Introduction to Clinical Pharmacy – Surgical wards
Aim
The aim of this rotation is to develop an understanding of the general pharmacy aspects of care of
surgical patients, including areas such as thromboprophylaxis, pain relief, fluid balance, and antibiotic
therapy. An increased awareness of relevant monitoring parameters for surgical patients; pre- and
post-operative management; and particularly the implications for drug therapy will be developed. The
ability to anticipate, recognise, prioritise and solve drug-related problems will be encouraged, as will
the skills to communicate effectively with health care staff and patients.
Objectives
At the end of the rotation, pre-registration pharmacists / pharmacists will be able to:

Monitor surgical patients' drug therapy effectively, utilising all relevant sources of information

Obtain accurate drug histories from patients

Identify and solve drug related problems

Advise on administration of drug therapy during the peri-operative period

Provide education to staff and patients to ensure that maximum benefit is obtained from
patients' drug therapy

Review parenteral therapy for compatibility, route, and rate of administration, and change to
alternative route when appropriate

Provide advice on analgesic and antibiotic choice

Prioritise clinical activities

Justify individualisation of treatment

Describe all the various prescription charts and associated documentation in use on the
Surgical Unit

Record interventions appropriately
Introduction
Prior to undertaking the surgical unit rotation you must ensure that you are familiar with the following
policies and procedures (available within pharmacy or on the hospital intranet):
Policy for prescribing of medicines
Procedure for administration of medicines
Procedure for administration of intravenous drugs
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Policy for administration of intravenous potassium
Procedure for storage of medicines
Antibiotics for surgical prophylaxis procedure
Guidelines for management of post-operative nausea and vomiting
Pharmacy guidelines for prescription chart endorsement
Topics to be covered
1. Anticoagulants / Thromboprophylaxis
1.
Risks for Thromboembolism
2. Management:
- Patient factors
- Surgical factors
- TEDS
- Early mobilisation
- Pharmacological treatment
3. Low molecular weight heparin and conventional heparin. Monitoring of each therapy.
4. Management of heparin induced-thrombocytopenia
a. Management of warfarin during surgery
b. Monitoring of heparin pump
Activities:
1. Observation of warfarin counselling
2. Pre-admission clinics – advice on discontinuation of warfarin
2. Antibiotics
1.
Risk factors for postoperative infection
2
Reducing the risks of postoperative infection
3
Cover for Specific Surgery
 which microbes
 which procedure
 which antibiotic
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Treatment and management of MRSA positive patients
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IV  Oral
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3. Pain / Analgesia
1. Analgesia post-operation
- Drugs available
- Routes of administration e.g. PO, PR, IV, IM, SC,
- PCA / epidural
2. Management / Monitoring of treatment regimes
3. Entonox
4. Neuropathic pain
5. Referral to pain specialist nurse
Activities:
1. Session with pain nurse specialist
2. Familiarise yourself with the nursing guidelines for PCA and epidural
4. Post-Operative Nausea and Vomiting (PONV)
1. Risk factors for PONV - Patient factors
- Surgical factors
- Anaesthetic factors
2. Mechanism of PONV
3. Treatment options
- Dopamine antagonists
- Anticholinergic
Mode / site of action
- Antihistamines
- 5HT3 antagonists
4. Cautions and contraindications for use (e.g. in acute abdomen / obstruction)
5. Administration
5. Fluid/Electrolyte Regimens/Balance
1. Normal fluid distribution, losses and electrolyte requirements
2. Assessment of fluid and electrolyte status
3. NBM – Fluid Replacement
4. Choice of Fluids
- Colloids
- Crystalloids
- Starches
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5. Sodium / Potassium replacement
6. Magnesium / Phosphate / Calcium replacement
7. Compatibility
8. Fluid Balance Chart and monitoring of fluid treatment
Activities:
1. Weigh up post-op fluid balance for a patient
6. Intravenous Drug Administration
1. Risks of intravenous administration
2. Reconstitution and dilutions of commonly used intravenous drugs
3. Administration / maximum rates
4. Compatibility- Ysite / additive
5. Priming IV Lines – Flushing
6.
Extravasation
Activities:
1. Calculations
2. Risk management of pumps - what drugs should be used in which pumps
- what risks are associated with each pump
3. Complete intravenous drugs workbook
7. NBM – Management of Long-term Medicines
1. Alternative routes
2. When to stop medicines
3. Which Medicines to Stop/Change and the importance of continuation
4. Different classes, e.g. cardiac, psychiatric
5. Administration of medicines down feeding tubes
Activities:
1. Spend a morning in preadmission clinic
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8. Laxatives
1. Opiate-induced constipation
2. Treatment options – mode of action, adverse effects
3. Monitoring
9. Diabetes
1. IDDM and NIDDM - Management during surgery
2. Insulin regimes:
Sliding Scale
3. Glucose monitoring – blood / urine dipsticks
4. Management of insulin pump
5. Referral to diabetic specialist nurse
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Clinical Pharmacy assessments
When reviewing a patient during a clinical pharmacy visit you will be expected to present the following
information to the supervising clinical pharmacist:
Presenting complaint
History of presenting complaint
Past medical history
Any relevant social or family history
Drug history
History of drug allergies
Working diagnosis
Results of relevant tests or medical examinations
Pharmaceutical problems including how such problems will be monitored
For each patient reviewed during the ward visit you will also be expected to consider the following
questions:
What pre-admission medicines have been cancelled? Is this appropriate (state reasons why)?
What analgesia is the patient currently receiving? How effective is this – how has the efficacy been
assessed?
What are the potential side effects of the analgesia for this patient and how might these be managed?
What prophylactic antibiotics has the patient received? Were these appropriate? (state reasons why)
Has the patient been started on aspirin or warfarin? Is this appropriate and what factors may influence
the choice?
For cardiac surgery patients, has the patient been started on diuretics? If so is this appropriate?
Describe the parameters you would use to monitor diuretic therapy.
How would you monitor the patient for PONV? Is the patient having issues with PONV? Is so are they
being managed appropriately?
For diabetic patients – is their diabetes being managed appropriately? Describe the parameters you
would use to monitor this.
Be prepared to discuss any changes you would expect to see in the patient’s medication over the
postoperative period.
For each medicine that the patient is taking you will be expected to know the mode of action, usual
dose, whether dose adjustments are needed in renal or hepatic impairment and potential side effects
or drug interactions.
Review discharge medication when written. What factors do you need to consider when reviewing
discharge medication?
Prepared by Medicines Management Pharmacist Aug 2006
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