbs in 4 to 6

weeks

Types of Hemostatics

Gelfilm Used in neuro, thoracic, and ophthalmic surgeries Looks like cellophane in dry form, but is elastic

when wet with thrombin or saline Absorbed by the body, so is safe to leave in the

patient’s body Gelfoam Powder Can be sprinkled on to a site or combined with

antibiotic powder, thrombin, or saline to form a mushy ball that can be spread on to bone

Types of Hemostatics

Avitene Comes in powder or fiber-like material Surgical site should be as dry as possible before it is

applied to get the maximum benefit (applies to any hemostatic)

A sponge is usually applied afterwards to apply pressure to promote efficacy (applicable to any hemostatic)

Use clean, dry forceps to apply (commonly use ring forceps with the powder)

Excess should be removed before wound closure

Types of Hemostatics

Surgicel and Oxycel Is a mesh, gauze-like material Excess should be removed before wound

closure Helistat Soft, pliable, sponge-like material Apply with dry instruments and or dry gloves Remove excess before wound closure

Other Hemostatic Methods

Phenol and Alcohol Will see used with appendectomy or GI

surgery Phenol will burn tissue and can cause

severe burns Alcohol neutralizes the phenol after it is

applied to the site it is intended for

Other Hemostatic Methods

Styptics 1. Epinephrine is a vasoconstrictor Vasoconstriction reduces the lumen size of vessels

which reduces blood loss Will see combined with topical agents such as

Gelfoam and combined in lidocaine or marcaine, medications used for numbing a surgical site

2. Silver Nitrate used on burns from trauma 3. Tannic Acid used on the mucous

membranes in nose and throat surgery

Summary

Care & Handling of Medications and Solutions:

Medication

Identification

Labeling

5 Rights

Medications Used in Surgery:

Antibiotics

Diagnostic Agents

Diuretics

Drugs Affecting Coagulation