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Pharmacology Lecture #2
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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
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Read Medication Labels and Check
Name (trade & generic)
Manufacturer Strength Amount Expiration
Route Lot number Handling/Storage
directions Classification (if
controlled substance)
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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
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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
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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
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MEDICATIONS
Antibiotics Ophthalmic agents Diagnostic Agents Local Anesthetics Diuretics Drugs Affecting Coagulation
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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
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ANTIMICROBIALS MICROORGANISM
Antibiotics BacterialStaphlococcus Aureaus
Antifungals FungiRing worm, athletes foot,
yeast
Antivirals VirusesHerpes, Hepatitis C, HIV
Antiparasitics ParasitesMalaria, trichomoniasis
Antiprotozoals ProtozoaGiardia, dysentary
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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
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Antibiotics
Their action may be bacteriostatic (inhibitive of bacterial growth) or bactericidal (bacteria killing)
Are a type of antimicrobial
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Types of Antibiotics
Aminoglycosides Cephalosporin's Macrolids Penicillin's Tetracycline's Each type has a variety of antibiotics in that
category
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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.
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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.
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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.
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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.
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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.
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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
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Eye Anatomy cont.
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Types of Ophthalmic Agents
Enzymes Irrigating Viscoelastic Miotics Mydriatics Ointments & Lubricants Anti-inflammatories Dyes Anesthetics
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Enzyme Agents
Speed up chemical reactions when mixed with anesthetic agents
Wydase (Hyaluronidase)
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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
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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)
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Miotic Agents
Constrict the pupil Post-cataract extraction to maintain
implanted lens position Laser iridectomy Pilocarpine
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Mydriatic Agents
Paralytic agents used to dilate the pupil Atropine Neo-Synephrine
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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
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Anti-inflammatory Agents
Steroids Suppress inflammatory response from
traumatic eye injury NSAIDs Decrease or minimize post-operative
inflammation
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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)
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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
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Diagnostic Agents
Includes: Contrast media Dyes Staining Agents
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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
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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
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Dyes
Used for marking skin as well as detecting injury in the urinary tract
Types include: Methylene blue, Indigo carmine, and Gentian violet
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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
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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
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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
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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
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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
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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
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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!
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Local Anesthetics
Cocaine Nasal surgery Vasoconstrictor and mucous membrane
anesthetic
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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)
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Diuretics Continued
Surgical uses: Prevent complications previously
mentioned as well as reduce intraocular pressure and to reduce intracranial pressure
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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
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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.
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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.
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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.
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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.
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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.
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Diuretics in the OR
Lasix Bumex Aldactone Mannitol These are given IV by the CRNA during
surgery
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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)
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Summary
Care & Handling of Medications and Solutions:
Medication
Identification
Labeling
5 Rights
Medications Used in Surgery:
Antibiotics
Diagnostic Agents
Diuretics
Drugs Affecting Coagulation