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Chapter 12

• Barbiturates (phenobarbital and pentobarbital) enhance GABA activity, causing CNS depression
• In 2016, the FDA issued a black box warning for combined use of opiods and benzodiazepines due to the risks of extreme sleepiness, respiratory depression, coma, and death
• Diazepam (Valium) is the first clinically available benzodiazepine, used for anxiety, mild sleep disturbances, procedural sedation, anticonvulsant therapy, and muscle relaxation
• Temazepam (Restoril) is an intermediate-acting benzodiazepine and a metabolite of diazepam, inducing sleep within 20-40 minutes
• Temazepam has a long onset, so patients take it 1 hour before bed, disrupting REM sleep and causing daytime sleepiness
• Kava is an herbal supplement used to treat anxiety, stress and promote sleep
• Kava is contraindicated in patients with Parkinson's, liver disease, depression, alcoholism, those operating heavy machinery, and pregnant/ breastfeeding women
• It may cause temporary yellow skin discoloration and visual disturbances with long-term use
• Eszopiclone (Lunesta) is a non-benzodiazepine, FDA approved for long-term use
• Patients should allow 8 hours of sleep and avoid intake when they must awaken in less than 6 to 8 hours
• Midazolam (Versed) is commonly used preoperatively for moderate sedation, causing amnesia, anxiolysis, and sedation.
• Ramelteon (Rozerem) reverses Midazolam
• Baclofen (Lioresal) is a skeletal muscle relaxant; caution patients against using alcohol and CNS depressants; client could take the medication with food to avoid dyspepsia; patients may have a pump implanted for continuous dosing to treat spastic muscle disorders
• Zolpidem (Ambien) is a short-acting nonbenzodiazepine hypnotic with lower daytime sleepiness compared to benzodiazepines; a special concern with this dosage form is sleepwalking
• Pentobarbital (Nembutal) is a short-acting barbiturate, used to relieve anxiety and provide sedation, and occasionally to control status epilepticus or withdrawal symptoms

Chapters 26 & 54

• Heparin turns off the coagulation pathway preventing clots
• Monitor bleeding times with activated partial thromboplastin time (aPTT)
• Protamine Sulfate reverses Heparin
• Warfarin (Coumadin) inhibits vitamin K synthesis by bacteria in the GI tract.
• Monitor prothrombin time/international normalized ratio (PT/INR)
• A therapeutic INR with warfarin ranges from 2 to 3.5, depending on the indication
• Herbal products can increase risk for bleeding while on Warfarin including dong quai, garlic, and ginkgo, while St. John's wort decreases its effect
• Watch intake of foods high in Vit K while on Warfarin
• NSAIDs with Warfarin increase risk for excessive bleeding (Ibuprofen, motrin, ASA)
• Enoxaparin (Lovenox) is a low molecular weight heparin and is obtained by enzymatically cleaving large unfractionated heparin molecules into small fragments
• Lab monitoring is not necessary when enoxaparin is used because of its greater affinity for factor Xa
• Only available as a SQ injectable
• Patient education required for home use: monitor signs of bleeding, rotate injection sites
• Rivaroxaban (Xarelto) is an oral factor Xa inhibitor for postoperative thromboprophylaxis, preventing clot formation in settings with a high likelihood of clot formation.

Continued

• Epoetin alfa (Epogen, Procrit) is a form of erythropoietin, promoting RBC synthesis, used to treat anemia
• Normal Hgb ranges from 13.5 to 17.5 g/dL for men, and 12.0 to 15.5 g/dL for women
• Guidelines recommend stopping the drug when hemoglobin reaches 10 g/dL for cancer patients, 11 g/dL for renal patients
• Hypertension is an adverse effect of hematopoietic drugs, along with headache, fever, pruritus, rash, nausea, vomiting, arthralgia, cough, and injection site reaction
• Thrombolytic Therapy coagulation modifiers that lyse thrombi in the coronary arteries
• Indications for thrombolytic therapy include acute MI, arterial thrombosis, DVT, PE, and acute ischemic stroke
• The most common side effect of Thrombolytic therapy is internal, intracranial, and superficial bleeding
• Antiplatelet Therapy prevents clot formation by preventing platelet adhesion at the site of blood vessel injury
• Common antiplatelets: ASPIRIN, CILOSTAZOL (PLETAL), CLOPIDOGREL (PLAVIX), PRASUGREL (EFFIENT) TREPROSTINIL (REMODULIN), ABCIXIMAB (REOPRO), EPTIFIBATIDE (INTEGRILIN), TIROFIBAN (AGGRASTAT), ANAGRELIDE (AGRYLIN), DIPYRIDAMOLE (PERSANTINE)
• Aspirin is recommended for stroke prevention in daily doses of 50 to 325 mg
• Aspirin is an antiplatelet most commonly given daily to prevent cardiac events
• Iron is essential, carries O2 via hemoglobin and myoglobin, deficiency leads to anemia, give Oral, IM, IV.
• Most common adverse effects are nausea, vomiting, upset stomach
• Recommend drinking liquid iron with a straw to prevent staining of the teeth
• When giving an IV dose, administer a test dose and assess for signs of reaction/anaphylaxis

Iron Absorption

• Some foods enhance iron absorption, including orange juice (vitamin C), veal, fish, and ascorbic acid
• Some foods impair iron absorption, including eggs, corn, and milk/yogurt (calcium)
• The Z-TRACK METHOD of I.M. injection prevents leakage of irritating and discoloring medications like iron dextran
• Liquid oral forms of iron need to be taken through a plastic straw to avoid discoloration of tooth enamel.