Common Medications and Their Associated Conditions

Common Medications and Their Associated Conditions

Happy last week of boot camp to you all. This week we have made a list that will help you early on in your clinical rotations. When you see a pre-op medications list early on it can be very overwhelming and, at times, unhelpful because they can be long, illegible, and many of the drug you will not learn about until the spring. With this table you should be able to look at a patient's medication list and get a good idea of what conditions your patient has (this is assuming, of course, you have a good patient who is taking their meds). I have organized these meds based on the frequency in which they are seen and how much they can impact anesthesia. If you have an in-patient many of the meds will be different. Meds on the same line are similar (either by mechanism, targets, etc.) Patterns in the suffices helps a lot, such as all drugs ending in -pril are ACE inhibitors for hypertension and those ending in -statin are for high cholesterol. Brand names are in parentheses and if a drug is better known by its generic or brand name I only included the one it is best known as.

The epocrates app is your best friend when trying to learn these drugs. Many instructors use this app regularly. Even if you can't make out the full name, type out what you can read and many times it will narrow the search enough for you to figure out which drug you're looking for. After finding the drug in question, look at the pharmacology tab. Here you will find the mechanism of action which should give you insight into that the drug is used for. If that doesn't help, wikipedia.

Best of luck tomorrow!

Hypertension

Metoprolol, Atenolol, Propranolol, Carvedilol(Coreg)       

Hydrochlorothiazide(HCTZ)

Clonidine                            

Lisinopril, Enalapril, 

Losartan(Cozaar)                        

Verapamil, Diltiazem

Nifedipine, Nicardipine, Amlodipine(Norvasc)

Diabetes

Insulin
Glyburide
Metformin

GERD

Ranitidine(Zantac), Famotidine(Pepcid)

Omeprazole(Prilosec), Pantoprazole(Protonix), Nexium

Alka-seltzer, Mylanta, Rolaids, Maalox, Tums

Pain

Codeine, Hydrocodone(Lortab), Oxycodone, OxyContin, Tramadol
Nalbuphine(Nubain), Buprenorphine

Aspirin(ASA), Ibuprofen(Motrin, Advil)

Acetominophen(Tylenol)

Hypothyroidism

Levothyroxine(Synthroid)

Asthma

Albuterol

Advair, Azmacort, Flovent, Pulmicort

Coagulopathies

Enoxaparin(Lovenox)

Warfarin(Coumadin)

Clopidogrel(Plavix)

Pradaxa

Psychiatric Drugs

Anti-depressants: Prozac, Zoloft, Lexapro

Anti-sseizure: Phenytoin(Dilantin), Keppra, Gabapentin

Parkinson's: Levodopa, Cogentin

Allergies

Diphenhydramine(Benadryl), Dimetapp, Claritin, Allegra

Hyperlipidemia

Simvastatin, Pravastatin

Lipitor, Crestor, Zocor

OR Tours

I hope you all are enjoying your time in the classroom and sim lab so far. Pretty soon  things are about to get a lot more exciting as you move your skills in to the OR. To help ease you into the experience, some of the second years are volunteering to take small groups on tours of the OR and walk you through the specific setup and MSMAIDS process as it pertains specifically to Memorial Hermann TMC. The times, tour leaders, and number of students allowed will be listed as a comment from that group leader. If interested, please reply specifically to that comment made by the group leader you would like to join. Pay attention to how many students have signed up for each group as to not cause overflow. These tours are completely optional but  can be very beneficial.

Table Top and Drug Cart Setup

Hello ladies and gents. I am going to give you a walk through for some of the general setups you will do across the street. A similar setup will be done at the outside hospitals but get the specifics for those setups from a 2nd year, for your own well-being, before you leave to said hospitals. My hope is for this to help simplify the setup process and allow you to see what it actually looks like. Below are the ways I typically set things up. I think all would be acceptable for any of you to do, in the right circumstances. I hope this can help you through your setups early on in the program until you discover your own preferences.

General Endotracheal Anesthesia Setup

Table top setup for a GETA case

The above image shows the table top setup for an adult general, endotracheal anesthesia case. The following should be included:

1. Oral area sizes 8, 9, 10 (80mm, 90mm, 100mm).
2. Miller 2 and Mac 3 blade. If you patient is tall/large consider using a Mac 4 instead of 3 and keep the Miller 2 out. If possible leave the blade in the packaging while connected to the handle.
3. Straight connector + accordion connector. This gives some flexibility to the circuit and is useful in cases with position changes or bed rotation.
4. Tongue depressor. Just to have in a situation where that pesky tongue is giving you trouble.
5. Temperature probe.
6. Humidivent. Keeps the patient's airway warm and humid.
7. Lubricant. Used to place and OG/NG tube, LMA, and a few other applications.
8. OETT 7 and 8 styletted to your favorite curvaceous shape with a 10 cc syringe attached. (You will see many ways to shape the tube, do what your preceptor wants until you find what you like best and shape it that way.)
9. Notice the suction to the left. This may not be considered part of the table top setup but it is near the setup in this instance and is very important. Always have suction setup, working, and on.

Drug cart setup for a GETA case

Here you can see the drugs for a GETA and how I organize them. This is assuming you are not doing a rapid sequence intubation. In this case you could use rocuronium as you paralytic but most will use succinylcholine. Here are the components of an adult GETA drug setup:

1. Versed - 2 cc syringe.
2. Fentanyl - 3 or 5 cc syringe (I'd go with a 5 if you are unsure).
3. Rocuronium - 5 cc syringe
4. Lidocaine - 10 cc syringe
5. Propofol - 20 cc syringe
6. Ephedrine - 10 cc syringe (This is currently back ordered don't make a syringe until you hear otherwise. It must be diluted in a 10 cc syringe to 5 mg/mL. But y'all know that!)
7. Phenylephrine - 10 cc syringe (This is pre-made and ready to go. All you have to do is take is from the cassette).

This is just how I choose to organize my drugs. I have my pressors in one area, induction meds in another, and narcotics in another. I may suggest separating your paralytic from the propofol and lidocaine so you have that separated as well. Your call. 

LMA Setup

Table top setup for an LMA case

You will notice this looks very familiar. If you are doing an LMA case this is how I would go about setting it up. It's the same as a GETA case with the addition of two LMAs. The idea is to have a back up LMA in case one does not seat/fit well or malfunctions. In this setup I have a 4 and 5. For women or smaller men you may choose to get out a 3 and 4 instead. Notice the OETT tubes and blades are still out. This is done so that in a critical situation your stuff is ready to go and you can quickly secure the airway. When using an LMA you will use the lubricant. Here you would use it on the point and superior surface to ease placement. Don't worry about doing this until your preceptor has decided which LMA to use and you know how to lube. The above setup is a little cluttered in order to get everything in the picture. I would place the blades and OETTs on a lower surface or on top of the machine so that they are readily available but not in the the way. Again, your call.

Drug cart setup for LMA case

Same as the GETA setup minus the paralytic. Keep in mind you will use other drugs regularly in cases. This is just the setup to get you through a normal induction. Anti-emetics, more pain meds, sympatholytics, etc. will be made and drawn up after induction unless your preceptor tells you otherwise.

Pediatric GETA Setup

Drug cart setup for pedi GETA

Alright so now things get a little more tricky. Some of you will do pedi cases pretty early on and the setup is quite different. In most instances you will be asked to prepare syringes and get drugs out but to not draw anything up. The main difference in pedi is that you use a syringe that gives an appropriate single dose for the patient and you always make an epinephrine bag/syringes. Here are the contents of a GETA pedi drug setup.

1. Atropine - comes in this box from the cassette. Just have it out and on the table.
2. Epinephrine in a 100 cc NS bag. Epi comes 1 mg/ml and is diluted to 10 mcg/ml. Then you will draw it up in a 1 cc syringe and a 3 cc syringe (unless you have a small, small child in which case 1 cc syringe only, will do).
3. Epi - 1 cc syringe.
4. Propofol - 10 cc syringe. Again, it can be done in any syringe and the choice is based on the size of the patient and the dose of the drug. Don't worry, you will learn this.
5. Fentanyl - 3 cc syringe. Same "rule" as propofol
6. Rocuronium - 3 cc syringe. Repeat?

Your first days in pedi will be a little overwhelming and the setup and drugs are a big part of that. The idea is to draw up only the amount you would need for a single dose for the patient as to avoid overdosing them. For now this is slightly above and beyond for you all, don't stress. 

IV Kit Setup

IV kit components

Shown above are the components that go in the basin labeled "8" to make up your IV kit. Making these correctly and well will show your preceptor your ready to try and place an IV. It should make the process a little easier for you. The components are listed below:

1. Tourniquet
2. Tegaderms - make sure you get the right size.
3. Tape - some use plastic tape(shown above), some use silk. Its a good idea to have both in order to appeal to your preceptor.
4. Needles and catheters. Shown left to right in pairs 16 ga, 18 ga, 20 ga. To start you could just put two 18 ga and two 20 ga because those are what will be placed, most likely.
5. Alcohol swabs - we don't want anymore infections spreading.
6. 4 x 4's - for that bloody mess that is just inevitable sometimes.
7. Flush syringes - these are made by placing a lure lock on the end of a 10 cc flush syringe.
8. Basin - all of these items should go neatly and organized in this container.

When you're starting off its a good idea to make sure there is two of everything in these kits so that if you are struggling, your preceptor can go try the other arm/hand without needing to take the equipment from you. The easiest way I remember all the items is to go through the process of placing an IV and ensure I have each piece I would need in the kit.

Everyone has their own way of doing these setups. This is a good place to start but if your preceptor tells you to do something else, do it. Until you find your own way do what your preceptor likes/asks. As you see more things pick out what you like and start to develop your own methods. Always have a reason behind your choices, however, and be ready to explain why you chose to do something a certain way.

Best of luck finishing up boot camp. If you have any questions about this or any thing else feel free to contact me or any of the other second years.