Surgical Technology CHAPTER 9- Surgical Pharmacology and Anesthesia

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Pharmacology
Study of drugs and their actions
Pharmacodynamics
Interaction of drug molecules with target cells resulting in biochemical and physiological action
Pharmacokinetics
Entire process drug undergoes in body ie absorption, distribution, biotransformation (metabolism), and excretion
Indication
Reason drug prescribed
Contraindication
Reason why drug undesirable or improper
Plants
Most drugs derived from plants at one time
Purple foxglove
Digitalis
Kelp – seaweed
Iodine
White poppy
Morphine
Animals
Primarily hormones
Bovine
Cows
Porcine
Pigs
Bovine, porcine
Insulin
Minerals
Minerals and mineral salts, diluted hydrochloric acid common epsom salts, sodium bicarbonate
Laboratory Synthesis
Majority of drugs today developed in lab by one or two methods
Synthetic
Manufactured from the laboratory chemicals
Semi synthetic
Chemically altered natural substance
Biotechnology
Newest source of drugs are genetically engineered, called recombinant DNA technology.
Onset
From time of administration to drug action to become evident
Peak effect
Length of drug at maximum effectiveness
Duration of action
Time between onset and cessation of action
Side effect
Expected, undesirable effect of drug – predictable, usually tolerable and treatable
Adverse effect
Undesirable consequences of drug – unintended, unpredictable, and unavoidable
Tolerance
Decreased therapeutic response following repeated administrations
Addiction
Physicological or psychological dependence upon a drug with increasing tendency toward its use and abuse
Drug interaction
Two substances administered concurrently cause modification of action of one or both drugs
Agonist
Drug potentiates or enhances effects of another drug
Antagonist
Drag blocks effect of another agent but doesn’t produce any physiological effect of its own
Enteral
Oral, rectal
Parenteral
Other than through GI tract, by injection
Intradermal
Between layers of skin
Subcutaneous
Under skin into adipose layer
Intramuscular
Within a muscle
Intravenious
Into a vein
Intra-articular
Within a joint
Intrathecal
Into the subarachnoid space of the spinal cord
Intracardiac
Into the heart
Topical
Applied to skin or mucous membranes to provide localized or systemic effect
Buccal
Between cheek and teeth until dissolved or absorbed
Sublingual
Under tongue until dissolved or absorbed
Inhalation
Direct administration via respiratory tract
Routes of administration
Topical, buccal, sublingual, inhalation
Forms of drugs
Solids, semi solids, liquids
Solids
Powders, tablets
Semi-solids
Ointments, gels
Liquids
Solutions, Tinctures, suspensions, and Emulsion
Trade or brand name
First letter is capitalized, symbols TM follow the name , makes pronunciation easier, proprietary name given by drug company
Generic Name
First light or not capitalized, universally used, given to drug before company developing drug makes drug brand name official
Chemical name
First White or not capitalized, exact chemical formula of a drug
Drug receptor interaction

Active substance in drug has affinity for specific chemical constituent of a cell

Interaction takes place on molecular level with a specific receptor on the cell surface or within cells to produce a pharmacological response

Drug enzyme interaction
Drug combines with specific enzyme to inhibit action of enzyme or altered the cellular response to enzyme
Nonspecific drug interaction
Drug accumulates on cell membrane or penetrates membrane and interferes physical or chemical with cellular function or metabolic process
Six basic rights
Right patient
Right drug
Right dose
Right route
Right time and frequency
Right documentation, including labeling
Surgical Technologist should never
Administer medication directly to patients, except medications from chipped or cracked files, except medications if they are cloudy or discolored, use medications if you’re in doubt of their identity
Surgical Technologist should always
Read preference card to make sure right dose, amount, dilution, etc are administered
All drugs should be identified a minimum of how many times
3
At what 3 times should the drug be identified three times

1- drug obtained from satellite pharmacy or storage area

2- prior to preparation for use or placement on sterile field

3 – when medication ready for administration or place on sterile field

Ways to label drugs on sterile field

May have sterile pre printed labels or plastic color coded markers

May have marking pin and blank sterile labels

Can use marking pen and steri strips

Drug handling techniques

Always labeled drugs

Sterile technique followed when mixing or transferring drugs onto the sterile field

If reconstitute a drug, remove hypodermic needle before injecting onto sterile field

Never discard any medication bottles until the end of the case

Before administering any medications to patient or onto sterile field but the circulator and surgical tech should
Ascertain patient allergies
Characteristics of anticoagulants

Used to prolong clotting time of blood

Used as irrigating solution and vascular surgery to prevent clot formation

Given IV to prevent embolus formation

Most commonly used is heparin sodium

Antagonist protamine sulfate

Most commonly used anticoagulant
Heparin sodium
Antagonist of anticoagulant
Protamine sulfate – keep refrigerated
Characteristic of hemostatic agents

Used to promote coagulation

Used where hemostatic Clips, clamps, or sutures contraindicated

Give IV to prevent embolus formation

Most commonly used Thrombin, Gelfoam, Avitene, Surgicel, Oxycel

Most commonly used hemostatic agent
Thrombin, Gelfoam, Avitene, Surgicel, Oxycel
Characteristics of antibiotics

Used to destroy or inhibit growth of pathogenic microorganisms

Used as irrigation solution are given IV

Characteristics of diuretics

Used to draw fluids away from tissues and into urinary system

Commonly used in surgery to reduce intraocular or intracranial pressure

Mannitol, furosemide

Most commonly used diuretics
Mannitol, furosemide
Characteristics of steroids

Used to reduce tissue inflammation and postoperative swelling

Particularly useful and CV, neuro, ophthalmic and plastic surgery

Characteristics of contrast medias

Used to observe various body structures through x-ray

Appear white on x-rays

Commonly used in by Larry surgery to determine presence of stones

Commonly used in cardiovascular and GI surgery to show strictures

Characteristics of dyes

Solutions that stain tissue

Used to mark incisional area

Used in diagnostic procedures to check for patency

Used topically as fungicides

Commonly used dyes
Methane blue, indigo carmine, brilliant green, gentian violet- never injected
Characteristics of IV solutions

IV route allows convenient and efficient method for administering medications, anesthetic agents, and blood or blood substitutes

IV solutions commonly compensate for fluid loss in to restore blood volume

Most commonly used IV solution
NaCl – normal saline, sodium chloride Solutions
Used for patient requiring easily metabolize source of calories – IV solution
Dextrose solution – in NaCl or water
Physiologic salt solution used to replenish patient’s electrolytes – IV solution
Ringers solution – used to improve circulation or to stimulate renal activity
More closely approximates electrolyte balance and blood – IV solution
Lactated Ringer’s solution
Characteristics of blood replacements

Used for patients experiencing significant blood loss

Whole blood
Plasma
Packed red blood cells
Platelets

Whole blood
Contains all components of blood and restores blood volume and increases hemocrit level
Plasma
Fresh frozen plasma rich in coagulation factors
Packed red blood cells
Increases hemocrit levels without worrying about circulatory overload
Platelets
Contain coagulation factors and used to treat hemorrhagic shock
Characteristics of blood substitutes

Used for patient experiencing significant blood loss and no time to wait for blood

Used for patients experiencing significant blood loss and worried about circulatory overload

Aminophyllin
Spasmolytic used to treat acute and chronic bronchial asthma, bronchial spasms, pulmonary embolism, and pulmonary edema
Epinephrine
Adrenergic used to treat anaphylactic shock, bronchospasms, and to restore cardiac rhythm and cardiac arrest
Benadryl
Sedating antihistamine used with epinephrine to treat anaphylaxis – used alone to treat histamine release
Lidocaine hydrochloride
Antiarrhythmic used to treat ventricular arrhythmias or ventricular tachycardia
Digitoxin
Drug acting directly on myocardium used to treat CHF, atrial tachycardia and atrial fibrillation and flutter
Atropine sulfate
Anticholinergic used to treat bradycardia and Brady arrhythmia
Sodium bicarbonate
Alkalinizer used to treat metabolic and respiratory acidosis, especially during cardiac arrest Pretoria rest
Sleep producing inhalations first used by
Egyptian and Arabian physicians
Endotracheal anaesthesia, first employed by open tracheotomy, was developed by
Dr. Fredreich Trendelenburg
Device ideas a passing tube through mouth and into trachea
Sir William Macewen
First endotracheal anesthesia was administered on
July 5th 1878
Anaesthesia
Comes from Greek word anaisthesis meaning lack of sensation
Partial or complete loss of sensation with or without loss of consciousness
Factors for choosing which type of anaesthesia

anticipate procedure an estimated duration

Physical, mental, and emotional status of patient

Age, size, weight

Patient positioning

Presence of pre-existing diseases

Current medications taken

Drug allergies

History of substance abuse

Emergency conditions

Surgeon, Anastasia, and patient preference

Expertise of anesthesia and anesthesiologist

Previous anaesthesia experience

Presence of infection at site of operation

Ideal anaesthetic agent for patient
Rapid acting, pleasant smelling, allowing for recovery period Free of discomfort
Ideal anesthetic agent for Surgeon
Produces good muscular relaxation, doesn’t increase bleeding, non-explosive
Ideal anesthetic agent for anesthesiologist
Wide margin of safety, leaves body system unaltered, potent, allows high percentage of oxygen to be used, non-explosive
Preanesthetic preparation of the patient – selection of preoperative medications

Age, body build, and general health

Heavy smokers, alcoholics, hyperthyroidism, emotional instability, high fever have higher metabolic rate and require more medications and oxygen

Sedatives and hypnotics
Produce calm, hypnotic state – cause drowsiness and reduction and anxiety – do not counteract pain
Benzodiazepines

Classification most commonly given

Midazolam
Generally administered IV, short acting metabolizes within 4 to 6 hours, retro amnesiac, may cause respiratory depression

Antiemetics / antinauseant
Minimize N&V, may potentiate effects of narcotics, usually used in combination with other drugs
Promethazine hydrochloride
Given IV for pre-op, interacts with other drugs to affect CNS
Hydroxyzine hydrochloride
Given I am, usually with narcotics, causes drowsiness, antihistaminic, anticholinergic – causes dry mouth
Morphine sulfate
Opiate given for moderate to severe pain, respiratory depressant
Meperidine hydrochloride
Opioid
Fentanyl
Opioid , good analgesia, and sedation effects, short-acting respiratory depressant, 80 to 100 more potent than in the MS
Anticholinergic
Interfere with stimulation of vagus nerve, increase cardiac and respiratory rate, bronchodilators, inhibit mucus secretions
Factors affecting type of anaesthesia used
Patient’s age, condition, built
Nature of operation
Anticipated length of operation
Time since last meal
Lap and x-ray findings
Pre-existing conditions or diseases
General anaesthesia
Permrates entire body and affects all its functions
Administered by inhalation, iv injection, or installation rectally
Inhalation
Inhale vaporize liquids or gases which are absorbed into bloodstream
Causes some muscle relaxation
Most common method
Anaesthesia interveniously

Generally used as an induction agent to be immediately followed by inhalation agents

May be used in conjunction with local anesthetics for Mac anaesthesia

, injected directly into bloodstream, produces rapid, pleasant general anaesthetic – no muscle relaxation – used for short procedures

Anaesthesia rectally
Used mainly in children, absorption of agent and: unpredictable, patients may not be monitored until taken into or, result and LOC and blockage of pain for transmitting center of brain
2 most critical times of anaesthesia

Induction and emergence

Cardiac arrest and vomiting ,circulator and section available at all times – quiet

Class 1 – ASA classification for assessing patience risk
No organic, physiological, biochemical, or psychiatric disturbances
Class 2- ASA classifications for assessing patient risk
Mild to moderate systemic disease disturbances – controlled HTN, asthma, anemia, smoker, control diabetes, mild obesity
Class 3 – ASA classifications for assessing patient risk
Severe systemic disease disturbance – angina, post MI, poorly controlled HTN, symptomatic respiratory disease, massive obesity
Class 4 – ASA classifications for assessing patient risk
Patients with disease and or disorders that are life threatening – unstable angina, CHG , Hepatorenal failure
Class 5 – classifications for assessing patient risk
Moribund patient with little chance of survival who is operated on in desperation
Class 6 – classifications for assessing patient
Brain dead, life support provided, organ procurement pending
Emergency modifier (E)
Applied when doing emergency surgery
Stage 1 of general anaesthesia

From beginning and ministration of drug or gas to loc

Preoxygenation, generally given IV barbiturates, pediatric patients – inhalation gas with oxygen, amnesia, exaggerated sense of hearing – be quiet comma patient may appear inebriated, drowsy or dizzy, must ensure patient airway and adequate ventilation

Surgical tech – be quiet and sending it back table, be ready to assist PRN

Stage 2 general anaesthesia

From LOC to muscle relaxation

YouTube potency a modern drugs, very short period of time, given muscle relaxants, inhalation agents, and oxygen, delirium, patient may appear excited, breed a regularly, may move arms and legs or body, patient very susceptible to external stimuli, Maci vomiting, laryngospasm , HTN and tachycardia

Surgical tech gas absolutely quiet at this time, be ready to assist.

Stage 3 general anaesthesia

State of relaxation to loss of reflexes, depression of vital functions

, partial to complete sensory loss – progression to complete intercoastal paralysis- quiet, regular thoracoabdominal respiration- constricted pupils, eyelid reflexes disappear – jaw relax – auditorium pain sensation lost

Surgical Technologist – consult with Surgeon pr and, variations due to specific patient made in suture, medication, instrumentation

Stage 4 general anaesthesia (overdosage)

Circulatory and respiratory distress – respiratory muscles paralyzed – pupils fixed and dialated – pulse thready and rapid – respiration cease

Surgical Technologist – stay sterile, protector of field, assist and closing patients ASAP or whatever else is needed – chest compressions, packing wound, etc

Phase 1 induction general anaesthesia

Altering patients level of consciousness – goes from conscious or unconscious – carried out by inhalation or IV – management of airway critical – patients hearing last sense to go and is usually more acute than normal

Surgical tech – be quiet

Phase 2 maintenance general anaesthesia
Surgical intervention takes place – maintenance of all body systems – anaesthesia monitors oxygen saturation, blood loss, muscle relaxant state, cardiac status
Phase 3 emergence general anaesthesia

Goto have patient as awake as possible at end of surgery – monitor adequate independent breathing and gag reflex – extubate is if possible – patient at risk for laryngospasm – temperature changes and shivering and rigidity

Surgical tech – be quiet, don’t rattle your instruments

Phase 4 recovery general anaesthesia

Patient returns to optimal level of consciousness and wellbeing – usually begins in OR suite

Surgical tech – be quiet, don’t write on your instruments

Advantages of general anaesthesia
Patient unaware of activities, Death Dandrea respirations can be controlled – medication dosages easily titrated – muscle relaxation easily achieved
Risk and complications of general anaesthesia
Aspiration – Laryngospasm – malignant hyperthermia – pseudocholinesterase deficiency syndrome- allergic reactions – shock – cardiac dysrhythmias – cardiac arrest
Laryngospasm
College fight flight trigger of gag reflex – may occur during induction or mergence – family to total airway obstruction – may have to give neuromuscular relaxant Andrian tube8
Malignant hyperthermia
Potentially fatal hypermetabolic state muscle activity – skeletal muscles contract, but due to inability to relax C++, muscles don’t relax – leads to rigidi, heat generation, and buildup of lactic acid and co2 – generally transmitted disease, more common in males and females, triggered by use of hallucinogenic gases
Pseudocholinesterase deficiency syndrome
Genetically transmitted trait that decreases the amount of acetylcholinesterase available at the NMJ to break down ACH during muscle stimulation
Allergic reactions
Range from mild to life-threatening – always take patient history – treatment varies according to severity – skin irritation, anaphylaxis
Shock
Caused by hemorrhage, sepsis, trauma
Cardiac dysrhythmias
Abnormal heart rate of rhythms such as ventricular tachycardia and ventricular fibrillation – TX may include lidocaine , defibrillation And pacemaker insertion
Cardiac arrest
Involves cessation of heart pumping action and blood circulation – leads ischemia , cellular death, metabolic and respiratory acidosis
Anesthetic inhalation agents
Oxygen
Nitrous oxide
Votatile agents
Halo thane
Enflurane
Isoflurane
Desflurane
Oxygen – anesthetic inhalation agent
Not typically an anesthetic agent dash essential for promoting respirations and cellular function
Nitrous oxide – anaesthetic inhalation agent
Only true gas still in use today – non-flammable, but supports combustion – rapid induction and recovery – good for short cases when muscle relaxation isn’t required
Volatile agents
Group of liquids who is evaporated vapors produced general anaesthesia – produced generalized myocardial respiratory depression – muscle tone generally decreased
Halothane
Non-irritating to respiratory tract and produces little N & v – toxic to liver and can produce severe or fatal jaundice – usually used only in children – shouldn’t be readministerd within a 3 month period- rarely used
Enflurane
Rapid induction and minimal in MD – supplemental muscle relaxation needed for abdominal surgery – reduces ventilation and BP as depth of anaesthesia – cardiac rate and rhythm and remain stable
Isolated
Newer of halogenated agents – non flammable – rapid induction recovery with minimum secretions – C / be stable, good muscle relaxation – no evidence of renal / hepatic damage
Deflurane
Newer agent – more rapid induction then halothane, enflurane, isoflurane- safe for use with hepatic damage – has pugnant odor so wouldn’t use for mass induction
Balanced anaesthesia
Term given to anesthetic produced by a combination of two or more methods for general anaesthesia
Intravenious induction
Safety related to ease of metabolism in depends on health of patient hepatic and renal system – do not provide analgesia (pain relief) – produce marked sedation and amnesia – hypotension and respiratory depression common side effects
Neuromuscular blocking agents
Used to provide muscle relaxation during intubation and surgery
Depolarizing agent
Produce neuromuscular block by acting like ACH to depolarize membrane of motor endplate- muscle contracts and drug prevents repolarization necessary for another contraction, so muscle remains relaxed
Nondepolarizing agents
Block effect of ACh at NMJ
ACH can stimulate muscle contraction
Divided into short – intermediate – long-acting
Regional anaesthesia

Conduction local anaesthesia often interchangeable with regional

Patient remains conscious

Causes loss of feeling in some area at body by temporarily interrupting transmission of nerve impulses to and from the specific area or region

Motor function may or may not be affected

Complications of regional anaesthesia
Overdosage of anesthetic agent
Accidental intravascular injection
Normal dose too sensitive patient
Local anesthetics

Classification of local anesthetics based on chemical structures

Amino esters and amino aides

Both groups block depolarization of nerve cells by inhibiting NA conduction across the cell membrane

Stop the message of pain from being transmitted along the peripheral nerves

Amino esters
Cocaine, propane, tetracaine
Cocaine discovered by
Incas in Peru
Karl Kooler
First use cocaine as an anesthetic agent in 1884 for ophthalmic procedure
Amine broke down by enzyme called
Pseudocholinesterase
Methylparaben
Chemically related to PABA- its antifungal preservative agent added to multiple-dose vials of local agents. Some positions prefer additive free agents so don’t have to worry about allergic reactions
Amino amides

New generation of local agent

Lidocaine, mepivacaine, bupivacaine

Lidocaine developed in
Sweden in 1943 by Loren and Lunquist
Amino amides metabolized by
Microsomal enzymes in liver
Amino amides
Hepatic disease interferes with effective metabolism and can result in toxic response even with normal doses
Surgical Technologist responsible for knowledge with local anesthetics

Types of local materials

Mechanisms of action

Complications associated with used in emergency treatment

Recommended dosages

Local – techniques of application of regional anesthetics

Injected in subcutaneous tissue surrounding wound or incision site

Most commonly used drug- lidocaine

Epinephrine sometimes added to increase length of anesthetic and to control bleeding

Never and Jack and two digits because epinephrine can cause ischemia- gangrene -amputation

Nerve blocks – techniques of application of regional anesthetics

Anesthesia of large single nerve or nerves, not necessarily at the immediate surgical site

Agent injected into and around nerves comment impulses from area supplied by nerve are prevented from reaching the brain

Uses of nerve blocks

Prevent pain during surgery

Identify cause a pain for a diagnostic processes

Relieve chronic pain

Increased vascular circulation in some areas

Techniques for nerve blocks

Axillary – used for arm and hand surgery

Bier- anesthetized below level of tourniquet

Intercostal – pain control

Supraclavicular -nerve blocks

Radio, ulnar, digital – surgical procedures

Spinal anaesthesia

Solution injected directly into CSF into the subarachnoid space at the 3rd, 4th, or 5th interspace

Drug comes into contact with spinal fluid and travel the length of spinal canal

All nerve roots in the path of the agent are anesthetized

Drag usually hyperbaric – heavier than spinal fluid – and level of anesthetic easily manipulated during first 5 minutes by adjusting the OR bed

Patient either sitting or fetal position with operative side down when injecting?
Spinal anaesthesia
Epidural anaesthesia

Solution injected into interspace of thoracic, Lumbar, or cervical spine into tissues directly above the dura mater where the agent is then absorbed into the CSF

Great for post op pain control

Catheter – epidural anaesthesia
Left in place and drugs administered intermittently to assist with vasodilation or pain relief
Must be monitored carefully and epidural anaesthesia
BP and R
Caudal
Type of epidural
Caudal epidural
Anesthetic agent is injected into the epidural space through the sacral hiatus into the caudal canal
Anesthesiologist provides
Monitored anaesthesia care – Mac

Preoperative evaluation

Preoperative medication

Intraoperative IV anesthetic agent

Monitoring a patient during procedure

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