The Role of a Pharmacist in a Transdisciplinary Geriatric Surgery Team


Drug

Dose

Time of action

Considerations and adverse effects

Labetalol

Loading dose 20 mg followed by 20–80 mg every 10 min, up to total 300 mg. May consider 1–2 mg/min infusion titrated until desired effect has been achieved (max total 300 mg)

Onset in 2–5 min, peaks at 5–15 min and lasts 2–18 h (accumulative effects)

Should not be used in patients with uncompensated heart failure, bradycardia, heart block greater than 1st degree (except if on functioning pacemaker), bronchospasm

Elimination half-life:~ 5.5 h

Nitroglycerin

The starting dose is 5 μg/min; it can be titrated at 5 μg/min every 3–5 min; after dose exceeds 20 μg/min, it can be increased by 10–20 μg/min, up to max 400 μg/min

Onset almost immediate, duration of action 3–5 min

Hypotension particularly in volume depletion and right ventricular infarction and reflex tachycardia. Tachyphylaxis onset within 24–48 h. Methaemoglobinaemia with prolonged infusion

Hydralazine

IV bolus: 3–20 mg repeated every 1–4 h as needed

Onset in 5–20 min; drop in BP can last up to 12 h. Circulating half-life is 2–8 h, 7–16 h in end-stage renal failure

Reflex tachycardia in ischaemic heart disease may result in iatrogenic MI. Avoid in patients with dissecting aneurysms. Can increase intracranial pressure further in pre-existing raised ICP

Use lower doses in renally impaired

Esmolol

500–1,000 μg/kg loading dose over 30 s, followed by infusion starting at 50 μg/kg/min and increasing by 50 μg/kg/min every 4 min, up to 300 μg/kg/min PRN

Onset ~2 min, lasts 10–30 min

Associated with hyperkalaemia; monitor potassium

Should not be used in patients with uncompensated heart failure, bradycardia, heart block greater than first degree (except if on functioning pacemaker), bronchospasm

Sodium nitroprusside

0.25–0.3 μg/kg/min titrated by 0.5 μg/kg/min every 1–2 min, max 10 μg/kg/min

Onset <2 min, lasts 1–10 min

May increase intracranial pressure due to profound vasodilation

Half-life nitroprusside ~2 min, thiocyanate ~3 days, doubled or tripled in renal failure

Coronary steal and post-load reduction, caution in acute myocardial infarction

Prolonged infusion iu doses >3 μg/kg/min over prolonged periods (>2 days) may result in cyanide toxicity, especially in renal and hepatic dysfunction



The postoperative patient is also at risk for venous thromboembolic (VTE) complications that can increase the patient’s length of stay. This is also an area where the pharmacist plays an active role in recommending prophylaxis in consultation with the team. Depending on the type of procedure, the presence of an ileostomy may result in increased fluid and electrolyte losses and the pharmacist may recommend necessary electrolyte replacements. The pharmacist may also suggest supplementation to achieve the necessary vitamin and mineral balance for patients who are at risk for malabsorption postoperatively (Bell et al. 2006). Additionally, postoperation pain control and the maintenance of bowel movement become the prime parameters which the primary team will pay absolute attention to. The use of multimodal analgesia can assist with pain control and may at times be opioid-sparing. However, other aspects of care are crucial, for example, there are many considerations in using Non-steroidal anti-inflammatory drugs (NSAIDs) in an elderly patient and especially if volume contracted. This is where the pharmacist plays an active role in his/her review of the medication charts of the GSS patients.

Other complications that could arise, like a newly acquired infection, could mean commencement of antibiotics which would also require considerations of current renal and hepatic function. The pharmacist aids the team in necessary dose titrations and makes a recommendation with knowledge of prevalent antibiograms of resistance strains of bacteria, thus allowing for a prudent choice of empirical antibiotic.

Table 6.2 lists a suggested mnemonic, modified from the mnemonic “FASTHUGS” in critical care, to aid the team in monitoring and adjustments of various medications.


Table 6.2
Medication considerations in critical care





















 
Parameter

What to monitor

Medication(s) of particular interest

Action and rationale

F

Feeding

Calories in/out, tailored according to premorbid state, presence of infection or catabolic states post operation

Oral hypoglycaemic agents (e.g. glipizide, gliclazide)

When oral intake is nil or poor and if BG is often below 8 mmol/L, review to take off all regular oral or injectable medications (see under “G” for more details)

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Apr 26, 2017 | Posted by in ANESTHESIA | Comments Off on The Role of a Pharmacist in a Transdisciplinary Geriatric Surgery Team
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