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I. Introduction:Preoperative medications are given to allay preoperative anxiety, produce some

analgesia and amnesia, and dull awareness of the OR environment. An ideal

preoperative medication has quick onset, short duration of action and minimal side

effects. Preoperative medication constitutes to a greater or lesser extent a part of the

overall anesthetic technique. Certain drugs may prolong the effect of the anesthetic

and increase a respiratory-depressant effect.

II. Preoperative Medications.A. Tranquilizers- produces a calm, hypnotic state.

a. diazepam (Valium)Drug classes: Antiepileptic, anxiolytic, skeletal muscle relaxant

Mechanism of Action: Acts mainly at the limbic system and reticular formation; may act in

spinal cord and at supraspinal sites to produce skeletal muscle relaxation.

Indication (preoperative): Relief of anxiety and tension and to lessen recall in patients prior to

surgical procedures, cardioversion and endoscopic procedures.

Contraindications: Contraindicated with hypersensitivity to benzodiazepines; psychoses; shock;

coma; acute alcoholic intoxication; pregnancy; lactation.

Dosage:

ParenteralUsual dose is 2-20mg IM or IV. Injection may be repeated in 1 hour. Preoperative- 10 mg IM. Cardioversion- 5-15mg IV 5-10 min before procedure Endoscopic procedures- 10mg or less, up to 20mg IV just before procedure or 5-10mg

IM 30mins before procedure

Adverse Effects:

CNS: transient, mild drowsiness initially, sedation, depression, lethargy, apathy, fatigue,light-headedness, disorientation, restlessness, confusion

CV: bradycardia, tachycardia, CV collapse, HPN, hypotension, palpitations, edema Dermatologic: Urticaria, pruritus, skin rash, dermatitis GI: constipation, diarrhea, nausea/vomiting, anorexia, dysphagia GU: incontinence, urinary retention, changes in libido, menstrual irregularities Hematologic: decreased hct, blood dyscrasias

Nursing responsibilities:

Assess for hypersensitivity to benzodiazepines.

Check vital signs.

Assess for psychoses, shock, coma

Assess if patient is pregnant or lactating.

Obtain liver function tests or renal function tests.

Instruct patient not to take in alcoholic beverages a week prior to surgery.

Inform patient of possible side effects.


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Monitor patient for manifestations of adverse reactions.

B. Sedatives- sedation reduces the effect of anxiety. Amnesia helps provide comfort.a. midazolam HCl (Versed)

Drug classes: benzodiazepine (short-acting); CNS depressant

Mechanism of Action: acts mainly at the limbic system and reticular formation; anxiolytic and

amnesia effects occur at doses below those needed to cause sedation.

Indications:

- IV/IM: Sedation, anxiolysis, and amnesia prior to diagnostic, therapeutic, or endoscopicprocedures or surgery.

- Induction of general anesthesia.Contraindications: Contraindicated with hypersensitivity to benzodiazepines; allergies to cherry

(syrup); psychoses; shock; coma; pregnancy and lactation.

Dosage:

Preoperative sedation (younger than 60 y/o): 70-80mcg/kg IM 1 hour before surgery(older than 60y/o or debilitated): 20-50mcg/kg IM 1 hour before surgery

Conscious sedation for short procedures (younger than 60y/o): 1-2.5mg IV initially,maintenance dose of 25% of initial dose.

(older than 60y/o): 1-1.5mg IV initially, maintenance dose of 25% of initial dose.

Adverse Effects:

CNS: transient and mild drowsiness (initially), sedation, depression, lethargy, apathy,fatigue, light-headedness, disorientation, confusion, crying, visual and auditory

disturbances, depressed hearing and nasal congestion

CV: Bradycardia, tachycardia, CV collapse, HPN, hypotension, palpitations, edema Dependence: drug dependence with withdrawal syndrome when drug is discontinued

(more common with abrupt discontinuation of higher dosage used for longer than 4

months).

Dermatologic: urticaria, pruritus, skin rash, dermatitis GI: constipation, diarrhea, nausea, anorexia, vomiting, disphagia, gastric disorders,

hepatic impairment

GU: incontinence, urine retention, changes in libido, menstrual irregularities Hematologic: decreased Hct, blood dyscrasias Others: phlebitis and thrombosis at IV injection sites, hiccups, fever, diaphoresis


Assess for hypersensitivity to benzodiazepines.

Check vital signs.





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b. promethazine HCl (Phenergan)Drug classes: antiemetic, antihistamine, anti-motion-sickness drug, dopaminergic blocker,

phenothiazine; sedative-hypnotic

Mechanism of Action: depresses the RAS, including the parts of the brain involved with

wakefulness.

Indications:

- Preoperative, postoperative, or obstetric sedation.- Adjunct to analgesics to control postoperative pain.

Contraindications: Contraindicated with hypersensitivity to antihistamines or phenothiazines,

coma or severe CNS depression; bone marrow depression; lactation

Dosage: Sedation: 25-50mg PO, IM or IV.

Preoperative use: 50mg PO the night before

Postoperative sedation: 25-50mg PO, IM or IV.

Adverse Effects:

CNS: dizziness, drowsiness, poor coordination, confusion, restlessness, excitation,seizures, tremors, blurred vision, vertigo

CV: hypotension, palpitations, bradycardia, tachycardia Dermatologic: urticaria, rash, photosensitivity, chills GI: epigastric distress, nausea/vomiting, diarrhea, constipation GU: urinary frequency, dysuria, urinary retention, decreased libido, impotence Hematologic: hemolytic anemia, hypoplastic anemia, thrombocytopenia, leucopenia,

agranulocytosis, pancytopenia

Respiratory: thickening of the bronchial secretions; chest tightness; dry mouth, nose andthroat; respiratory depression; suppression of cough reflex; potential for aspiration

Others: tingling, heaviness and wetness of the handsNursing responsibilities:

Assess for contraindications like hypersensitivity to antihistamines or phenothiazines, coma or

severe CNS depression.

Check vital signs.






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c. secobarbital sodium (Seconal sodium)Drug classes: antiepileptic; barbiturate (short acting); sedative-hypnotic

Mechanism of Action: General CNS depressant; inhibit impulse conduction in the ascending

RAS, depress the cerebral cortex, alter cerebellar function, depress motor output and can produce

excitation, sedation, hypnosis, anesthesia and deep coma.

Indications: Intermittent use as a sedative, hypnotic, or pre-anesthetic medication.

Contraindications: Contraindicated with hypersensitivity to barbiturates; marked liver

impairment; severe respiratory distress; cor pulmonale; previous addiction to sedative-hypnoticdrugs and pregnancy.

Dosage: Preoperative sedation: 2-6mg/kg PO, 1-2 hours before surgery; maximum dose,

100mg.

Adverse Effects:

CNS: dizziness, drowsiness, poor coordination, confusion, restlessness, excitation,seizures, tremors, blurred vision, vertigo

CV: hypotension, bradycardia, syncope Hypersensitivity:rashes, urticaria, exfoliative dermatitis, Stevens-Johnson syndrome GI: epigastric distress, nausea/vomiting, diarrhea, constipation Respiratory: hypoventilation, apnea,respiratory depression, laryngospasm,

bronchospasm, circulatory collapse

Others: tolerance, anaphylaxis, angioedema, withdrawal syndromeNursing responsibilities:

Assess for contraindications like pregnancy, lactation.

Check vital signs.







C. Analgesics- relieves pain.a. Morphine sulfate

Drug classes: opioid agonist analgesic


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Mechanism of Action: Acts as agonist at specific opioid receptors in the CNS to produce

analgesia, euphoria, sedation

Indications: Relief of moderate to severe acute and chronic pain.

Preoperative medication to sedate and allay apprehension, facilitates induction of anesthesia, andreduces anesthetic dosage

Contraindications: Contraindicated with hypersensitivity to opioids; pregnancy.

Dosage: IM or subcutaneous- 10mg every 4 hours or as directed by physician

IV- 2-10mg/70kg of body weight in 4-5ml water for injection administered over 4-5min, or as

directed by physician.

Adverse Effects:

CNS: light- headedness, dizziness, sedation, euphoria, delirium, hallucinations,disorientation

CV: facial flushing, peripheral circulatory collapse, tachycardia, bradycardia,palpitations, HPN

Dermatologic: Pruritus, urticaria, laryngospasm, bronchospasm, edema GI: Nausea/vomiting, dry mouth, anorexia, constipation GU: Ureteral spasm, spasm of vesical sphincters, urine retention or hesitancy, oliguria,

antidiuretic effect

Local: tissue irritation and induration (subcutaneous injection) Major Hazards: respiratory depression, apnea, circulatory depression, respiratory

arrest, shock, cardiac arrest

Others: sweating, physical tolerance and dependenceNursing responsibilities:

Assess for hypersensitivity to opioids.

Check vital signs.

Assess for contraindications like CV diseases; acute asthma, etc.


Inform patient to avoid drinking alcoholic beverages when taking this medication.

Caution patient not to chew or crush slow release preparations.



b. fentanyl citrate (Sublimaze)Drug classes: opioid agonist analgesic

Mechanism of Action: Acts at specific opioid receptors, causing analgesia, respiratory

depression, physical depression, euphoria

Indications:


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- Administration with a neuroleptic as an anesthetic premedication, for induction ofanesthesia, and as an adjunct in maintenance of general and regional anesthesia

Contraindications: Contraindicated with hypersensitivity to opioids, diarrhea, upper airway

obstruction, pregnancy.

Dosage: Premedication: 50-100mcg IM, 30-60 min before surgery

Adjunct to general anesthesia: Initial dosage is 2mcg/kg. Maintenance dose, 2-20mcg

IV or IM; 25-100mcg IV or IM when changes in v/s indicate surgical stress

Adjunct to regional anesthesia: 50-100mcg IM or slowly IV over 1-2 minutes

Postoperatively: 50-100mcg IM for the control of pain

Adverse Effects:

CNS: sedation, clamminess, sweating, headache, vertigo, floating feeling, dizziness,lethargy, confusion, light-headedness, unusual dreams, fear, anxiety, impaired mental and

physical performance

CV: increase or decrease in BP, circulatory depression, palpitations, bradycardia,tachycardia, cardiac arrest, shock

Dermatologic: rash, hives, pruritus, sensitivity to cold, warmth EENT: diplopia, blurred vision GI: dry mouth, nausea/vomiting, anorexia, constipation GU: ureteral spasms, oliguria, urinary retention or hesitancy, decreased libido,

antidiuretic effect, spasm of vesical sphincter Local: phlebitis following IV injection, pain at injection site; tissue irritation and

induration (subcutaneous injection)

Respiratory: slow, shallow respiration, apnea, suppression of cough reflex,bronchospasm, laryngospasm

Others: physical tolerance and dependenceNursing responsibilities:

Check vital signs.

Assess for psychoses, shock, and coma






c. meperidine HCl (Demerol)Drug classes: opioid agonist analgesic


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Mechanism of Action: Acts as agonist at specific opioid receptors in the CNS to produce

analgesia, euphoria and sedation

Indications: Preoperative medication, support of anesthesia, and obstetric analgesia.

Contraindications: Contraindicated with hypersensitivity to opioids, diarrhea caused bypoisoning, COPD, cor pulmonale; respiratory depression; anoxia; increased ICP; pregnancy;

seizure disorder.

Dosage: Preoperative medication: 50-100mg IM or subcutaneously, 30-90 min before beginning

anesthesia.

Support of anesthesia: Dilute to 10mg/ml, and give repeated doses by slow IV injection;

or dilute to 1mg/ml and infuse continuously.

Adverse Effects:

CNS: Light-headedness, dizziness, sedation, delirium, insomnia, lethargy, mood changes. CV: hypotension, palpitations, bradycardia, tachycardia, syncope, facial flushing Dermatologic: urticaria, edema, pruritus, laryngospasm, bronchospasm GI: nausea/vomiting, anorexia, constipation GU: ureteral spasm, urinary retention, decreased libido, potency Local: Tissue irritation and induration Major hazards: Respiratory depression, circulatory depression, respiratory arrest,

shock, cardiac arrest.


Assess for contraindications.

Check vital signs.





D. Anticholinergicsa. atropine sulfate (AtroPen)

Drug classes: anticholinergic, antidote, antimuscarinic, antiparkinsonian, Belladonna alkaloid,

parasympatholytic

Mechanism of Action: Competitively blocks the effects of acetylcholine at muscarinic

cholinergic receptors that mediate the effects of parasympathetic postganglionic impulses,depressing salivary and bronchial secretions, dilating the bronchi, inhibiting vagal influences on

the heart, relaxing the GI and GU tracts, inhibiting gastric acid secretion, relaxing the pupil and

preventing accommodation for near vision; also blocks the effect of acetylcholine in the CNS.

Indications: Antisialagogue for preanesthetic medication to prevent or reduce respiratory tract

secretions.


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Contraindications: Contraindicated with hypersensitivity to anticholinergic drugs.

Dosage: Surgery: 0.5mg (0.4-0.6mg) IM (or subcutaneously or IV) prior to induction of

anesthesia; during surgery, give IV; reduce dose to less than 0.4mg with cyclopropane

anesthesia.

Adverse Effects:

CNS: dizziness, nervousness, increased IOP, headache, insomnia, mental confusion orexcitement, nasal congestion.

CV: palpitations, bradycardia (low doses), tachycardia (high doses) GI: dry mouth, altered taste perception, nausea/vomiting, constipation, PARALYTIC

ILEUS

GU: urinary hesitancy, urinary retention, impotence Others: decreased sweating and predisposition to heat prostration, suppression of

lactation



Check vital signs.

Assess for psychoses, shock, and coma





b. Glycopyrrolate (Robinul)Drug classes: anticholinergic (quaternary), antimuscarinic, antispasmodic, parasympatholytic

Mechanism of Action: Competitively blocks the effects of acetylcholine at receptors that

mediate the effects of parasympathetic postganglionic impulses, depressing salivary and

bronchial secretions, dilating the bronchi, inhibiting vagal influences on the heart, relaxing the

GI and GU tracts, inhibiting gastric acid secretion

Indications:

- Reduction of salivary, trachea-bronchial, and pharyngeal secretions preoperatively;reduction of the volume and free acidity of gastric secretions; and blocking of cardiac

vagal inhibitory reflexes during induction of anesthesia and intubation; may be used

intraoperatively to counteract drug-induced or vagal traction reflexes with the associatedarrhythmias.

- Protection against the peripheral muscarinic effects (bradycardia, excessive secretions) ofcholinergics that are used to reverse the neuromuscular blockade produced by

nondepolarizing neuromuscular junction blockers.


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Contraindications: Contraindicated with glaucoma; stenosing peptic ulcer, paralytic ileus,

severe ulcerative colitis; COPD, cardiac and metabolic problems, lactation.

Dosage: Preanesthetic medication: 0.004mg/kg IM 30-60min before anesthesia

Intraoperaive: 0.1mg IV; repeat as needed at 2-3 min intervals

Adverse Effects:

CNS: headache, flushing, nervousness, drowsiness, fever, mental confusion CV: palpitations, tachycardia GI: dry mouth, altered taste perception, nausea/vomiting, dysphagia, constipation GU: urinary hesitancy, urinary retention, impotence Others: decreased sweating and predisposition to heat prostration, suppression of

lactation



Check vital signs.



Ensure adequate hydration; provide environmental control to prevent hyperpyrexia.



E. Histamine H2-receptor antagonista. ranitidine (Zantac)

Drug classes: Histamine H2-receptor antagonist

Mechanism of Action: Inhibits the action of histamine at the H2 receptors of the stomach,

inhibiting gastric acid secretion and reducing total pepsin output.

Indications:

Prophylaxis of stress-induced ulcers and acute upper GI bleeding in critical patients.

Contraindications: Contraindicated with allergy to ranitidine, lactation.

Dosage: Prevention of upper GI bleeding: Continuous IV infusion of 50mg/hr. Do not treat

beyond 7 days.

Adverse Effects:

CNS: dizziness, headache, tinnitus, vertigo CV: palpitations, peripheral edema Dermatologic: Rash, alopecia


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GI: abdominal pain, nausea/vomiting, diarrhea, constipation, dry mouth GU: gynecomastia, impotence or decreased libido Other: arthralgias



Check vital signs.

Administer drug with meals and at bedtime.

Provide concurrent antacid therapy to relieve pain.





b. cimetidine (Tagamet)Drug classes: Histamine H2-receptor antagonist

Mechanism of Action: Inhibits the action of histamine at the H2 receptors of the stomach,

inhibiting gastric acid secretion and reducing total pepsin output.

Indications: Prophylaxis of stress-induced ulcers and acute upper GI bleeding in critical

patients.

Contraindications: Contraindicated with allergy to cimetidine.

Dosage: Prevention of upper GI bleeding: Continuous IV infusion of 50mg/hr. Do not treat

beyond 7 days.

Adverse Effects:

CNS: dizziness, somnolence, headache, confusion, hallucinations CV: hypotension, cardiac arrhythmias, cardiac arrest GI: diarrhea Others: impotence, gynecomastia, rash



Check vital signs.


Administer drugs with meals and at bedtime.



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II. Types of AnesthesiaAnesthesia involves the use of medicines to block pain sensations (analgesia) during surgeryand other medical procedures. Anesthesia also reduces many of our bodys normal stressreaction to surgery.

A. GeneralPermits procedure involving large operative fields usually without time limitations. It

affects the brain as well as the entire body. In addition, general anesthesia often

causes forgetfulness (amnesia) right after surgery (postoperative period).

a. Inhalation agentsa.1. Nitrous oxide

Uses: Rapid induction and recovery; Short procedures when muscle relaxation unimportant;adjunct to potent agents

a.2. Halothane (Fluothane)

Uses: A widely used halogenated hydrocarbon, halothanereduces myocardial oxygen consumption more than

it depresses cardiac function.

Advantages: Nonflammable, potent, versatile, chemicallystable; rapid smooth induction.

Disadvantages: Potentially toxic to liver. Progressivelydepressant to respiration. Can cause hypotension,

bradycardia, and cardiac arrest.

a.3. Enflurane (Ethrane)

Uses: Rapid induction and recovery; wide spectrum for maintenance

Advantages: Salivation not stimulated, broncomotor tone not affected. Cardiac rate and rhythm

remain relatively stable.

Disadvantages: Respiration and BP are progressively depressed with deepening anesthesia.

a.4. Isoflurane (Forane)

Uses: Rapid induction and recovery with minimal

aftereffects; wide spectrum for maintenance

Advantages: Less cardiac depression; increased cardiacoutput wide margin of cardiovascular safety; No CNS

excitatory effects .


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Disadvantages: Expensive. Profound respiratory depressant and reduces respiratory minute

volume.

b. IV anesthesiab.1. thiopental sodium (Pentothal)

Uses: Rapid induction and recovery; short procedures when muscle relaxation not needed; basal

anesthetic.

b.2. propofol (Diprivan)

Uses: Rapid induction and recovery; short procedures alone; prolonged anesthesia in

combination with inhalation agents or opioids.

b.3. ketamine HCl (Ketalar)

Uses: Rapid induction; short procedures when muscle

relaxation not needed; children and young adults.

c. Muscle relaxantspancuronium (Pavulon)

CLASSIFICATION(S)Therapeutic: neuromuscular blocking agents-nondepolarizing

INDICATIONS

Induction of skeletal muscle paralysis and facilitation of intubation after induction ofanesthesia in surgical procedures. Facilitation of compliance during mechanicalventilation

ACTION

Prevents neuromuscular transmission by blocking the effect of acetylcholine at themyoneural junction. Has no analgesic or anxiolytic properties

Contraindicated in:

Hypersensitivity to bromides. Products containing benzyl alcohol should be avoided inneonates

ADVERSE REACTIONS/SIDE EFFECTSRespiratory: bronchospasm,

CV: hypertension, tachycardia,

GI: excessive salivation,

Derm: rash,

Misc: ALLERGIC REACTIONS INCLUDING ANAPHYLAXIS

DOSAGE

IV (Adults and Children >12 yrs): 0.15 mg/kg initially; incremental doses of 0.15mg/kg may be given q 20-60 min as needed to maintain paralysis or as a continuousinfusion of 0.02-0.04 mg/kg/hr or 0.4-0.6 mcg/kg/min.

IV (Children > 1 yr): 0.15 mg/kg q 30-60 min as needed or as a continuous infusion of0.03-0.1 mg/kg/hr or 0.5-1.7 mcg/kg/min IV (Neonates and Infants): 0.1 mg/kg q 30-60 min as needed or as a continuous

infusion of 0.02-0.04 mg/kg/hr or 0.4-0.6 mcg/kg/min

AVAILABILITY Injection: 1 mg/ml in 10-ml vials, 2 mg/ml in 2- and 5-ml ampoules


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NURSING RESPONSIBILITIES

Assess respiratory status continuously throughout therapy with neuromuscular blockingagents. These medications should be used only to facilitate intubation or in patients

already intubated

Monitor ECG, heart rate, and blood pressure throughout administration Toxicity and Overdose: If overdose occurs, use peripheral nerve stimulator to determine

the degree of neuromuscular blockade. Maintain airway patency and ventilation until

recovery of normal respirations occurs

vecuronium (Norcuron)

CLASSIFICATION(S)Therapeutic: neuromuscular blocking agents-nondepolarizing

INDICATIONS

Induction of skeletal muscle paralysis and facilitation of intubation after induction ofanesthesia in surgical procedures

ACTION

Prevent neuromuscular transmission by blocking the effect of acetylcholine at themyoneural junction. Have no analgesic or anxiolytic properties; skeletal muscle paralysis

Contraindicated in:

Hypersensitivity to bromides (pancuronium, vecuronium only). Products containingbenzyl alcohol should be avoided in neonates

DOSAGE

IV (Adults and Children >10 yr):Intubation--80-100 mcg/kg for intubation (60-85mcg/kg if given after steady-state anesthesia achieved or 40-60 mcg/kg after

succinylcholine-assisted intubation and anesthesia; wait for disappearance ofsuccinylcholine effects; or 50-60 mcg/kg during balanced anesthesia). Up to 150-280

mcg/kg have been used in some patients; maintenance--10-15 mcg/kg 25-40 min afterinitial dose, then q 12-15 min as needed or as a continuous infusion at 1.5-2 mcg/kg/min

IV (Children > 1 yr): 100 mcg/kg q 1 hr as needed or as a continuous infusion of 1.5-2.5mcg/kg/min

IV (Infants > 7 wks -- 1 yr): 100 mcg/kg q 1 hr as needed or as a continuous infusion of1-1.5 mcg/kg/min

IV (Neonates ): 100 mcg/kg initially then 30-150 mcg/kg/dose q 1-2 hr as needed AVAILABILITY: VecuroniumPowder for injection: 10 mg and 20 mg vials

NURSING RESPONSIBILITIES Assess respiratory status continuously throughout therapy with neuromuscular blocking

agents. These medications should be used only to facilitate intubation or in patients

already intubated

Neuromuscular response should be monitored with a peripheral nerve stimulatorintraoperatively. Paralysis is initially selective and usually occurs sequentially in the

following muscles: levator muscles of eyelids, muscles of mastication, limb muscles,

abdominal muscles, muscles of the glottis, intercostal muscles, and the diaphragm.

Recovery of muscle function usually occurs in reverse order

Monitor ECG, heart rate, and blood pressure throughout administration Toxicity and Overdose: If overdose occurs, use peripheral nerve stimulator to determine

the degree of neuromuscular blockade. Maintain airway patency and ventilation untilrecovery of normal respirations occurs

succinylcholine (Anectine, Quelicin)

CLASSIFICATION(S)Therapeutic: neuromuscular blocking agents-depolarizing


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INDICATIONS

Used during surgical procedures to produce skeletal muscle paralysis after induction ofanesthesia and provision of opioid analgesics

ACTION

Prevents neuromuscular transmission by blocking the effect of acetylcholine at themyoneural junction; Has agonist activity initially, producing fasciculation; Causes therelease of histamine; Has no analgesic or anxiolytic effects; Skeletal muscle paralysis

Contraindicated in:

Hypersensitivity to succinylcholine or parabens; Plasma pseudocholinesterase deficiency;Personal history of malignant hyperthermia; Children and neonates (continuous

infusions)

ADVERSE REACTIONS/SIDE EFFECTS

Most adverse reactions to succinylcholine are extensions of pharmacologic effects

Resp: APNEA, bronchospasm,

CV: arrhythmias, bradycardia, hypotension,

FE: HYPERKALEMIA,

MS: RHABDOMYOLYSIS, muscle fasciculation,

Misc: MALIGNANT HYPERTHERMIA, myoglobinemia

(increased in children), myoglobinuria (increased in children), tachyphylaxis

DOSAGE

Test Dose

IV (Adults ): 5-10 mg (0.1 mg/kg), then assess respiratory functionShort Procedures

IV (Adults ): 0.6 mg/kg (range 0.3-1.1 mg/kg) up to 150 mg total dose; additional dosesdepend on response, maintenance: 0.04-0.07 mg/kg q 5-10 min as needed

IV (Children ): 1-2 mg/kg, up to 150 mg; additional doses depend on response,maintenance: 0.3-0.6 mg/kg q 5-10 min as needed, (continuous infusion not

recommended in children or neonates because of the risk of malignant hyperthermia)

Prolonged Procedures

IV (Adults ): 2.5 mg/min infusion (range 0.5-10 mg/min)Intramuscular Dosing

IM (Adults ): same as IV IM (Children ): 2.5--4 mg/kg (total dose not to exceed 150 mg)

NURSING RESPONSIBILITIES

Assess respiratory status continuously throughout use of succinylcholine.Succinylcholine should be used only by individuals experienced in endotracheal

intubation, and equipment for this procedure should be immediately available

Assess patient for history of malignant hyperthermia before administration. Monitor forsigns of malignant hyperthermia (tachycardia, tachypnea, hypercarbia, jaw muscle spasm,

lack of laryngeal relaxation, hyperthermia) throughout administration

Lab Test Considerations: May cause hyperkalemia, especially in patients with severetrauma, burns, or neurologic disorders

Toxicity and Overdose: If overdose occurs, use peripheral nerve stimulator to determinedegree of neuromuscular blockade. Maintain airway patency and ventilation untilrecovery of normal respirations occurs

B. Regionala. Topical

benzocaine(Americaine)


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tetracaine (Pontocaine, Viractin)

CLASSIFICATION(S)Therapeutic: anesthetics (topical/local)

INDICATIONS

Topical: Relief of pruritus or pain associated with minor skin disorders including burns,abrasions, bruises, insect stings/bites, dermatitis, hemorrhoids, or other forms of skin

irritation

Mucosal: Provide local anesthesia to mucosal surfaces before instrumentation, minorprocedures, or endoscopy. Decrease irritation caused by minor mouth and throatconditions including sore throat, gingivitis, stomatitis, or teething. Also used to suppress

the gag reflex during endoscopy or intubation

ACTION

Inhibit initiation and conduction of sensory nerve impulses. Local anesthesia withsubsequent loss of sensation or relief of pain and/or pruritus

Contraindicated in:

Hypersensitivity. Cross-sensitivity may occur among related agents (amide types--dibucaine; ester types--benzocaine, tetracaine)

Hypersensitivity to any components of preparations including stabilizers, colorants, orbases

Active, untreated infection of affected area Not to be used in the eye Some products contain alcohol and should be avoided in patients with known alcohol

intolerance

Topical benzocaine products should not be used in children


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Lidocaine (Dilocaine, Lidoject, Nervocaine, Octocaine, Xylocaine)

CLASSIFICATION(S)Therapeutic: anesthetics (topical/local), antiarrhythmics (class IB)

INDICATIONS

IV: Ventricular arrhythmias

IM: Self-injected or when IV unavailable (during transport to hospital facilities) Local: Infiltration/mucosal/topical anesthetic Patch: Pain due to post-herpetic neuralgia

ACTION

IV: IM: Suppresses automaticity and spontaneous depolarization of the ventricles duringdiastole by altering the flux of sodium ions across cell membranes with little or no effect

on heart rate

Local: Produces local anesthesia by inhibiting transport of ions across neuronalmembranes, thereby preventing initiation and conduction of normal nerve impulses;

Control of ventricular arrhythmias; Local anesthesia

Contraindicated in:

Hypersensitivity; cross-sensitivity may occur Advanced AV block

Use Cautiously in:

Liver disease, CHF, patients weighing


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b. Field blocks

c. Caudal and Epidural blocks

b. Spinal

III. AntibioticsCephalosporins (cefuroxime)

Drug classes: Antibiotic; Cephalosporins (second generation)

Therapeutic Actions: Bactericidal: Inhibits synthesis of bacterial cell wall, causing cell death.

Indications: Pharyngitis, tonsillitis caused by Streptococcus pyogenes. Lower respiratory

infection, UTIs, uncomplicated gonorrhea; Skin and skin structure infections. Dermatologic

infections, septicemia, bone and joint infections.

Contraindications and Cautions:

Contraindicated with allergy to cephalosporins or penicillins. Use cautiously with renal failure, lactation, pregnancy.

Dosages: Adult: PO: 125-500 mg bid

Pediatric: PO: 125-250 mg bid

Adverse effects:

CNS: Headache, dizziness, lethargy GI: nausea, vomiting, diarrhea GU: Nehprotoxicity Hematologic: bone marrow depression Hypersensitivity: ranging from rash to fever to anaphylaxis Local: Pain

Aminoglyoside (amikacin sulfate)

Drug Class: Aminoglycoside

TherapeuticActions: Bactericidal: Inhibits protein synthesis in susceptible stains of gram-

negative bacteria, and the functional integrity of bacterial cell membrane appears to be disrupted,causing cell death.

Indications: Primarily gentamycin- and tobramycin- resistant gram- negative infections alongwith severe staphylococcal infection.

Contraindications and Cautions:

Contraindicated with allergy to any aminoglycosides, renal or hepatic disease, preexistinghearing loss, myasthenia gravis, parkinsonism, infant botulism, lactation.


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Use cautiously with elderly patients, any patient with diminished hearing, decrease renalfunction, dehydration, neuromuscular disorders, preganancy.

Dosages: Adult and Pediatric: IV: 15 mg/kg/day divided bid- tid or 15- 20 mg/kg once daily Neonatal: IV: 10 mg/kg load, then 7.5 mg/kg q12h

Adverse Effects:

CNS: confusion, disorientation, headache, tremor CV: Palpitations, hypotension, hypertension GI: nausea, vomiting, anorexia, diarrhea GU: Nephrotoxicity Hematologic: hemolytic anemia Hepatic: hepatic toxicity, hepatomegally Hypersensitivity: rash, urticaria, itching

Betalactams

Penicillins (amoxicillin trihydrate)

Drug Class: Antibiotic (penicillin- ampicillin type)

Therapeutic Actions: Bactericidal; Inhibits synthesis of cell wall of sensitive organisms,

causing cell death.

Indication: Infections due to susceptible stains of Haemophilis influenza, Escherichia coli,

non- penicillinase producing staphylococci.

Prevention and treatment of infections caused by susceptible bacteria.

ContraindicationandCaution:

Contraindicated with allergies to penicillins, cephalosporins, or other allergens. Use cautiously with renal disorders, lactation.

Dosages: Pediatric: PO: 40-90 mg/ kg/ day divided q8-12h

Adult: Po: 250-500 mg q8h

AdverseEffects:

CNS: Lethargy, hallucinations, seizure GI: gastritis GU: Nephritis Hematologic : Anemia, prolonged bleeding Hypersensitivity: rash, fever, wheezing, anaphylaxis Others: Superinfections- oral and rectal moniliasis, vaginitis

Carbapenems

Drug Class: Antibiotic (carbapenem)

TherapeuticActions: Bactericidal: Inhibits synthesis of bacterial cell wall and causes cell death

in susceptible cells.


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Indications: Infection with gram- positive, gram- negative, and aerobic bacteria, includingPseudomonas aeruginosa; includes infections of bone, joint, skin, or soft- tissue and endocarditis,

pneumonia, UTI, intraabdominal and pelvic infections and septicemia.

ContraindicationsandCautions: Contraindicated with allergy to cephalosporins, penicillins, betalactams; lactation. Use cautiously with CNS disorders, seizures, renal or hepatic impairment, pregnancy.

Dosages: IV: 1000 mg q8h

AdverseEffects:

CNS: Headache, dizziness, lethargy, seizure GI: pseodomembranous colitis, nausea, vomiting, diarrhea

MONOBACTAMS (aztreonam)

Drugclass: monobactam antibiotic

TherapeuticActions: Bactericidal: Interferes with bacterial cell wall synthesis, causing cell

death in susceptible gram- negative bacteria, ineffective against gram- positive and anaerobicbacteria.

Indications: Primarily UTI caused by gram- negative organisms, severe systematic infections

ContraindicationsandCautions

Contraindicated with allergy to aztreonam Use cautiously with immediate hypersensitivity reaction to penecillins or cephalosporins,renal and hepatic disorders, lactation.

Dosages: IV/IM: 500- 1000 mg q8-12h

AdverseEffects:

Dermatologic: rash, pruritis GI: nausea, vomiting, diarrhea Hypersensitivity: Anaphylaxis Local: local phlebitis or thrombophlebitis at IV injection site, swelling or discomfort at

IM injection site

MACROLIDES AND KETOLIDES (erythromycin)

DrugClass: Macrolide Antibiotic

Therapeutic Action: Bacteriostatic or bactericidal in susceptible bacteria; binds to cell

membrane causing change in protein function, leading to cell death.

Indications: Acute infections caused by sensitive strains of streptococcus pneumonia

URIs, lower respiratory tract infection, skin and soft tissue infection

Contraindicationsandcautions:

Systemic administration

Contraindicated with allergy to erythromycin Use cautiously with hepatic impairment, lactation

Ophthalmic ointment:


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Contraindicated with allergy to erythromycin; viral, fungal, mycobacterial infections ofthe eye.

Dosages: Adult: PO: 250- 500 mg qidPediatric: 30-100 mg/kg/day divided qid

Adverse Effects:

Cardiovascular: palpitations, chest pain CNS: headache, dizziness, vertigo GIT: nausea, hepatotoxicity, heartburn, vomiting, diarrhea, flatulence Integumentary: rash, pruritus, urticaria, thrombophlebitis (IV site) Other: hearing loss, tinnitus

Sulfonamides (sulfadiazine)

DrugClasses: Antibiotic, Sulfonamide

TherapeuticActions: Bacteriostatic: Competitively anatagonizes PABA, an essential

component of folic acid synthesis in gram- negative and gram-positive bacteria; prevents cell

replication.

Indications: Treatment of acute infections caused by susceptible organisms: UTIs, acute otitis

media, rheumatic fever, meningococcal meningitis.

Orphan drug use: With pyrimethamine for treatment ofToxoplasma gondii encephalitis in

patients with AIDS.

ContraindicationsandCautions:

Contraindicated with allergy to sulfonamides , sulfonylureas, thiazides; pregnancy(teratogenic; may cause kernicterus); lactation (risk of kernicterus, diarrhea, rash).

Use cautiously with impaired renal or hepatic function, G6PD deficiency, porphyria.Dosages: Loading dose: 2-4 g PO. Maintenance: 2-4 g/ day PO in three to six divided doses.

AdverseEffects:

CNS: Headache, peripheral neuropathy, mental depression, seizure, ataxia, hallucination,tinnitus, vertigo, insomnia, hearing loss, drowsiness, transient lesions of posterior spinal

column,

Dermatoloogic: Photosensitivity, cyanosis, petechiae, alopecia GI: nausea, emesis, abdominal pains, diarrhea, hepatitis, anorexia. GU: hematuria, oliguris and anuria Hematologic: hemolytic anemia, thrombocytopenia Hypersensitivity: Stevens- Johnson syndrome Others: drug fever, chills


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COLLEGE OF NURSING

Silliman University

Dumaguete city

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December 1, 2011

ordrug..final

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