Chapter 9 - Surgical Pharmacology and Anesthesia

ketorolac (Toradol)

A non steroidal anti-inflammatory drug used for moderate pain control. This agent is given IM to aid in pain management during emergence and recovery.

Class 5

ASA Physical Status Classification - a patient who is near death and is not expected to survive with or without the surgical procedure

Class 2

ASA Physical Status Classification - a patient with mild to moderate systemic disease disturbance, controlled hypertension, history of asthma, anemia, smoker, controlled diabetes, mild obesity, age less than 1 or greater than 70

Class 4

ASA Physical Status Classification - a patient with severe systemic disease, disorders that are life threatening, unstable angina, congestive heart failure, debilitating respiratory disease, hepatorenal failure

Class 3

ASA Physical Status Classification - a patient with severe systemic disturbance or disease, angina, post-myocardial infarction (MI), poorly controlled hypertension, symptomatic respiratory disease, massive obesity

Class 1

ASA Physical Status Classification - a patient without organic, physiological, biochemical, or psychiatric disturbances

Class 6

ASA Physical Status Classification System - brain dead patient on life support for the purposes of organ procurement

1. patient is unaware of activity 2. aspiration prevented once airway is secured 3. medical dosage easily controlled 4. muscle relaxation for easy intubation and access to surgical site

Advantages of general anesthesia (4)

peripheral intravenous catheter or a central venous delivery system

Agent injection is accomplished by use of a venous access device, usually a. . . or a . . .

induction phase of anesthesia

Agents are administered usually followed by a muscle relaxant. Patient's respiration is controlled with ventilation by an ET tube or LMA. A rigid or flexible fiberoptic laryngoscope is used to expose the glottis for intubation.

induction, maintenance, emergence, recovery

All of the following are phases of anesthesia:

cervical cancer

Schiller's test uses iodine to test for . . .

aspiration regurgitation

Sellick's maneuver is performed to reduce the risk of _______________. The ST holds the esophagus to prevent ______.

neuromuscular blockade

Skeletal muscle relaxants interfere with passage of impulses from motor nerves to skeletal muscles resulting in muscle weakness and paralysis

Stage II - Excitement of delirium stage

Stage of General Anesthesia - Consists of the period from the loss of consciousness to the return of regular breathing and loss of eyelid reflex. - Uninhibited patient movements demonstrated - Vomiting, laryngospasm, hypertension, and tachycardia may be seen during this stage - The activities of this stage may be reduced or passed through rapidly by the administration of an IV induction agent which rapidly brings the patient from Stage I to Stage III

Stage I - Amnesia Stage

Stage of General Anesthesia - begins with the initial administration of an anesthetic agent to loss of consciousness

Stage III - Surgical anesthesia stage

Stage of General Anesthesia - consists of the period between the onset of regular breathing and loss of eyelid reflex to the cessation of breathing - the patient is unresponsive to painful stimuli and sensation with the sense of hearing being the last sense to be blunted - this stage is often divided into four planes, with planes 2 and 3 considered to be the optimum level of anesthesia for surgical intervention

Stage IV - Overdose stage

Stage of General Anesthesia - dilated and nonreactive pupils are noted, the cessation of respiration and marked hypotension lead to circulatory failure; if uncorrected, this stage leads to patient death.

emergence

Termination of anesthesia and the process of regaining consciousness is called _____

1. induction 2. maintenance 3. emergence 4. recovery

The 4 phases of general anesthesia are. . .

irrigation

The ST must keep track of the amount of ____ used in wounds so that estimated blood loss can be calculated.

spinal (intrathecal) block

agent injected Ito the cerebrospinal fluid within subarachnoid space injected between 3rd and 4th or 4th and 5th lumbar vertebrae used for surgery on lower part of body ***Trendelenburg position can be used only after the drugs have fixed to the nerves. Always consult the anesthesia provider before changing patient positioning***

nerve plexus block

agent injected in tissues surrounding a major nerve plexus such as the brachial (axillary), cervical (neck), caudal (sacrum), or lumbar (lower back) plexus

epidural

agent injected into space above the dura continuous infusion can be used for lighter level of general anesthesia and post operative pain control used for anesthesia of lower limbs

Oropharyngeal Airway

This airway management device is frequently used after surgery. It holds the airway open when the throat is relaxed.

Laryngeal Mask Airway (LMA)

This airway management device is used for shorter procedures on healthier patients. There are higher numbers of aspiration and regurgitation incidents with these.

Endotracheal tube

This airway management device is used when the procedure duration will be 2 hours or longer

Preinduction period

This period begins when premedication is administered and ends when the induction of anesthesia is begun. The patient may receive supplemental oxygen during this period.

Emergence phase

This phase occurs at the end of the procedure when the anesthetic agents are discontinued and allowed to wear off. When the patient is breathing on their own, the ET tube is removed (extubation)

recovery phase

This phase occurs when the vital signs are stable and the patient is taken to the PACU. This phase usually begins in the OR.

- oral or nasal airway - face mask - laryngeal mask airway (LMA) - endotracheal tube

Tools used to manage/maintain patient's airway during induction:

hyaluronidase (Wydase) and epinephrine

Two adjective agents associated with nerve conduction blockade agents that influence the onset and duration of action of these agents

Ketamine

What anesthetic drug is injected intramuscularly?

1. agent inhalation 2. agent injection 3. agent instillation (less common)

What are the three techniques general anesthesia can be accomplished?

midazolam (Versed)

What drug is administered to relieve anxiety and provide amnesia?

adverse effect

What has an undesirable and potentially harmful effect of a medication that can lead to organ donor or failure?

agent instillation

What involves the administration of medication into an area such as the rectum, where is agent is absorbed via the mucous membranes and transported to the CNS by the circulatory system? This method is used in selected cases where patent cooperation is less than optimal.

general anesthesia

What is described as an alteration in the patients' perception of their environment through alterations in their level of consciousness?

Have the patient as awake as possible at the end of the procedure

What is the goal of the emergence phase?

adequate and independent respiratory rate, function, and gag reflex

What is the primary focus during the emergence phase?

sedate the patient and reduce anxiety

What is the primary purpose of premedication before anesthesia?

NPO after midnight

What is the standard "rule" for fasting before a surgical procedure?

Level II

What level of controlled substance include a substance that has a high abuse potential and high ability to produce physical and psychological dependence?

cardioesophageal sphincter

What sphincter is relaxed by induction agents or neuromuscular blockades, allowing gastric contents to enter the esophagus?

analgesics or narcotics

What types of drugs are ordered if preoperative discomfort is anticipated?

balanced anesthesia

When several agent delivery methods are used during general anesthesia administration, the technique is called. . .

the circulator

Who ensures all preoperative protocols have been carried out (e.g. appropriate attire, IV inserted and patent, jewelry removed, prothesis removed, surgical site marked if indicated)

the anesthesia provider

Who orders additional diagnostic studies and/or consultations with other physicians regarding the patient's condition?

pulse oximeter

____ is a digital sensor that detects oxygen saturation through the skin

Ringer's solution

_____ are administered during surgery to balance the patient's electrolytes

amnesia

_________ is the depths of anesthesia when the initial administration of anesthetic agent is given to loss consciousness?

oxygen

__________ is a component of the most anesthetic administration?

intrathecal

_____________ involves injection of medication into the subarachnoid space of the spinal cord.

Morphine sulfate Meperidine (Demerol) Fentanyl Sufentanil

______________: (analgesic standard) Duration 2 to 4 hours _____________: 10% as powerful as morphine. Duration 2 to 3 hours ______: 100x more powerful than morphine Duration 30 to 45 minutes _______: 1,000 times more powerful than morphine Duration 1 hour

pharmacokinetics? or therapeutic action?

________is the study of drugs' onset, peak effect, and duration of action on living organism.

aspiration pneumonia

a chemical pneumonitis that can lead to development of a bacterial lung infection

acetic acid (vinegar)

a colored staining agent used to identify areas of cervical dysplasia.

oxygen

a component of most anesthetic administration. Its pure form provides the gas essential to the survival of the patient by promoting cellular function

malignant hyperthermia

a potentially fatal hyper metabolic state of muscle activity resulting from a defect in calcium transportation within the muscle fibers of skeletal muscles

retrobulbar

a regional anesthetic nerve block in the area located behind the globe of the eye. Wydase is used around the optic nerve injection of local anesthetic into the space constitutes a ____ block

D5W (5% dextrose solution)

a solution of water with a 5% concentration of dextrose monohydrate added that serves as a source or glucose, sugar normally obtained by eating Used to correct hypoglycemia and replace water lost during normal metabolism.

0.9% saline (normal saline)

a solution of water with the addition of sodium chloride used to correct deficits of sodium and chloride and treat metabolic alkalosis

antimuscarinic agents

act to block the cholinergic effects of certain drugs or stimulation of the PNS, including excessive salivation and bradycardia formerly known as anticholinergics

patient positioning

advanced in surgical procedure demand advantageous access to the surgical site - this is achieved by optimal . . .

mepivacaine hydrochloride (Carbocaine)

amino amide local region, rapid onset, 1-3 hours duration

dosage

amount of medication delivered to the patient in order to achieve the desired effect

shock

an abnormal physiological state indicated by the presence of reduced cardiac output, tachycardia, hypotension, and diminished urinary output

hypnosis

an altered state of consciousness related to the patient's perception of the surgical procedure

Bacitracin

an antibiotic used topically for infections caused by various bacteria Is available in powder or ointment form Keep powder in the refrigerator Dissolve powder in a saline solution Ointment is designed to be placed directly in the wound; ointment does not need to be refrigerated Use powder topically for irrigation; powder should NEVER be injected

Versed (Midazolam)

an intravenous Benzodiazepine; sedative, short-acting amnesic, CNS and respiratory depressant

Valium (Diazepam)

an intravenous Benzodiazepine; tranquilizer that produces amnesia, sedation, and muscle relaxation. Used as a premedication, awake intubation, and induction.

Brevital (Methohexital)

an intravenous barbiturate; potent, circulatory and respiratory depressant, used for rapid induction and brief anesthesia

pentothal sodium (Thiopental sodium)

an intravenous barbiturate; potent, short acting with cumulative effect, rapid uptake by circulatory system, no muscle relaxation, respiratory depression. Used for rapid induction and recovery, short procedures with muscle relaxation is not needed, a basal anesthetic

meperidine (Demerol)

an opiate used to treat severe to moderate pain

fentanyl citrate (sublimaze)

an opiate with rapid onset and short duration

topical anesthesia

involves placement of a nerve conduction blocking agent onto the skin or mucous membrane tissue effect is limited to the area in contact with agent example: cryoanesthesia agents applied directly to the skin are absorbed and come into contact with the peripheral nerve endings

Bair hugger

patient warming device utilizes air blown into a special blanket that is placed over the patient

amnesic agents

provide a lack of recall or perioperative events and permit the use of safer, less toxic anesthetic agents and technique while providing a calm and cooperative surgical patient

bier block (intravenous)

provides anesthesia to distal portion of upper extremity used for extremity surgery less than 1 hour long agent injected into a vein in the arm that has been drained of blood following placement of a tourniquet analgesics may be given for tourniquet pain

gentian violet

purple dye used frequently to mark skin incision should never be injected.

allergic reaction

result of histamine release in response to an allergen, a triggering protein

benzodiazepines

sedatives and tranquilizers reduce anxiety and apprehension of preoperative patient adjunct to general anesthesia to reduce amount and concentration of other more potent agents class IV drugs

dissociative agents

selectively interrupt pathways of the brain

induced hypotension

involves a controlled decrease of blood pressure during anesthetic administration results in a decrease in bleeding increases visibility in surgical field used for those who do not desire to receive a blood transfusion

regional blockade

involves administration of an anesthetic along a major nerve tract

cardiac dysrhythmias

involve abnormal heart rate or rhythm evidenced by ECG monitoring

Lacri-lube Duratears

2 lubricants used to protect cornea when eye is unable to close or when natural lubrication of eyes in impaired prevent corneal drying during general anesthesia

hypnoanesthesia acupuncture

2 methods of nontraditional anesthesia options

1. IV induction agent 2. inhalation of gaseous vapors

Anesthesia induction may be carried out in two ways:

propofol

Another name for Diprivan is ______________.

fentanyl citrate

Another name for Sublimaze is __________.

penicillins

Antibiotics effective against a wide variety of gram positive and gram negative bacteria Can be administered orally, intramuscularly, or intravenously deepening on the medication Are given prophylactically to patients preoperatively and intraoperatively to prevent postoperative wound infections Common penicillins include ampicillin, amoxicillin, carbenicilliin, mezlocillin, penicillin V, and pipeeracillin

cephalosporins

Are bactericidal antibiotics active against many gram positive and some gram negative microorganism Are used prophylactically in various surgical procedure to prevent postoperative wound infection Routes of administrations include oral, intramuscular, and intravenous depending on the medication Are used for serious infections of the respiratory and genitourinary tract, skin, soft, tissue, bone and joints, Common examples used in surgery include Kefzol, Ancef, Duricef, Zinacef, and Rocephin

macrolides

Are bacteriostatic antibacterial agents used against several gram positive bacteria such as streptococcus erythreus Are administered orally Common examples include erythromycin, which is available in topical ointment and solutions used for ophthalmic infectious

tetracyclines

Are broad spectrum antibiotics; have a bacteriostatic actions against many gram positive and gram negative bacteria. Can be administered orally, topically, occasionally intramuscular, or intravenously. Example: Chlortetracycline hydrochloride is available in an ophthalmic and topical ointment

antibiotics

Are used to destroy or inhibit the growth of pathogenic microorganisms. May be used topically as an irrigating solution, applied as an ointment, or given intravenously before or during a surgical procedure for prophylaxis against postoperative wound infections. are categorized in large classes such as aminoglycosides, cephalosporins, macrolides, penicillins, and tetracyclines.

induction phase

Aspiration is most likely to occur in this phase of anesthesia administration.

liver

Biotransformation most often takes place in the ______?

Schedule / Class II

Controlled Substances Act - high abuse potential and high ability to produce physical and psychological dependence. Morphine sulfate, oxycodone, codeine, anabolic steroids

Schedule / Class I

Controlled Substances Act - high abuse potential and no current approved medical use Recreational drugs, heroin, marijuana, LSD

Schedule / Class III

Controlled Substances Act - less potential of abuse than drugs in schedule II and for which there is an approved medical use. Hydrocodone, codeine and others in combination with drugs

1. ACP (anesthesia care provider) 2. MDA (anesthesiologist) 3. CRNA (certified registered nurse anesthetist) 4. AA (Anesthesia assistant) 5. Anesthesia technologist

Different types of anesthesia personnel (5)

3-5 minutes

How long is oxygen administered to oxygenate the body and eliminate waste gasses?

deprival (Propofol)

Intravenous agent for anesthesia: Alkyl phenol, potent, short-acting sedative-hypnotic; cardiovascular depressant. Used for rapid induction and recovery, short procedures. For prolonged procedures, used alongside inhalation or opioids.

sublimaze (Fentanyl), sufenta (Sufentanil)

Intravenous opioids for anesthesia: potent narcotic, metabolizes slowly, respiratory depressant. A high-dose narcotic anesthesia used with oxygen.

laryngeal mask airway

LMA stands for

respiratory, circulatory

Medication effect does not rely on _____ function for distribution, only ____ function.

regional anesthesia

Nerve plexus block, bier block, spinal block, and epidural block are common types of ____

acetylcholinesterase

Nondepolarizing agents may be revered by the administration of agents that inhibit ________, the enzyme that breaks down acetylcholine

4 hours

Patient has ingested breast milk - how long to fast before procedure?

2 hours

Patient has ingested clear liquids - how long to fast before procedure?

6 hours

Patient has ingested infant formula, nonhuman milk, or a light meal - how long to fast before procedure?

8 hours or longer

Patient has ingested solids (meat, fried, or fatty foods) - how long to fast?

extubation

Removal of the endotracheal tube is called

1. aspiration 2. laryngo/brochospasm 3. malignant hyperthermia 4. pseudo cholinesterase deficiency syndrome 5. allergic reaction, shock, cardiac arrest

Risks of General Anesthesia (5)

Ketamine HCl

The most commonly used dissociative agent that produces vivid imagery and morbid hallucinations during administration is

emergence

The phase of general anesthesia after cessation of the general anesthetic is called ____

aminoglycosides

antibiotics antibacterial and are active against aerobic, gram negative bacteria and some gram positive bacteria such as Staphylococcus. Are used for short term treatment of serious infections of the skin, bones, respiratory tract, alimentary tract, and central nervous system. Are completely absorbed when applied topically during a surgical procedure; intramuscular and intravenous are the most common route of administration. Common examples used in surgery include Amikin, kanamycin Kantrex, gentamycin (Garamycin and Jenamicin, neomycin (Neobiotic), streptomycin, tobramycin (Nebcin)

droperidol (Inapsine) metoclopramide (Reglan) ondansetron HCl (Zofran) granisetron HCl (Kytril) dolasteron mesylate (Anzemet)

antiemetics used to prevent post-operative nausea and vomiting (POVN) usually IV

warming/cooling devices

assist with patient IV fluid delivery

flumazenil (Mazicon)

benzodiazepine antagonist competes for the inhibitory receptor sites rapid onset, but may not reverse amnesia effects convulsions may occur monitor patient for rebound sedation and respiratory depression

indigo carmine

can be administrated intravenously to color urine for evidence of bladder and kidney functions May also be used for tracking fissures, fistulas, and determine the patency of fallopian tubes.

pharmacokinetics

changes to a drug when it enters the body is called

Nitrous oxide

clear with a fruity odor and is the only true gas still in use. Must be used in addition to general anesthesia.

nerve conduction blockades - the amino esters

cocaine HCl (Cocaine) procaine HCl (Novocaine) tetracaine HCl (Prontocaine, Cetracaine)

volatile agents

consist of a group of liquids whose potent vapors when inhaled produce the general anesthesia through CNS depression and decreased ECG activity

intravenous agents

delivered directly into the bloodstream act quickly permit a rapid transition from consciousness to unconsciousness

Rapid infusion pump

device attached to the IV line used to rapidly deliver a large volume of blood or other fluid to the patient

dantrolene sodium (Dantrium)

drug administered specifically for malignant hyperthermia crisis

Schedule / Class IV

drugs for which there is a relatively low abuse potential and for which there is a current approved medical use Benzodiazepines like Valium and Ativan

Schedule / Class V

drugs in this category consist mostly of preparations containing limited amounts of certain narcotic drugs for use to treat coughing and diarrhea. Cough syrups with codeine and diphenoxylate (Lomotil)

actions

effects of the substance at the target

local anesthesia

injection of nerve conduction blocking agent into tissues surrounding a peripheral nerve or nerves that serve only the tissue at the site of surgical intervention

anesthesia

freedom from pain is the major focus of this . . .

citric acid (Bicitra) - oral cimetidine (Tagamet) - IV ranitidine (Zantac) - IV metoclopramide (Reglan) - cholinergic agent that can promote pyloric emptying

gastric acid management drugs histamine (H2) antagonists and antacids used to alter the pH of gastric secretions and reduce gastric volume given during preop/intraop

pseudocholinesterase deficiency syndrome

genetically transmitted trait that decreases the amount of acetylcholinesterase available in the neuromuscular junction to break down acetylcholine during muscle stimulation

opiates / opioids

group of narcotics classified as analgesics euphoria or feeling of happiness and wellbeing may reduce anxiety biotransformation takes place

isoflurane (Forane)

halogenated provides a moderately rapid induction and recovery profound respiratory depressant that may cause hypotension increases ICP which is reversible with hyperventilation

desflurane (Suprane)

has a pungent aroma contraindicated use during induction rapid onset and recovery safe to use for patients with hepatic insufficiency

Lactated Ringer's (LR) solution

has sodium lactate added in addition to the electrolytes which enables it to serve as a glucose for body metabolism used to correct fluid/electrolyte deficiencies and mild acidosis.

neuroleptanalgesia / neuroleptanesthesia fentanyl citrate (Sublimaze) meperidine HCL (Demerol)

high doses used to induce a state of diminished anxiety, sedation, and amnesia PATIENT CAN RESPOND TO COMMANDS and 2 common medications

respiratory system gaseous

inhalation agents are passed into the blood stream via the . . . and are delivered in a . . . state

aspiration

inhaling foreign fluids or solids into the lungs where inadequate time for gastric emptying has elapsed, such as trauma patients with a full stomach

induced hypothermia

involves the artificial, deliberate lowering of the body's core temperature below normal limits (normal is 98.6) results in reduced body metabolism reduction in oxygen, glucose consumption, and waste production permits use of lower dosages of inhalation and IV agents providing a safer level of anesthetic agent administration

cardiac arrest

involves the cessation of heart pumping action and blood circulation

regional anesthesia

involves the prevention of sensory nerve impulse transmission in a specific location of the body

nerve conduction blockades

involves use of pharmaceutical agents to prevent transmission of sensory nerve impulses used in low concentrations (.25-4%) with one exception (topical cocaine HCl, usually used up to 10%) divided into amino amides and amino esters

enflurane (Ethrane) and halothane (Flurothane)

less commonly used inhalation agents (volatile agents)

nerve conduction blockades - the amino amides

lidocaine HCl (Xylocaine, Lignocaine) mepivacaine HCl (Carbocaine) bupivacaine HCl (Marcaine, Sensorcaine) etidocaine HCl (Duranest) ropivicaine HCl (Naropin)

indication

listing of common medical conditions that a particular medication is used to treat

bupivacaine hydrochloride (Marcaine and Sensorcaine)

local regional amino amide slow onset 2-5 hours duration

succinylcholine

main depolarizing agent has a rapid onset useful in producing rapid neuromuscular blockade for intubation can trigger malignant hyperthermia

infusion control device

mechanical devices that regulate the delivery of IV fluids and medications

Ketamine HCl

most commonly used dissociative agent in pediatric surgery and burns administered IM or IV rapid onset of amnesia state major drawback is production of morbid hallucination during administration and recovery

amino amides

nerve conduction blockers metabolized by the liver and excreted by the kidneys

edrophonium chlorine and neostigmine

neuromuscular blockade antagonists prevent cholinergic crisis usually given in conjunction with atropine or Robinul.

muscle relaxation

neuromuscular blocking agents used in combination with inhalation agents, are capable of producing a profound effect

NPO / "nothing by mouth"

non per os / nil per os

maintenance phase

this phase of anesthesia administration begins after the insertion of the airway and continues until the operation is completed. Anesthesia administration is most dynamic during this phase.

etidocaine (Duranest)

topical amino amide local region, slow onset , 3-12 hours duration

lidocaine hydrochloride (Xylocaine and Lignocaine)

topical amino amide local region, rapid onset, 1-3 hours duration

1. atropine sulfate 2. glycopyrrolate (Robinul)

two most common antimuscarinics / anticholinergics

homeostasis of vital function

use of invasive and noninvasive monitoring devices to track the patient's critical physiological process as well as the use of safer anesthetic agents allows the continuous . . .

methylene blue

used in surgery as a stain for marking the skin and to determine the fallopian tube patency

fluid warming devices

used to raise temperature of blood and other IV fluids to body temperature just prior to infusion

Lugol's solution

used to stain cervical tissue

Ringer's solution

water based solution for injection contains essential serum electrolytes in the form of sodium chloride, potassium chloride, and calcium chloride physiologically similar to plasma used to correct fluid/electrolyte deficiencies and mild acidosis.

megaclopramide (Reglan)

what drug is given to to empty the stomach and reduce nausea and vomiting?

an anticholinergic, such as atropine

what drug is used to prevent bradycardia in pediatrics, control secretions in patients undergoing oropharyngeal procedures, and to control the cardiac reflux that may result in bradycardia in adults?

antacids or H2 receptor blocking meds such as cimetidine (Tagamet, Rantidine, or Zantac) or famotidine (Pepsid)

what drugs decrease gastric acid production or the acidity of gastric contents?

agent injection

what involved the intravenous administration of medications directly into the bloodstream?

agent inhalation

what involves the delivery of gasses across lung's alveolar membrane where the agent enters the vascular system and is transported to the brain where it is able to cross the blood-brain barrier and effect the CNS function?

the anesthesia provider

who assigns patient risk status according to ASA guidelines?

the anesthesia provider

who orders or administers premedication if necessary?

nondepolarizing agents

work by competing for post synaptic receptor sites at NMJ presents acetylcholine from stimulating muscle contraction

depolarizing agents

work by mimicking a release of acetylcholine across the NMJ binds to the postsynaptic receptors, causing muscle contraction to occur which is followed by a period of muscle fatigue this action is referred to as FASCICULATION and patient may experience post op muscle soreness CANNOT BE PHARMACOLOGICALLY REVERSED!