Medication Summary
The goals of pharmacotherapy are to reduce morbidity and prevent complications. Preoperative sedation and premedication is given, usually clonidine, metoclopramide, and midazolam and intravenous ceftriaxone. Mannitol is given throughout the surgery, and dexamethasone is given for 4 days. Furosemide is added when necessary.
Alpha 2-adrenergic Agonist Agents
Class Summary
These agents may reduce sympathetic outflow, which may produce a reduction in muscle tone.
Clonidine (Catapres, Nexiclon, Kapvay, Duracion)
Clonidine stimulates alpha2-adrenoreceptors in the brain stem, activating an inhibitory neuron, which in turn results in reduced sympathetic outflow.
Prokinetic Agents
Class Summary
Medications that increase gastric motility (eg, Reglan) may be administered. Gastric motility also may be increased if the patient eats small, frequent meals and sleeps with his/her head elevated.
Metoclopramide (Reglan, Metozolv)
The antiemetic effect of metoclopramide appears to be due to its ability to block dopamine receptors in the chemoreceptor trigger zone (CTZ) of the central nervous system (CNS). This agent also enhances gastrointestinal motility and accelerates gastric emptying time.
Anxiolytics, Benzodiazepines
Class Summary
In the operating room, intravenous (IV) administration of a small dose of midazolam before arterial line insertion can reduce anxiety, tachycardia, and hypertension.
Midazolam
Midazolam is a short-acting benzodiazepine with a rapid onset of action.
Antibiotics, Other
Class Summary
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Ceftriaxone (Rocephin)
Ceftriaxone is a third-generation cephalosporin with broad-spectrum gram-negative activity. It arrests bacterial growth by binding to one or more penicillin-binding proteins. Initiate treatment with a high dose for adequate treatment of potential penicillin-resistant pneumococcal infection. Administer 2 g intravenously for 24 hours; begin at the time of surgery and continue for the duration of the intravenous infusion, usually for 5 days.
Corticosteroids
Class Summary
Corticosteroids have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body’s immune response to diverse stimuli.
Dexamethasone (Baycadron)
Dexamethasone has many pharmacologic benefits but also significant adverse effects. It stabilizes cell and lysosomal membranes, increases surfactant synthesis, increases serum vitamin A concentrations, and inhibits prostaglandin and proinflammatory cytokines. Administer 4 mg every 8 hours for 4 days.
Diuretics, Loop
Class Summary
These agents should be reserved for well-hydrated patients with insufficient diuresis.
Furosemide (Lasix)
Furosemide increases the excretion of water by interfering with the chloride-binding cotransport system. This, in turn, inhibits sodium and chloride reabsorption in the ascending loop of Henle and the distal renal tubule.
Diuretics, Osmotic Agents
Class Summary
These agents increase osmolarity of glomerular filtrate and induce diuresis. They hinder tubular reabsorption of water, causing sodium and chloride excretion to increase.
Mannitol (Osmitrol)
Mannitol is an osmotic diuretic that lowers blood viscosity and produces cerebral vasoconstriction with normal CBF. A decrease in ICP occurs subsequent to a decrease in cerebral blood volume (CBV). Administer 0.5 mg/kg intravenously.
