lUNIT 2 Drugs Used in Surgery J

Dio:;nostic inll1sinh (::~,--";'.L~

DvesDiureticsCentral nen','u" ,\'ste':' J:C:l'nts

, ,

EmL'rgenC\' pc,tl)cl11 c::",:c',S

Antimicrobii\l (,llltiintec:\l'. antibil,ticiAnticoagulclntsHemostatic agent:;()x\,tocicsSteroids (i\ntlintbmm,':)j'\1

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9.10.

Unlike other mt:'Liicati"",,, ,lcirninistel','e1 h' t";enurse, administration of the",: "sents does nut" \\Titten physician's urdeL ~:Il,,'t'it is considered ~:,,',-e1clfdprotocol during the intr ,"'Ft'ra li \'e PlTiO,i,,HI the physician preterl'nct' ':,Hd and or " \C'r::-,:',c)rder from the surgell1l cluril1c'. -urgery,

The f,,\lowing ml,nogra('L ,11'scribes the ten Cltt-gl,ries of drugs communl\ ,',1::,inistered in th,'

"ting room:

T'l,Mmacologic i\gent" ,lre Cl)];-"'"n\\' pl,1(,'d lIltl) c"t-,,,',.':urit's "ccordin", tll their ~;mibritll'~ iT: actic'n,':nd ur their physi"le)gic efft'C ,,\hen intwciuced in[,)

~ ~"'-C' SV5 tl?n\.As with anv 11lt'c!iutil,n ~>l' nurse slwL:lc! ha\c'

knowledge of the ,lclion", rnt':>",b of administntil'n,:!ld nursing consider~lticm' >,;uciated \\lt1: eelc;'

CATEGORIES OF DRUGS

As an added precautiun, r,c'itner thenL:~se nor thl' scrub nurse/tech;',ici"n can permit fi\-p',:liarity with <:l bottle shapl' (';' -ile, L,bel. O~ culu~LI't,,,rtefl' with the pruper procedure", Pl)l'ftechnique i\nd disregclfd tllr ~,l:d\' may result in in-i'"q; to ur ad\'erse re,lctll111b\ t:',c p,ltient,

saline) to the sterile held, tl) ,l\'oid contamination

uf the held,• Document on the intr"L)t'c'fatiye recor,i ill)

drugs/solutions i\dminiskred to the sterill' fidel,

Kno\\' tilt:' proper reconstitutiun ,\!ld prepclrationprocedures, using the manubcturer's reClHnmen-dations ,lnd or the institutioni\l policies,KnO\\' the proper dosagt', rouks or administra-tion, and p'lssibie complications and side drectsof ei\ch drug ,ldministered,Check \\'ith the manubcturer"s reu)mm"nclct-tilms for stl,ring a drug t,l ITLlint,lin the dmg'"maximum eftl'cti\'eness,Cc)ntirm the drug h'p" "nd dl,sage requeskdprior to i\dministratiun to the ~terilc fidd (h)ththe scrub and circuLltl>r must dl) this) The drugsh,HJld be checked tur (()jor ar1d (unsic:tenc\', i\ndit a ch,ms" ha~ bel'n notil"ed. the pn1duct slwulci

lwt be uSc:'d,Llh,l e,lch agl'nt ()r iI' ",lutil,n \\'ith till'l1l1:11t:' (1l'lLl ll!1\\.)unt lHl thl) (l.'Il'!".; ~yrins(' Lift--:f,1L'hninistr,ltion tl) the skrile [iLU,L,e ,1 ~krijl' '\k",1i1ting SPl'\.\ \d1l'n d",1uti,)l\~ from ,In l\ L',"'" I LT,1finil,'J

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Reconstituted p'lwders or liquid medications d;'(' C

\j\'ered to the scrub nurse/technician by the circuLi['ins nurse, The contents mew be transferred I\el'. '

-terile syringe or by pouring \'i,11 contents intl' ,11'a;.'propriate receptacle according tl) accept,lble insti-tutional policy. In either case, the procedure rur ac-cepting or preparing a drug requires the use of strict

a-t'ptic technique,As with ,111\' drug, the nurse IT\U~t:

PREPARATION ANDADMINISTRATION GUIDELINES

• administered parenterally• ,ldministered topically• administered in irrigation sL'luh'n• introduced into a hollow O~~Jn ,'C' dtlct for diaS-

nostic purposes

Dru c:s used in surgerY include those th" t are

Monograph of Common DrugsUsed in Surgery

nl' 'IltilllicrolJial L4I1tiill(ecti,'e; Alltiln'otic)Catego , ' "' .' 'General DescnptlOn:Chemical agents that eliminate li\'ing organisms

nJthoaenic to tht' host (patit'nt). The methodsr (. 0

for classif\'ing thest' agents include:

Administration i\kthod:LV. (administered by anesthesiologist) l)r i:', 'rn-gation solution (Heparinized saline So!util'ni

'\lJrsi-ng Consider,1tions for 5urgen':

b7PHI-.R'/> "PTER 5 SURG

It is clinicalIv safer and far more accura:c tl'meJsure the dOSe' in units than in milligra:~1S.Intravenuous heparin must be administered\'ia an infusion pump.Heparin should be administered in an isorc'nicsodium chloride solution (I.V). not a sUcliumchloride irrigation solution.Heparin is available in units mL; a\',,;1,,[,il:.'either as Bm'ine or Porcine. Check \\ith ,-,j_

cian as to proper dosage.Document irrigation solution ontive record.

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\lechanism of action-inhibition of pl'()tLins\'l1thesis, activit\. on the cell membrane, alkr-a'tion of the nucleic acid meta bolism,Spectrum of acti\'ity-gr,lm positive or gramnegati\'e.5i;1ilant\' in cht'mical stnlcture---penicillins;cephalo;purins; aminoglycosides; sulfonamidl's.5uurctc~living organisms; chemical synthc~is.

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Selection is based on the organism's sensiti\'it\, P,1-tient \'ariations, and the relati\'e toxicit\ l)f tlwpmposed aben t.

~\.\\1rLE5 include, but are not limited to:• penicillins (e.g., ampicillin)• cephalosporins ceteJLl)lin r Ancd]l• aminogl\cosides le,g., neomvcin sulfate';

gentam\'cin sulfate' [Caram\'cinj)• sulfonamilies (e.g.gantrisin)• others le.g., bacitracin, chloromvcctin, \aIKU-

mycin, tetracvcline)

CLltcgory: Hemostatic AgentsGeneral Description:

Hemostatic agents reduce capillan' b!c'ed::~gand "rrest blood now, thereby assisting 111bie "eiclotting during surgerv.

!::\A\IPLE5:

• absorbable gelatin sponge (e.g., Gelfll,,:'l1• microfibrillar collagen (e.g., Awtine)• oxidiLed cellulose (e.g., 5urgicel; OX\C(1)

• Topical thrombin• 5vstemic Hemostatic / Amicar

Administration \lethl)din saline irrigation solution

'\ ursing Considera tions for 5urgcn':

Category: AnticoagulantsCeneral Descri ption:

,.'I,nticoagulants Me pn'n tu prolong the time ittakes the bloud to clot h pn'\'l'nting the com'l'r-sion of fibrinogen to fibrin. In addition, the\' ,11Cused to pre\'ent the occurrence of clot enlarge-ment or fragmentation (thmmbuembolism),

,Although cephalospurins ma\' be used for pa-tients allergic to penicillin, some patients ma\'shmV' sensiti\'ity anci subscquL'ntly develop al-lergics to this group.All drugs in irrigation solution in the sterilefield must be labeled to a\'oid confusion \\'ithplain solutions,All agents uSt'd in irrigation must be docu-mented un the intLluperatin' record.

Administration Method:placed topicallv on the bleeding surface tosorb blood and reduce bleeding; sprawd 'rectlv on area

'\ursing Considerations for Surgery:

• Topical thrombin is reconstituted befllre ,:"e.and is generallv used with Celfoam for gn',':erabsorbancy. It can also be used in spra\' fOrI~'

• Amicar must be reconstituted, and is gi\t:n 1\• Gclfoam docs not have to be remm'ed; hen,,-

ever, the oxidized cellulose should be remo\~jafter hemostasis has been accomplished.

• A\'itine is applied directly to the bleeding aruin dry-powdered form, but \\'ill adhere to \.:t.'tgloves, instruments, or tissue surfaces. Handle.\\'i th smooth, drv forceps.

Category: OxytocicsOxvtocics arc normallv found in the postl'rior pi,,:-

itarv gland and stimulate smooth muscle ut theuterus during childbirth, thereby forcing ti,euterus to contract and thus decreasing bleedi:~c:after a cesaraen section.liquaemin sl)eiium)hq:'Jrin

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68 MODULE II BIOPHYSICAL SCIENCES

EX:\\\I'LE5:• oxytocin (Pitocin)• methergine

Although tht' incidencl' ut iudine cotivitv related to clmtr,bt medici is 1,\",'.atiYe assessment uf problems ,'''''''~:.::l'_~. ,.,pre\'ious \-rCl\" pruced ures shuuk ','c'

immediatel\"Be prepared to tre"t am ad\"er~e k. ~:jl\n'(usually \\"ith 13en,idn"j) ,,"hen 1.1<,',2 Cl,r,rrc'c:media.The surgeun is respl,nsible for in~:;lL,::.'n l\l

the agent during the X-ren° proced~:reLabel all s\Tinges and check with ~,_: c1" tl'dilution strength if requested or rt'c->lirc:;Document "gent ['n intraoperati\e

Document medication on intraoperati\e re-corel

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I\\\II'LFS: include', [Ill( ,He' nl,t limite',; ee'

• nwtln"kne blue'• ind l,lr:-,11!ll'

EX:\\WLE5: include, but Me nut limited t"• Renografin (cholangiographY,

hvstersalpingogra ph \")• Cystografin, C\"stu-Cll1',ra\"

kvstourethwgra ph\ i

• Hypaque• Hvskon

Category: DyesCeneral Descri ptil,n:

Solutiuns u:'e'd to ~Llin ,lr m,trk" "c:ri,"'L-cor area. 'd"st o',J\utr,'ns lur skin n-"-r,,in'~ h.nbel'n rt.'p1,lc,.'d b\ ~ll':-'k "markin:~ :'ens :1,".t'Vl'r, dye~ C~l!l (ll~(~ bl.' used tel (oll.'l ::,,-,ll:~:lln:-- \'

to test tlw F'"klK\ l,f spt'lific org,,,,,

Administration \1t'tlwd:direct instill"l1un intll l~uCt ur llrgan : t.c:""cl'rspecial catheter

:\ ursing Consiclt'ra tiem~ f, '1' Surgery:

Category: Diagnostic Imagi1lg AgentsGeneral Description:

Contrast imaging agents Me also kno\\"n asmdiopni)1iC mcdin. Thev allow radiologic \isua!-ization of internal stmctures during opt'ratiwprocedures, such as intraoperative chobngio-grams, cystoretrogrades, and su on.

Depending on its structure, the cun:~astmedia may be instilled directlY intu ,\ duct ororgan and mc1\ or m,n not be diluted ,,'.!t1, nur-me'll saline. Therefore, check with th~ '1.;r'~cunfor administratiun prett'rences.

U:-<l;'::'C.l'rLl\idc s,Tub nur"t' kclinici"n \\'ith " Incedle for \\'ithdra\\,,! ,lil\.i ,,23g te' 27g nt"'l1\"tln' injcction (~urge'lm's prdcrt'nccJ

\hciwcurti"l'lll' (\rtdl slll'llld be c:i\,'nd e'l'~I 1.\ 1.C,Hdulh' (hl'lK 1,11'l'1r,\)"rl'cullllil,'l:dl,d l"l'lltL'l't "dministr"liL\l"

1\(',",1I1S titu te J\."corc!ing t" m,m utactu rer' s rc(-l,mmenLicttiuno'.Agitate tel dissuh'e p,utides prior tl' dt'li\','r\'L,L,t'l ~\ringl' l,n b,ll"k Lib:,,' tu ,l\'l,id ,lCcic1e'nU!

Store at temperatures below 23 cC (7TFl: a\"oid

freezing.Oxtocics can have an antidiuretic effect: moni-tor intake and output.Thev are usually administered after deli\"l'n" (,fthe placenta.Cse cautiously in patienh with a history ofcen"ical or uterine suq.',ery and in primigrJ \-ida women O\"er 33 Vt'clfSof age.RotJte bottle gently to distribute dmg in solu-tion.Do not use ampuks \\"ith discolored soluti,'llr.v. methergine is used for emergencies only .

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:\,iministration \\ethod:adnlinio'tered pMentcr,11h' t" tht' affected site bvtht.' "urgeon

'\ ,1rsing ConsiderJ til,IIS for Surgt.'ry:

Administration Method:added to l.v. (by anesthesiologist)

Nursing Considerations for Surgery:

[\.-\\IPIE5: include, but Mt' Iwt limited tel:• l1t'cad ron• hex,ldrol• Solu-Cortef• Solu-\;\edrol• Dt'p(l-\\edrol• :~ri"toCl1ft• Ken,,!clg

Categol,!l: Steroids (A1ltii1lf1al11111£JtoryJGeneral Description:

Corticosteroids are hormunes produced natu-r,,!!v by the adrenal cortex, T1K'v Me used insurgery to reduce inflamm"tion and pos~iblt'posto~-'erative swelling.

E\\\ll'LE5: include, but ]1L)tlimikd to:• furosemidl.' (Lasix)• mannitolrOsmitroj)

Adminlstration Ml.'thods:• adc1ec1to solutlOn• administered directlv into StrucrUfl'

- 'lJ '~a tl)nical marker on skin• U~t..1 (I- r" --]1" C()]blderations for Sun:;en':,",urSl 0 ,- -

Categorl/: DiureticsGeneral Description:

Diuretics reduce the bodv's total volume of\\'ater and salt bv increasing their urinary excre-tiClI,. This occurs mainlv because diuretics im-pair sodium chloride reabsorption in the renaltubules. Additionalh', diuretics can increase theosmutic pressure, inhibiting tubular reabsorp-tion of \\'ater and electrolvtes, thus reducing re-tention of \\'ater and possible reduction ofs\\Tlling in traumatized areas, for example, thebrain.

=...,6PTER 5 Si~RGICALPll!\Ri'/.;'COLOC:! 69

2. Tranq'clilizers: red uce anxietv \\'ithou t ind llC-

ing sleep. Most trilnquilizers have muscle-fl'-lilxilnt ilnd ilnticmwulsive properties, andclose I\' resemble sed iltive-hypnotics in phM-mac"iogic properties. Examples include, butare not limited to:

• dia7t'pilm (Villium)• midil70lilm (Versed)• droperidol (Inilpsine)

NOTE: In high doses, narcotic analgesics can befurther classified as anesthetic agents, and Meildministered by the anesthesiologist ilnd / orC.R.'\ ..-'I.., not the perioperati\'e nurse.

All these agents can alter the patient's per-ceptil1n of pain or \\ell being, and must be uSl'dwith extreme caution since unfa\'()rabll.' interac-tiems ilnd / or reactions arc often encounterl,d.

E\A\lPLF3:

1. Analgesics: bind \\'ith opiate receptors at milm'sites in the centrill ner\'llUS s:;stem, illteringboth F'ilin and the emotiol1ill response to pain .Examples include, but ilre not limited to:

• fentand ilnd fentilnvl deri\'ati\'es, .

(Sublimaze); Alfenta; Sufenta• morphine sulfate• (demero1) rvleperidine• codeine• (dilaudid) Hydromorphone

'\ l) ad \'erse effects ha ve been reported.\1,1\' be diluted per surgeon's preference.Rin'sl.' container immediate!v after use as itmav caus~' permanent d iscolora tion.It i;,stilled internally, document use on intra-l'perati\'e record.

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Administratic'l1 \lcthod:IV (b\' anestl1l.'siologistl

'\ursing ConSIderations for Surgerv:

Admini,triltion rv1ethod: l.v.'\ursing Considerations for Surgerv:

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Lasix shc)uld be gin'n o\'('r 1 to:2 minutes.\lonitor serum potassium len'b. \lake note ofpatients on digitalis.\bnniwl solution often crvsta!iLes, especiallvilt hw: temperatures, Therefore, store it in asolution-\\'arming cabinet.Do not use solution with undissolved crystals .Hemod\'nilmic monitoring equipment shouldbe a\'aibble (c.S., central \'enous pressure cath-eter, Folev catheter \\'ith urimeter).

• Kno\\' the institutional policies for administril-tion protocols before ildministering these ilgents .

• During illaca] procedure, document illl piltientresponses everv 15 minutes or more often asneeded.

• Keep ilntilgonist ilgents a\'aililble when admin-istering these agents.

Chapter 6 contains further discussion specific toanesthetic ilgents, narcotics, ilnd tranquilizers.

Category: Centrnl "'en'ous Systelll AgentsGeneral Descri prilJ!1:

Central nen:ous 'ivstem (C\S) a~~'nts are thosethat affect the bOli\,.s response [('j stimuli, coor-dination of activit~., and Jc\'el of wnsciousness.This Gl includes agents such as analge-sics. tranllUilizers, ,lnticomubants, and anes-thetic < (see Chapter hJ.

Category: Emergency Protocol D11IgsGenerill Description:This category includes:

• cardiilc stimulilnts (e.g., epinephrine)• \-ilsoconstrictors (e.g., levophed)• \'asodilators (e.g., nipridl'l• cMdiotonics (e.g., disitalis)• antiilrrhvthmics (e.g., lidociline)

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ErndgenC\' drugs

Vl,\',lnle expander

C'\~ Agents

Ar::c~)agu\ants

Hen-,l,st,ltics

O,\-:o(i(~

Diurc:ics

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6,

Contr"st media is usu"llv prep"red as a mi:dun'

of the agent "nd r,oml"\ saline.

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5.

1. Volume expanders, to increase circulating tluidvolume, (Examples include hespan, albumin, and

hdas ta rch.)2. Blood and blood components, to restore cell vol-

ume. (Examples include fresh-frozen plasma,washed packed cells, \\hole blood, cryoprecipi-

tate, and factor VIll)3. Intravenuous solution~, with or \\'ithout electro-

lytes. (Examples incluL\c D,\\' DelR, lactate

Ringer'S)

maintain hemostasis durins the perioperative period.

Th~se agents include:

causes contF1cticll1 and constriction

kills or inhibIts ti'.l' gro\dh of microorganisms

promott's blL,(lc1clottingreduces tissue ,\\'elling ,1l1dintlammatil1n

radil1paque: \'l-<lcllizes intenlal structures

prolongs b\ol,d clotting

draws tluid l,ut L,ftissues

changes perceptll1n; reduces pain

incre,lses blued n,\ume

first line drus' [llr c,1fdiac arrhvthmias

True Llbe

COLG,,[\ .-\

Inkrn,,\ ir;i'::,,['l'n USU,1\\V requires tIll' USL' of

l,li" '\,lCl

------------------------------------------~~otes

The perioperative nurse should be prepared,through annual Basic Life Support review, tohandle correctly the common drugs used duringemergency situations, including dosages, ad-ministration routes, and indications for use.

By following the current American Heart As-sociation protocol for Advanced Cardiac LifeSupport (A.C.lS), the perioperative nurse candeliver comprehensiq, emergencv care and as-sist as necessary in the preparation and admin-istration of emeq:',enc\' drugs and solutions.

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3.

e.

1',\

d.

c

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1. \latch the descriptil,n in Column A with the cat-

egorv in Column B

Self-assessment Exercise #6

Nursing Considerations for Surgery:

In addition to the pre\'il1uS categories, the surgicalpatient may receive additional drugs and solutions to

Supplemental Drugs and Solutions

70 MODULE II BIOPHYS,C,"', SCIENCES