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Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods, they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (1) on procedures featured or (2) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
ISBN: 978-0-323-66121-8
Director, Content Development: Ellen Wurm-Cutter
Senior Content Strategist: Nancy O’Brien
Content Development Specialist: Melissa Rawe/Kathleen Nahm
Publishing Services Manager: Shereen Jameel
Project Manager: Nadhiya Sekar
Design Direction: Ryan Cook
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
Dedication
This edition of the textbook is dedicated to our friends, mentors and colleagues Kathy Snyder and Chris Keegan for their commitment to the advancement of the surgical technology profession and their passion for educating future surgical technologists and surgical first assistants.
Reviewers
James A. Budde, PharmD, RPh, FSVHP, DICVP , Pharmacy Director, University of Wisconsin School of Veterinary Medicine, Madison, Wisconsin
Terry M. Herring, Ed.S, CST/CSFA, CSPDT, CSIS, COA, FAST , Division Chair Surgical Services, Fayetteville Technical Community College, Fayetteville, North Carolina
Shawn B. Jeune, MS, APRN-ACNS, RN, CST, CNOR , Program Director Surgical Technology, Hudson Valley Community College, Troy, New York
April N. Kesler, AAS, CST , Surgical Technology Program Coordinator, Northwestern Michigan College, Traverse City, Michigan
Elizabeth Ness, BA, CST , Program Coordinator Surgical Technology, Macomb Community College, Clinton Township, Michigan
Renona Marie Smutny, CST, AAS, BAS , Certified Surgical Technologist, Adjunct Faculty, Oakland Community College, Hazel Park, Michigan
Preface
More than 20 years ago, a committee of instructors met to work on revisions to the Core Curriculum for Surgical Technology. During the meeting, the topic of textbooks surfaced in particular, pharmacology textbooks. It was generally agreed that no adequate pharmacology textbook for surgical technologists existed. As the discussion progressed and we complained about the situation, a question was posed: “Well, are you going to be part of the problem or part of the solution?” This fifth edition of Pharmacology for the Surgical Technologist is our continuing response to that question. It offers a distinct combination of subject matter. The text is organized into three units, each focusing on information specific to the surgical environment. Students learn a framework of pharmacologic principles to apply the information in surgical situations; review basic math skills; learn commonly used medications by category, with frequent descriptions of actual applications; and learn basic anesthesia concepts, not previously presented at this level, to function more effectively as a surgical team member.
Special learning tools used in this text include the following:
• Learning Objectives, which are stated at the beginning of each chapter
• Key Terms, which are boldfaced in the chapters
• Insight boxes, which offer additional information on the subjects
• Quick Questions, which encourage students to review materials and apply previous knowledge
• Illustrations, including surgical photographs, which are
designed to familiarize the student with the surgical environment
• Tables and boxes, which condense information to enhance learning
• Tech Tips, Caution, and Make It Simple features, which aid in understanding and applying information
• Chapter Key Concept summaries and Chapter Review questions, which emphasize critical content
• Advanced Practices sections, which emphasize the role of the surgical first assistant
• Drug Category Index by surgical specialty
• Glossary of terms
These features have been developed to assist the student in learning new and often unfamiliar material. Key terms are bolded in the text and included in the glossary. Students should be encouraged to use a medical dictionary, as needed, for routine medical terminology used throughout the text. Learning objectives are used to guide the students through the material, emphasizing important concepts. Additional learning activities available on the Evolve website are designed to help students think about concepts from a broader perspective and apply content at a more personal level, particularly at their local clinical facilities.
Acknowledgments
We would like to acknowledge and sincerely thank Kathy Snyder and Chris Keegan for their 20 plus year commitment developing and revising the first four editions of this textbook. We are honored to have been asked to move forward with the revisions for the fifth edition. We are humbled by your confidence to continue your vision for educating future surgical technologists/surgical first assistants and advocating for all surgical patients. We would also like to thank all students, instructors, and practitioners who have been involved in the creation and revisions of all editions. We are grateful to Kathleen Nahm, Nancy O’Brien, and Melissa Rawe at Elsevier for their expertise and guidance through the fifth edition. Thank you to the Western Dakota Tech Surgical Technology Program for use of their laboratory and supplies for textbook photos. Thank you to our family, friends and colleagues for their continued support and patience, while we collaborated on this textbook revision.
UNIT I
Introduction to Pharmacology
OUTLINE Introduction
1. Basic Pharmacology
2. Medication Development, Regulation, and Resources
3. Pharmacology Mathematics
4. Medication Administration
Introduction
As a surgical technologist, you will mix and measure medications and deliver them to and from the sterile field. This means you will be dealing with pharmacology the science of drugs. In this unit, we look at general pharmacological information, including how medications are measured, what kinds of medications are used, the laws that pertain to them, how they are labeled, and how they are administered to the surgical patient. We look at the medications themselves their sources, names, classifications, routes by which they are administered, and their forms. This unit provides a framework of pharmacological terms, concepts, and principles; ones that help you understand current information about medications and prepare you to assimilate new information effectively. We then focus on laws, regulations, and medication labels. You will see the importance of laws to regulate medications and the information found on medication labels, what types of laws exist, and which government agencies enforce the laws. You will also learn what acts govern your scope of practice in regard to medications. Next, we address precision because it is critical to delivering exactly the right quantity and strength of any medication. Thus we review mathematics that you need to do the job. We include an initial mathematics quiz, so you can determine your skills and what areas you need to review. There is a refresher on basic computation techniques and a review of measurement systems used in medicine, especially the metric system and basic conversions. Patient safety depends on accuracy, and the surgical technologist is the last line of defense against medication errors at the sterile field. Finally, we concentrate on methods you will use when handling medications, including aseptic technique, the steps for proper medication identification, and clear labeling of all
medications on the sterile field.
1 Basic Pharmacology
OBJECTIVES
After completing this chapter, you should be able to do the following:
1. Define terms and abbreviations related to pharmacology.
2. State sources of drugs and list examples of drugs from each source.
3. List and describe several classes of drugs relevant to surgical practice.
4. Explain medication orders used both in prescriptions and in surgery
5. List the parts of a medication order used in surgery.
6. Identify drug distribution systems used in hospitals.
7. List and describe types of drug forms.
8. Compare and contrast medication administration routes used in surgery.
9. Explain the four processes of pharmacokinetics.
10. Identify and discuss aspects of pharmacodynamics.
The science of pharmacology is a diverse study of the interactions between chemicals and biological systems. In the broadest sense, it includes toxicology, food science, agriculture, and medicine. When chemicals are used to treat diseases, we call them drugs or
medications. Medical pharmacology is a rapidly expanding field of study because new drugs are being developed nearly every day. An understanding of basic principles in pharmacology can help the surgical technologist deal with such constant developments. Students should seek to build a framework of principles so they can incorporate new information more easily. When a new drug is introduced into surgical practice, the surgical technologist should be able to understand information about the drug by applying the principles of pharmacology. This chapter presents an introduction to the foundations of pharmacology that can be applied throughout a professional career in surgical technology.
Drug Sources
Drugs in use today come from three main sources: natural sources, chemical synthesis, and biotechnology. Natural sources include plants, animals, and minerals. The study of drugs derived from natural sources is called pharmacognosy.
At one time, plants were nearly the only source of medicines available. Today, only a few prescription drugs relevant to surgical practice are still derived directly from plant sources. Examples of current drugs made from plants include atropine from the roots of the belladonna plant (Atropa belladonna; deadly nightshade; Fig. 1.1), digitalis from the leaves of the purple foxglove, and morphine from the seeds of the opium poppy (Table 1.1). The trend toward alternative medicines has initiated a closer look at plants as sources of important and helpful chemicals in the natural state (Insight 1.1). Chemicals produced by plants also hold great promise in the development of drugs to treat cancer. One such drug is paclitaxel (Taxol), which is derived from Taxus baccata and is used to treat breast cancer.
Animals provide a source for some drugs, particularly hormones. Cattle and hog endocrine glands were the best available source of hormones before the advent of biotechnology. We describe drugs derived from hogs as porcine and those from cattle as bovine. Thus
thyroglobulin (Proloid)—a purified extract of hog thyroid gland—is porcine in origin, whereas thrombin (Thrombogen) a topical hemostatic is bovine in origin. The early form of insulin is both bovine and porcine because it was obtained from the pancreas of cattle and hogs. Estrogen was another hormone obtained from an animal source. Conjugated estrogen (Premarin) was obtained from the urine of pregnant horses and so is referred to as equine in nature.
FIG. 1.1 Atropa belladonna. Courtesy Martin Wall Botanical Services. (From Ulbrich C: Natural standard herbal pharmacotherapy, ed 1, St Louis, 2010, Elsevier.
TABLE 1.1
Examples of Plant-Derived Drugs Relevant to Surgical Practice
Minerals, such as calcium, magnesium, and silver salts in several forms, are used in some pharmacological agents. For example, Tums and Mylanta are antacids that contain calcium (Tums) and magnesium (Mylanta) hydroxides. Silver sulfadiazine (Silvadene cream) is an antimicrobial agent used in dressings for burn patients that contains silver salts (see Chapter 5). Even gold is used, as in aurothioglucose (Solganal), an antiarthritic agent.
The second major source of drugs is chemical synthesis in the laboratory (Fig. 1.2). There are two ways for drugs to be synthesized, that is, put together. Synthetic drugs are drugs that are synthesized from laboratory chemicals. Semisynthetic drugs are drugs that start with a natural substance that is extracted, purified, and altered by chemical processes. The vast majority of modern drugs are either synthetic or semisynthetic. Meperidine (Demerol) is an example of a synthetic drug; it is made from chemicals, yet its pain-relieving effects are similar to those of opium. Many types of penicillin, such as amoxicillin, are semisynthetic drugs. The penicillin group of drugs was originally derived from a natural mold (Penicillium), the active substance of which is extracted and purified in the chemical laboratory. Another example of semisynthetic drugs is the
aminoglycoside group of antibiotics, the active substance of which is obtained from the bacterial species Streptomyces.
An increasing source of drugs has been provided by the science of biotechnology. The term biotechnology is used to refer to the concepts of genetic engineering and recombinant deoxyribonucleic acid (DNA) technology. The science of biotechnology has many applications in pharmacology and has provided significant improvements in the treatment of various conditions. Biotechnology is a process that allows scientists to produce proteins from bacteria proteins that were previously available only from animals. Molecular biologists use bacteria as tiny factories to produce the proteins they need to make drugs. They do this by altering the DNA of bacteria, such as Escherichia coli (E. coli). How? By physically inserting a gene into the DNA of a single E. coli cell a gene that codes for (tells the cell to make) a certain protein (Fig. 1.3). When the bacterial cell has this gene incorporated into its DNA, it becomes a miniature copying machine, producing daughter cells that have daughter cells that have daughter cells—each with the new gene and each producing the desired protein. Because this reproduction process occurs very rapidly, large volumes of the desired protein can be obtained quickly. The specific protein is extracted and purified in the laboratory and prepared for administration into a patient. Molecular biologists also use cultures of mammalian cell lines, such as genetically altered Chinese hamster ovary (CHO) cells, to produce various therapeutic proteins. Adalimumab (Humira) is an example of a drug developed with recombinant DNA technology and mammalian cell lines. In general, CHO cells provide more stable gene expression and higher volumes of the desired proteins than bacterial cells and are becoming the primary choice of cell lines for pharmacological use.
INSIGHT 1.1 In Search of New Drugs
Sometimes the quest for new drugs involves some very old sources. It has long been said that a glass of wine is good for you, and archaeologists know the ancient Egyptians thought the same. When the 5100-year-old tomb of Pharaoh Scorpion I was excavated, more
than 700 jars were discovered in one of the chambers. Some of the jars contained wine residue with medicinal additives. These additives might have come from a relative of the present-day wormwood (Artemisia sieberi), blue tansy, herbs, and tree resins. The jars were imported from several sites in the ancient world, in what we know today as Israel and Palestine. These jars demonstrate how humans from thousands of years ago had turned to their natural environments for effective plant remedies. It will take our modern technology using biomolecular analysis to isolate these active components. Scientists are working with physicians to see whether any of these compounds might be useful today perhaps in the fight against cancer.
FIG. 1.2 A pharmaceutical laboratory iStock com/LajosRepasi
