134 Section I / Overview and Background Surgical Information

What laboratory test should be used to follow effect?

What is the standard lab target for therapeutic heparinization?

Who is at risk for a protamine anaphylactic reaction?

What is the half-life of heparin?

How long before surgery should it be discontinued?

Does heparin dissolve clots?

aPTT—activated partial thromboplastin time

1.5–2.5 times control or measured antifactor X level

Patients with type 1 diabetes mellitus, s/p prostate surgery

90 minutes (1–2 hours)

From 4 to 6 hours preoperatively

No; it stops the progression of clot formation and allows the body’s own fibrinolytic systems to dissolve the clot

What is LMWH?	Low Molecular Weight Heparin
What laboratory test do you	None, except in children, patients with
need to follow LMWH?	obesity, and those with renal failure,
	which is the major advantage of LMWH
	(check factor X levels)
WARFARIN (COUMADIN®)
ACRONYM basis for name?	Wisconsin Alumni Research Foundation
Describe its action.	Inhibits vitamin K–dependent clotting
	factors II, VII, IX, and X, (i.e., 2, 7, 9
	and 10 [Think: 2 7 9 and 10]),
	produced in the liver
What are its uses?	Long-term anticoagulation (PO)
What are its associated risks?	Bleeding complications, teratogenic in
	pregnancy, skin necrosis, dermatitis
What laboratory test should	PT (prothrombin time) as reported as INR
be used to follow its effect?
What is INR?	International Normalized Ratio

	Chapter 21 / Common Surgical Medications 135
What is the classic therapeutic	INR of 2–3
INR?
What is the half-life of	40 hours; thus, it takes about 2 days to
effect?	observe a change in the PT
What reverses the action?	Cessation, vitamin K, fresh-frozen
	plasma (in emergencies)
How long before surgery	From 3 to 5 days preoperatively and IV
should it be discontinued?	heparin should be begun; heparin should
	be discontinued from 4 to 6 hours
	preoperatively and can be restarted
	postoperatively; Coumadin® can be
	restarted in a few days

How can warfarin cause skin necrosis when first started?

Initially depressed protein C and S result in a HYPERcoagulable state! Avoid by using heparin concomitantly when starting

MISCELLANEOUS AGENTS

Describe the following
drugs:
Sucralfate (Carafate®)	Treats peptic ulcers by forming an acid-
	resistant barrier; binds to ulcer craters;
	needs acid to activate and thus should
	not be used with H2 blockers
Cimetidine (Tagamet®)	H2 blocker (ulcers/gastritis)
Ranitidine (Zantac®)	H2 blocker (ulcers/gastritis)
Ondansetron (Zofran®)	Antinausea
	Anti-emetic
PPI	Proton-Pump Inhibitor: Gastric acid–
	secretion inhibitor; works by inhibiting
	the K /H -ATPase (e.g., omeprazole
	[Prilosec®])
Promethazine	Acute antinausea agent; used
(Phenergan®)	postoperatively

136 Section I / Overview and Background Surgical Information

Metoclopramide (Reglan®)	Increases gastric emptying with increase
	in LES pressure; dopamine antagonist;
	used in diabetic gastroparesis and to help
	move feeding tubes past the pylorus
Haloperidol (Haldol®)	Sedative/antipsychotic (side effects
	extrapyramidal symptoms, QT
	prolongation)

Ondansetron (Zofran®)

Albumin

Anti-emetic/serotonin receptor blocker

5% albumin

25% albumin—draws extravascular fluid into intravascular space by oncotic pressure

Albuterol

Octreotide

Famotidine (Pepcid®)

Aspirin

Furosemide (Lasix®)

Dantrolene (Dantrium®)

Misoprostol (Cytotec®)

What is an antibiotic option for colon/appendectomy coverage if the patient is allergic to penicillin?

If the patient does not respond to a dose of furosemide, should the dose be repeated, increased, or decreased?

Inhaled 2 agonist (bronchodilator)

Somatostatin analog

H2 blocker

Irreversibly inhibits platelets by irreversibly inhibiting cyclooxygenase

Loop diuretic (watch for hypokalemia)

Medication used to treat malignant hyperthermia

Prostaglandin E1 analog Gastroduodenal mucosal protection

1.IV ciprofloxacin (Cipro) AND

2.IV clindamycin or IV Flagyl

Dose should be doubled if there is no response to the initial dose

	Chapter 21 / Common Surgical Medications 137
What medication is used to	Diphenhydramine hydrochloride IV
treat promethazine-induced	(Benadryl®)
dystonia?
Which medication is	Digitalis
classically associated with
mesenteric ischemia?
What type of antihypertensive	ACE inhibitors
medication is contraindicated
in patients with renal artery
stenosis?
Does acetaminophen	No
(Tylenol®) inhibit platelets?
What medications are used	Benzodiazepines (e.g., lorazepam
to stop seizures?	[Ativan®]); phenytoin (Dilantin®)
List examples of preop
antibiotics for:	Ancef ® (gram-positive coverage)
Vascular prosthetic
graft
Appendectomy	Cefoxitin, Unasyn® (anaerobic coverage)
Colon surgery	Cefoxitin, Unasyn® (anaerobic coverage)
NARCOTICS

What are common postoperative IV narcotics?

What is Percocet®

What is Demerol’s claim to fame?

Morphine (most common), meperidine (Demerol®), fentanyl, Percocet®, Dilaudid®

PO narcotic pain reliever with acetaminophen and oxycodone

Used commonly with acute pancreatitis/ biliary pathology because classically morphine may cause sphincter of Oddi spasm/constriction

What are side effects of	Respiratory depression, hypotension,
narcotics?	itching, bradycardia, nausea