Type of paper: Research Paper

Topic: Blood, Nursing, Control, Drugs, Actions, Viruses, Sugar, Analgesia

Pages: 3

Words: 825

Published: 2020/11/09

PRIOR TO SURGERY:

The glargine insulin initially used to control the blood sugar levels of Jeff was a long acting insulin preparation which according to Katzung, Masters and Trevor (2012, 12th ed., p. 749) is a peakless insulin and provides a sustained, low levels of insulin in the circulation. It is slower in onset and peaks in 4 to 6 hours. Plasma half-life is 11 to 24 hours. On the contrary, insulin lispro was prescribed to Jeff later when the optimal glycemic control was not achieved. Insulin Lispro is a rapid-acting insulin. According to Katzung, Masters and Trevor (2012, 12th ed., p. 749), rapid acting insulin provides a better replacement to physiologic prandial insulin. This replacement is mainly due to rapid action and early peak resembles the normal endogenous insulin secretion. Their duration of action is 4 to 5 hours and it is for this reason Jeff was taking Lispro every 3 hours. Insulin Lispro is readily absorbed within 5 to 15 minutes and its activity is peaked in 1 hour after injection. Jeff’s sugar has been consistently high on Insulin Glargine thus warranting a need for rapidly acting insulin which in this case is Insulin Lispro. Higher level of blood sugar was providing a favorable milieu for the bacterial growth.
Before the results of culture, Jeff was started on Zosyn which is a combination antibiotic consisting of an extended spectrum Penicillin, Piperacillin combined with a β Lactamase inhibitor tazobactam. Extended-Spectrum Penicillins have wider coverage against gram negative bacteria mainly because they can easily penetrate through the outer membrane of gram negative bacteria. Penicillins acts by inhibiting the bacterial growth. This bacteriostatic action of penicillins is achieved by interference in the transpeptidation of cell wall synthesis in bacteria. Levinson (2014, p 166) describes that piperacillin is used against Pseudomonas Aeruginosa and Jeff’s first culture e showed growth of P.Aeruginosa. This justifies the use of piperacillin. However, Katzung, Masters and Trevor (2012, 12th ed.) further elaborates that addition of tazobacam with piperacillin extends the efficacy against Beta lactamase producing strains of Staphylcoccus Aureus and others. Finkel, Cubeddu and Clark (2009, 4th ed., p. 582) elaborates that penicillins are safe to use but adverse reactions associated with penicillins includes hypersensitivity, diarrhea, nephritis, neurotoxicity, hematologic toxicities and cation toxicity. Later, after the obtaining results of second culture when the bacterial growth was of Methicillin Resistant Staphylococcus Aureus (MRSA), Jeff was started on vancomycin. Katzung, Masters and Trevor (2012, 12th ed.) describes the mode of action of vancomycin that it inhibits cell wall synthesis by inhibiting transglycosylase which orevents the elongation of peptidoglycan. This causes the weakening of the cell and makes it prone to lysis. This property makes vancomycin a bactericidal antibiotic. The rationale nehind switching Jeff from Zosyn to vancomycin was because vancomycin is effective against MRSA, if taken parenterally. Adverse reactions from vancomycin intake are mostly minor and include phlebitis and fever with chills. Ototoxicity is also reported along with nephrotoxicity, but their occurrence is rare. It also causes flushing giving rise to peculiar “red man” or “red neck” syndrome. Levinson (2014) describes other bacteria besides MRSA that are susceptible to vancomycin and they include Staphylococcus epidermidis and enterococci.

POSTOPERATIVE CARE:

Morphine is a prototype strong opioid. The pharmacological effect of morphine is achieved when it interacts with opioid receptors in the Central nervous system (CNS), gastrointestinal system and the urinary bladder. Opioids acts on nerve cells causing their hyperpolarization, inhibition of their firing and pre synaptic inhibition of transmitter secretion. Morphine specifically acts on μ (mu) opioid receptors in the Lamina I and II of the dorsal horn of the spinal cord. This receptor then inhibits secretion of Substance P which alters the pain perception in the spinal cord. Morphine is also responsible for the dampening of various other nociceptive (painful) neurotransmitters. Pharmacokinetically, morphine is absorbed from the gastrointestinal tract slowly and erratically. Significant first-pass metabolism occurs in case of morphine making the intramuscular, subcutaneous or IV routes appropriate for reliable responses. Oral preparations are mostly extended-release type for sustained plasma levels. It readily penetrates into all body tissues and can cross the placenta in pregnant women. It is therefore, unsafe to use morphine during pregnancy. Albeit, minute quantity of morphine crosses the blood-brain barrier mainly because of its lowest affinity for lipids. It is conjugated in the liver to glucoronic acid. The conjugated complex is excreted readily in the urine with small amounts excreting through bile. Morphine’s duration of action is 4 to 6 hours but it increases if injected epidurally. In old age, morphine should be given in low doses because it can be very potent even in smaller doses. The most lethal adverse effect of morphine is severe respiratory depression leading to death. It may also cause vomiting, hypotension and dysphoria. It can also elevate the intracranial pressure in posttraumatic patients. Patients having benign prostatic hyperplasia may develop urinary retention. It also causes dependency and tolerance to pharmacologic effects of morphine. It causes severe constipation and constricted pupils.
Healthwise staff (2014) described the benefits of Patient Controlled Analgesia (PCA). The article concluded that besides providing analgesia, PCA canmake patients feel less anxious and give them liberty to control their medicine. Effective and in-time analgesia is achieved by PCAs.
Katzung, Masters and Trevor (2012, 12th ed.) describes hydrocodone as mild to moderate opioid agonist and combination of hydrocodone with acetaminophen is used to control moderate to severe pain. Finkel, Cubeddu and Clark (2009, 4th ed., p. 582) states that codeine based opioid analgesics are converted to morphine. It is less potent but has high oral efficacy. Moreover, it is less likely to be abused and it seldom causes dependence.
An evidence based monograph devised by The Natural Standard Research Collaboration (2013), states that St.John’s wort is safe to be used for less than 3 months but it should be used with precautions and can cause adverse effects. Drugs metabolizing by Cytochrome P450 may increase in the blood. St.John’s wort has capacity to interact with other drugs and food supplements. Jeff is using Lisinopril, Hydrodiuril and Norvasc for his hypertension, Atorvastatin for hyperlipidemia and Metformin and Lispro for diabetes. According to the study, St.John’s wort can cause increased levels of all these drugs and it can also increase blood sugar levels. It was recommended that diabetic patients should be monitored closely. He is also using Zoloft for depression and it can also be increased in blood by intake of St.John’s wort. Jeff is also taking morphine and hydrocodone. St.John’s wort significantly increases the amount of these drugs and their increased levels can be fatal.
Dietary supplements and herbs are also metabolized through Cytochrome P450. It may cause bleeding when taken with supplements promoting bleeding like Gingko biloba, saw and garlic palmetto. It should also be taken with great care while taking cholesterol lowering herbs, antibacterials, hear-rate regulating herbs. (The Natural Standard Research Collaboration, 2013)

References

Finkel, R., Clark, M., & Cubeddu, L. (2009). Lippincott's Illustrated Reviews: Pharmacology (4th ed.). Philadelphia: Lippincott Williams & Wilkins.
Katzung, B., Masters, S., & Trevor, A. (2011). Basic and Clinical Pharmacology 12/E (12th ed.). New York: McGraw-Hill Medical Publishing Division.
Levinson, W. (2014). Review of Medical Microbiology and Immunology (13th ed.). New York: McGraw-Hill.
Pain Management: Patient-Controlled Analgesia (PCA) Pump. (2014, April 23). Retrieved February 12, 2015, from http://www.uofmhealth.org/health-library/zx1143
St. John's wort (Hypericum perforatum). (2013, November 1). Retrieved February 12, 2015, from http://www.mayoclinic.org/drugs-supplements/st-johns-wort/background/hrb-20060053

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