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The goal of anesthetic pharmacology is to provide unconsciousness (anesthesia), pain relief (analgesia), loss of memory (amnesia), and muscle paralysis. Current anesthesia practice employs polypharmaceutical approaches. Small doses of a number of specific receptor-active medications affords the clinician the ability to rapidly induce anesthesia and promote a speedy emergence in order to meet the flow of surgical and scheduling requirements in today’s modern operating environment. Because many varied drugs are used, significant drug interactions may occur. The important clinical interactions will be discussed in this chapter. Consideration must also be given to a patient’s existing medications including herbal agents and other over-the-counter preparations.1 Clinically, it is not uncommon for patients to take some form of herbal preparation.² Consequently, knowledge of the principles of pharmacology becomes a meaningful and useful tool in the delivery of nursing care to the patient in the postanesthesia care unit (PACU).

Definitions

Additive Effect Occurs when a second drug with properties similar to the first is added to produce an effect equal to the algebraic sum of the effects of the two individual drugs. The shorthand often used to represent this is 1 + 1 = 2.

Agonists Drugs such as dopamine that attach to and activate specific receptors.

Antagonists Drugs such as naloxone (Narcan) that attach to a specific receptor and do not activate it but instead prevent an agonist or body chemical such as a neurotransmitter from stimulating the receptor.

Bioavailability The amount of drug (expressed as a percentage) that enters the blood in an unchanged form after administration. Will vary depending on the route of administration.

Competitive Antagonist Occurs when the concentration of the antagonist is higher than the agonist concentration. Results in reversal or antagonism of the agonist. Examples include naloxone (Narcan) competitively antagonizing or reversing fentanyl and flumazenil (Romazicon) reversing midazolam (Versed). The shorthand often used to represent this is 1 + 1 = 0.

Cross-Tolerance Existing tolerance to a drug because of a prior developed tolerance to a similar drug. For example, a patient who has developed a tolerance to morphine, because of repeated administration, will also require higher doses of all other opioids.

Efficacy of a Drug Refers to the maximum effect that can be produced by a drug.

Half-Life Generally refers to the elimination half-life, which is the time it takes the plasma concentration to fall by one half. It takes four to five half-lives to totally eliminate a drug.

Hyperreactivity An abnormal reaction to an unusually low dose of a drug. For example, patients with Addison’s disease, myxedema, or myotonic dystrophy react with a hyperreactivity to unusually low doses of barbiturates.

Hypersensitivity (Anaphylaxis) A drug-induced antigen-antibody reaction. The particular hypersensitivity reaction can be either an immediate (anaphylactic) or a delayed reaction. Hypersensitivity reactions can occur with succinylcholine, antibiotics, and many other drugs administered in the PACU (see Chapter 18).

Hyporeactivity An indication that a person needs excessively large doses of a drug to obtain a therapeutic or desired effect.

Idiosyncrasy An adverse drug reaction (not an allergy) that occurs in a small number of persons and has no correlation to dosage or type of therapy. An example is phenytoin-induced liver dysfunction.³

Mechanism of Action The means by which a drug exerts its effect on cells or tissues. Usually acting via a receptor.

Pharmacodynamics The study of drug mechanisms of action as well as other biochemical and physiologic effects on the body.

Pharmacokinetics The study of the movement of drugs throughout the body including the processes of absorption, distribution, biotransformation or metabolism, and excretion.

Potency of a Drug The necessary dose of a particular drug to produce a specific effect designated as the effective dose (ED). When that effect is achieved in a particular percentage of patients, it is quantified as ED₅₀ for 50% of the patients and ED₉₅ for 95% of the patients who show an effect from the drug.

Potentiation The enhancement of the action of one drug by a second drug that has no detectable action of its own. The shorthand often used to represent this is 1 + 0 = 3.

Receptors The portion on or within a cell, usually a protein complex, where the attachment of drugs leads to a physiologic response. The receptors are selective in that they recognize and uniquely bind to specific pharmacologic or physiologic agents.

Synergistic Effect Addition of a second drug to a drug with properties similar to the first that results in an effect greater than the algebraic sum of the effects of the two individual drugs. The shorthand often used to represent this is 1 + 1 = 3.

Tachyphylaxis An acute diminished response to a drug after successive doses requiring an increased amount to achieve a similar effect. For example, succinylcholine administered by intravenous drip. Over time, a higher drip rate is needed to achieve the necessary response.

Tolerance A type of hyporeactivity acquired during chronic exposure to a drug in which unusually large doses are needed to reach a desired effect. A prime example is a person who has become dependent on opioids and needs larger than normal doses to elicit the desired therapeutic response.

Effects of physiologic dysfunction on pharmacokinetic action

Renal Disease

Kidney disease reduces the effectiveness of drug clearance and results in a prolongation in the action of the drugs relying on the kidneys for removal. Evaluation of renal drug clearance includes creatinine clearance laboratory analysis which measures glomerular filtration (see Chapter 13). Creatinine clearance can be used to predict overall renal function and the degree of a drug’s renal clearance. In anephric patients or in patients with severe kidney disease, the elimination clearance is decreased and the t_½B is increased, thus prolonging the effects of circulating medications that rely on renal clearance especially with repeated administrations.⁸

Hepatic Disease

Patients with hepatic diseases such as cirrhosis may have difficulty clearing some anesthetic drugs from the body. Liver function testing is unreliable for predicting the level of impairment in hepatic clearance of drugs. Any patient with documented liver disease should be considered at risk for decreased hepatic clearance of drugs. Therefore, when a patient has a documented hepatic disease, all drugs administered in the PACU should be titrated to the desired effect, using the lowest dose possible, for an appropriate pharmacologic outcome.9

Cardiovascular Disease

Cardiovascular diseases that cause a reduction in tissue perfusion have a significant effect on drug distribution and clearance. For example, when lidocaine is administered to patients with congestive heart failure, the dose should be reduced by half, because a full dose could be toxic due to changes in the volume of distribution and clearance. Patients who have undergone cardiopulmonary bypass surgery can have a hemodilution of drugs. Patients with cardiac disease should have their medications given at lower doses over longer dosing intervals with careful monitoring.10 Drugs used in the PACU are listed in Table 19.1.

Table 19.1

Drugs Used in the Postanesthesia Care Unit: Perianesthesia Drug List

Drug	Route	Onset	Peak	Duration of Action	Classification
Adenosine (Adenocard)	IV	<  20 s	20–30 s	1 min	Antiarrhythmic
Acetaminophen (OFIRMEV)	IV	15 min	30 min	6 h	Nonopioid analgesic, antipyretic
Acetaminophen (Acephen, FeverAll)	Rectal (suppository)	30 min	1 h	6 h	Nonopioid analgesic, antipyretic
Albuterol (Proventil, Ventolin)	INH	<  5 min	30 min–2 h	3–6 h	Bronchodilator
Alfentanil (Alfenta)	IV	1–2 min	1–2 min	10–60 min	Opioid agonist
	Epidural	5–15 min	30 min	30–60 min
Aminocaproic acid (Amicar)	IV	1–2 h	—	8–12 h	Hemostatic agent
Aminophylline	IV	1–2 min	30–60 min	4–10 h	Bronchodilator
	PO	<  30 min	1–5 h	4–8 h
Aprepitant (Emend)	IV	30	2 h	24 h	Antiemetic
Atenolol (Tenormin)	IV	5 min	5 min	12–24 h	Beta-adrenergic blocker
	PO	30–60 min	2–4 h	24 h
Atracurium (Tracrium)	IV	2–5 min	3–5 min	20–35 min	Nondepolarizing NMB agent
Atropine	IV – cardiac	30–60 s	1–2 min	15–30 min	Anticholinergic
	IV – antisialagogue activity	20–60 min	60–90 min	4 h
	IO	1–2 min	5–10 min	1–2 h
	ETT	10–20 s	1–2 min	30–45 min
	IM	5–40 min	20–60 min	2–4 h
	INH	3–5 min	15–90 min	3–6 h
Bumetanide (Bumex)	IV	1–5 min	15–30 min	4 h	Loop diuretic
Bupivacaine (Marcaine, Exparel)	Epidural	4–7 min	30–45 min	2–7 h	Local anesthetic
	Infiltration Infiltration (liposomes)	2–10 min 4–10 min	30–45 min 2 h	3–7 h 72–96 h
	Spinal	<  1 min	15 min	2–4 h
Butorphanol (Stadol)	IV	1–2 min	5–10 min	3–4 h	Analgesic (agonist-antagonist combination)
	IM	10–15 min	30–60 min	3–4 h
Captopril (Capoten)	PO	<  15 min	1–2 h	2–6 h	ACE inhibitor
Clevidipine (Cleviprex)	IV	1–2 min	5–10 min	15 min	Calcium channel blocker
Chloroprocaine (Nesacaine)	Epidural	6–12 min	10–20 min	30–60 min	Local anesthetic; not to be used for spinal anesthesia
Cimetidine (Tagamet)	IV	30–45 min	60–90 min	4–5 h	Histamine receptor antagonist
	PO	15–45 min	1–2 h	2–4 h
Cisatracurium (Nimbex)	IV	1–4 min	2–7 min	22–65 min	Nondepolarizing NMB agent
Clonidine (Catapres)	PO	30–60 min	2–4 h	6–8 h	Antihypertensive
	IV	30–60 min	2–4 h	6–10 h
	Epidural	<  15 min	3–4 h
Cocaine HCl	Topical	<  1 min	2–5 min	30–120 min	Topical anesthetic; vasoconstrictor
	PO	30–60 min	—	2–4 h
	IM	20–60 min	—	2–3 h	Opioid agonist
Cyclosporine (Sandimmune)	PO	1–6 h	8–12 h	1–4 d	Immunosuppressant
Dantrolene (Dantrium, Ryanodex)	IV	<  5 min	60 min	3 h	Skeletal muscle relaxant; for treatment of malignant hyperthermia
	PO	1–2 h	4–6 h	8–12 h
Desflurane (Suprane)	INH	1–2 min	—	Emergence in 8–9 min after discontinuation	Inhalational anesthetic agent
Desmopressin (DDAVP)	IV	30 min	1.5–3 h	8–20 h	Synthetic vasopressin analog
	Intranasal	<  60 min	1–5 h	8–20 h
Dexmedetomidine (Precedex)	IV	1–3 min	5–10 min	Effects last 3–5 min after discontinuance of IV infusion	α2b-Receptor agonist sedative agent
Dexamethasone	IV	<  8 h	12–24 h	36–54 h	Long-acting corticosteroid
(Decadron)	IM	<  8 h	1–2 h	72 h
(Respihaler)	INH	<  20 min	2–4 h	12 h
(Turbinaire)	Intranasal	<  15 min	—	12–24 h
Diazepam (Valium)	IV	1–5 min	4–8 min	15–60 min	Benzodiazepine
	IM	15–30 min	—	3–6 h
	PO	30–60 min	1–2 h	3–6 h
Digoxin (Lanoxin)	IV	5–30 min	1–5 h	3–4 d	Inotropic agent
	IM	30 min	4–6 h	3–4 d
	PO	30 min–2 h	6–8 h	3–4 d
Diltiazem (Cardizem)	IV	1–3 min	2–7 min	1–3 h	Calcium channel blocker
	PO	30 min	2–3 h	4–6 h
	PO, extended	1–3 h	4–11 h	18–24 h
Diphenhydramine (Benadryl)	IV	<  3 min	1–2 h	3–6 h	Antihistamine
	PO	1 h	1–2 h	4–6 h
Dobutamine	IV	2 min	1–10 min	5–10 min	Vasopressor (adrenergic agonist)
Dolasetron (Anzemet)	IV	5–15 min	30–60 min	8–12 h	Antiemetic
Dopamine (Intropin)	IV	2–4 min	5 min	<  10 min	Catecholamine
Doxapram (Dopram)	IV	20–40 s	1–2 min	5–12 min	Respiratory and cerebral stimulant
Droperidol (Inapsine)	IV, IM	3–10 min	30 min	8–16 h	Tranquilizer, antiemetic
Edrophonium (Enlon, Tensilon)	IV	30–60 s	1–5 min	5–20 min	Anticholinesterase (NMB reversal agent)
	IM	2–10 min	5–10 min	10–40 min
Enalapril (Vasotec)	PO	1 h	4–6 h	12–24 h	ACE inhibitor
Enalaprilat (Vasotec IV)	IV	10–15 min	1–4 h	6 h	ACE inhibitor
Enoxaparin (LMW heparin)	SC	20–60 min	3–5 h	12 h	Anticoagulant
Ephedrine	IV	<  30 s	2–5 min	10–60 min	Sympathomimetic
	IM	1–3 min	<  10 min	30–60 min
Epinephrine (Adrenalin)	IV	<  30 s	2–3 min	5–10 min	Catecholamine, sympathomimetic
	ETT	15–30 s	15–25 min	—
	INH	1 min	1–5 min	1–3 h
	SC	5–15 min	20 min	—
Esmolol (Brevibloc)	IV	1–2 min	5–6 min	10–20 min	Cardio-selective blocker
Ethacrynic acid (Edecrin)	IV	5–15 min	30 min	2 h	Loop diuretic
Etidocaine (Duranest)	Infiltration	3–5 min	5–15 min	2–3 h	Local anesthetic
	Epidural	5–15 min	15–20 min	3–5 h
Etomidate (Amidate)	IV	30–60 s	1 min	5–14 min	Non-barbiturate hypnotic
Famotidine (Pepcid)	IV	<  30 min	30 min	8–12 h	H2 antagonist
	PO	20–45 min	1–3 h	8–12 h
Fenoldopam (Corlopam)	IV (continuous infusion)	5 min	15 min	Rapidly metabolized after discontinued	Antihypertensive
Fentanyl (Sublimaze)	IV	<  30 s	3–7 min	30–60 min	Opioid agonist
	Epidural, spinal	4–10 min	<  30 min	3–8 h
	IM	<  8 min	20–30 min	1–2 h
	Transdermal	12–18 h	1–3 d	3 d
Flumazenil (Romazicon)	IV	1–2 min	6–10 min	45–90 min	Benzodiazepine-receptor antagonist
Furosemide (Lasix)	IV	2–5 min	20–30 min	2 h	Loop diuretic
	PO	30–60 min	1–2 h	4–8 h
Glucagon	IV, IM	5 min	2–20 min	10–30 min	Antihypoglycemic
Glipizide (Glucotrol)	PO	60–90 min	2–3 h	10–24 h	Hypoglycemic
Glycopyrrolate (Robinul)	IV – Cardiac	1–3 min	3–5 min	2–3 h	Anticholinergic
	IV – antisialagogue activity	15–20 min	30–45 min	2–7 h
	IM	15–30 min	30–45 min	2–7 h
Granisetron (Kytril)	IV	2–4 min	5–8 min	24 h	Serotonin receptor antagonist
Haloperidol (Haldol)	IV	5–30 min	1 h	6–8 h	Long-acting tranquilizer
Heparin (Liquaemin, Pan heparin)	IV	Immediate	Dose dependent	Dose dependent	Anticoagulant
	SC	20–30 min	2–4 h	12–16 h
Hetastarch (Hespan)	IV	15–30 min	1 h	24–48 h	Plasma expander
Hyaluronidase (Wydase)	SC	Immediate	—	30–60 min	Enzyme to increase absorption
Hydralazine (Apresoline)	IV	5–20 min	10–60 min	2–4 h	Direct-acting arterial vasodilator
	IM	10–30 min	30–80 min	2–8 h
	PO	30–120 min	2 h	2–8 h
Hydrocortisone sodium succinate (Solu-Cortef)	IV, IM	5 min	—	30–36 h	Corticosteroid
Hydromorphone (Dilaudid)	IV	<  60 s	5–20 min	2–4 h	Opioid (mixed)
	IM, PO	15–30 min	30–60 min	4–6 h
Ibutilide fumarate (Covert)	IV	Immediate	10 min	10–30 min	Antiarrhythmic
Insulin, Lente	SC	1–4 h	7–15 h	18–26 h	Antidiabetic agent
Insulin, NPH	SC	1–2 h	4–12 h	18–26 h
Insulin, Regular	SC	30–60 min	1–5 h	5–8 h
Insulin, Semilente	SC	1–3 h	4–10 h	12–16 h
Insulin, Ultralente	SC	4–8 h	14–24 h	28–36 h
Insulin, NPH 70/Regular 30	SC	30 min	2–12 h	24 h
Ipratropium (Atrovent, Itrop)	INH	15–30 min	1–2 h	4–5 h	Anticholinergic for reactive airways disease
Isoflurane (Forane)	INH	1–2 min	—	Emergence in 10-15 min after discontinuation	Inhalational anesthetic agent
Isoproterenol (Isuprel)	IV	Immediate	1 min	1–5 min	Sympathomimetic
Ketamine (Ketalar)	IV	30–60 s	1 min	5–15 min	Dissociative anesthetic
	IM	3–4 min	5–8 min	12–25 min
Ketorolac (Toradol)	IV	<  1 min	30 min	4–6 h	Nonsteroidal anti-inflammatory
	IM	<  10 min	45–60 min	4–6 h
	PO	30–60 min	1–3 h	3–7 h
Labetalol (Normodyne, Trandate)	IV	1–3 min	5–15 min	15 min–2 h	Adrenergic antagonist
	PO	20–40 min	1–4 h	4–12 h
Lansoprazole (Prevacid)	PO	1 h	2 h	>  24 h	Proton pump inhibitor
Lidocaine (Xylocaine)	IV	45–90 s	1–2 min	10–20 min	Local anesthetic
	Epidural	5–15 min	20–30 min	60–120 min
	Infiltration	<  60 s	20–30 min	30–120 min
	Spinal	<  60 s	<  10 min	60–90 min
Lorazepam (Ativan)	IV	1–5 min	20–40 min	4–6 h	Benzodiazepine
	PO	20–30 min	2 h	10–20 h
Magnesium sulfate	IV	Immediate	2–3 min	30 min	Anticonvulsant
Mannitol (Osmitrol)	IV, diuresis	15–60 min	1–3 h	3–8 h	Osmotic diuretic
	Epidural	<  15 min	60 min	3–8 h
	IV, IOP	30–60 min	1–2 h	4–6 h
Meperidine (Demerol)	IV	1–3 min	5–20 min	2–4 h	Synthetic opioid agonist
	IM	5–10 min	30–50 min	2–4 h
	PO	10–45 min	60 min	2–4 h
Mepivacaine (Carbocaine)	Epidural	5–15 min	15–45 min	3–5 h	Local anesthetic
	Infiltration	3–5 min	15–45 min	45–90 min
Metaproterenol (Metaprel)	INH	<  60 s	60 min	1–4 min	Bronchodilator
Methadone (Dolophine)	IV	1–3 min	15 min	6 h	Synthetic opioid
	IM	3–60 min	30–60 min	6 h
	PO	30–60 min	45 min	6 h
Methohexital (Brevital)	IV	<  30 s	30–120 s	5–10 min	Ultra–short-acting barbiturate
	Rectal	5–7 min	5–10 min	45–90 min
Methylene blue (Urolene Blue)	IV	<  1 min	<  1 h	Varies	Antidote for methemoglobinemia
Methylergonovine (Methergine)	IV	Immediate	5–10 min	45 min	Oxytocic
	IM	2–5 min	30 min	3 h
Metoclopramide (Reglan)	IV	1–3 min	30–60 min	1–2 h	Prokinetic agent, dopamine-receptor antagonist, antiemetic
	IM	10–15 min	30–60 min	1–2 h
	PO	30–60 min	1–2 h	1–2 h
Metoprolol (Toprol)	IV	<  5 min	20 min	5–8 h	Beta-adrenergic blocker
	PO	<  15 min	90 min	12–19 h
Midazolam (Versed)	IV	1–5 min	2–5 min	15–90 min	Benzodiazepine
	IM	10–15 min	30–60 min	1–3 h
	PO	10–15 min	30–60 min	2–6 h
Milrinone (Primacor)	IV	2 min	15 min	2 h	Inotropic agent
Morphine	IV	<  1 min	20 min	2–7 h	Opioid agonist
Morphine (Duramorph)	Epidural	60 min	90 min	6–18 h	Opioid agonist
	IM	1–5 min	30–60 min	3–7 h
	PO	15–60 min	30–60 min	3–7 h
	PO, extended	60–90 min	1–4 h	6–12 h
	Spinal	<  60 min	1–2 h	12–24 h
Nalmefene HCl (Revex)	IV	2 min	5 min	4–6 h	Opioid antagonist
	IV	2–3 min	15–30 min	3–6 h
	IM	15 min	30–60 min	3–6 h
Naloxone (Narcan)	IV	1–2 min	5–15 min	1–4 h	Opioid antagonist
	IM	2–5 min	5–15 min	1–4 h
Naltrexone (ReVia)	PO	5 min	1 h	24–72 h	Opioid antagonist
Neostigmine (Prostigmin)	IV	<  3 min	7 min	45–60 min	Anticholinesterase (NMB reversal agent)
Nicardipine (Cardene)	IV	1 min	15 min	3 h	Calcium channel blocker
	PO	<  30 min	30–60 min	3 h
Nifedipine (Procardia)	PO	15–20 min	30–120 min	4–12 h	Calcium channel blocker
	PO, extended	20–30 min	6 h	24 h
	SL	5 min	20–45 min	4–12 h
Nitroglycerin	IV	1–2 min	1–5 min	3–5 min	Antihypertensive, nitrate vasodilator
	Ointment	20–60 min	3–6 h	—
	SL	1–3 min	30–60 min	—
	Transdermal	40–60 min	18–24 h	—
Nitroprusside (Nipride)	IV	30–60 s	—	1–10 min	Peripheral vasodilator
Nitrous oxide (N2O)	INH	1–5 min	—	5–10 min after discontinued	Inhalational anesthetic agent
Nizatidine (Axid)	PO	30–60 min	30 min–3 h	8–12 h	H2-receptor antagonist
Norepinephrine (Levophed)	IV	<  60 s	1–2 min	2–10 min	Catecholamine, sympathomimetic
Omeprazole (Prilosec)	PO	1 h	2 h	72 h	Proton pump inhibitor
Ondansetron (Zofran)	IV	<  30 min	1–1.5 h	12–24 h	Serotonin (5-HT3) receptor antagonist
Oxazepam (Serax)	PO	30 min	2 h	8–12 h	Benzodiazepine
Oxytocin (Pitocin)	IV	<  30 s	20–40 min	60 min	Oxytocic
	IM	3–5 min	40 min	2–3 h
Palonosetron (Aloxi)	IV	5–15 min	2–4 h	24–72 h	Antiemetic
Pancuronium (Pavulon)	IV	1–3 min	3–5 min	40–90 min	Nondepolarizing NMB agent
Phentolamine (Regitine)	IV	1–2 min	—	10–15 min	Alpha-adrenergic blocker
	IM	5–20 min	—	30–45 min
Pentobarbital (Nembutal)	IV	Immediate	1–2 min	15 min	Barbiturate
Phenylephrine (Neo-Synephrine)	IV	<  30 s	1 min	15–20 min	Alpha-adrenergic agonist
Phenytoin (Dilantin)	IV	3–5 min	1–2 h	22 h	Anticonvulsant
Physostigmine (Antilirium)	IV	3–8 min	5–10 min	30 min–5 h	Anticholinesterase (NMB reversal agent)
Prilocaine (Citanest)	SC	1–2 min	<  30 min	30 min–1.5 h	Local anesthetic
	Epidural	5–15 min	<  30 min	1–3 h
Procainamide (Pronestyl)	IV	Immediate	5–15 min	2.5–5 h	Antiarrhythmic
Procaine (Novocain)	SC	2–5 min	<  30 min	15–30 min	Local anesthetic
	Spinal	2–5 min	<  30 min	30 min–1.5 h
	Epidural	5–25 min	<  30 min	30 min–1.5 h
Prochlorperazine (Compazine)	IV	3–5 min	15–30 min	3–4 h	Antiemetic, antipsychotic
	IM	10–20 min	15–30 min	3–4 h
	PO	30–40 min	2–4 h	3–4 h
	Rectal	60 min	3–4 h	—
Promethazine (Phenergan)	IV	3–5 min	1–2 h	2–8 h	Phenothiazine, H1-receptor antagonist
	IM	20 min	1–2 h	2–8 h
Propofol (Diprivan)	IV	30–60 s	1 min	5–20 min	Nonbarbiturate anesthesia induction agent
Propranolol (Inderal)	IV	<  2 min	1 min	1–6 h	Beta-adrenergic receptor antagonist
	PO	30 min	60–90 min	8–12 h
Protamine sulfate	IV	30–60 s	<  5 min	2 h	Heparin antagonist
Ranitidine (Zantac)	IV	<  15 min	1–2 h	6–8 h	H2-receptor antagonist
	PO	<  30 min	2–3 h	8–12 h
Remifentanil (Ultiva)	IV	1–5 min	—	Opiate effect ceases 18 min after discontinued	Opioid
Rocuronium (Zemuron)	IV	45–90 s	1–3 min	30–120 min	Nondepolarizing NMB agent
Ropivacaine HCl (Naropin)	SC	1–5 min	—	2–6 h	Local anesthetic
	Epidural	5–13 min	—	3–5 h
Salmeterol (Serevent)	INH	10–20 min	30 min	12 h	Long-acting beta-adrenergic agonist (LABA)
Scopolamine (Transderm-Scop)	IV	Immediate	—	30–60 min	Anticholinergic
	IM	30 min	—	4–6 h
	Transdermal	4 h	—	72 h
Sevoflurane (Ultane)	INH	1–2 min	—	Emergence in 9–12 min after discontinuation	Inhalational anesthetic agent
Sodium citrate (Bicitra)	PO	2–10 min	60 min	60–90 min	Nonparticulate neutralizing buffer
Somatostatin (Zecnil)	IV	5–10 min	45 min	1 h	Synthetic somatostatin
Sotalol HCl (Betapace)	PO	1 h	2.5–4 h	4–6 h	Antiarrhythmic
Sodium bicarbonate	IV	2–10 min	10–30 min	30–60 min	Neutralizing buffer
Sodium citrate	PO	<  60 s	3–4 min	2 h	Neutralizing buffer
Sodium nitroprusside	IV	30–60 s	1–2 min	1–10 min	Antihypertensive, nitrate vasodilator
Succinylcholine (Anectine, Quelicin)	IV	30–60 s	1 min	4–6 min	Depolarizing NMB agent
	IM	2–3 min	10–30 min	—
Sufentanil (Sufenta)	IV	1–3 min	3–5 min	20–45 min	Opioid agonist
	Epidural, spinal	4–10 min	<  30 min	2–4 h
Sugammadex	IV	1–3 min	15–25 min	2 h	Cyclodextrin (NMB reversal agent)
Terbutaline (Brethine)	INH	5–30 min	1–2 h	3–4 h	Beta-adrenergic agonist
	PO	30 min	2–3 h	4–8 h
	SC	15 min	30–60 min	1.5–4 h
Tetracaine (Pontocaine)	Spinal	<  10 min	15–60 min	1.25–3 h	Local anesthetic
Torsemide (Demadex, Presaril)	IV	10 min	1–2 h	6–8 h	Loop diuretic
Vancomycin (Vancocin)	IV	15–30 min	4–6 h	8–12 h	Antimicrobial agent
Vasopressin (Pitressin)	IV	15–30 min	30–60 min	2–8 h	Antidiuretic hormone, vasopressor agent
Vecuronium (Norcuron)	IV	2–3 min	3–5 min	25–40 min	Nondepolarizing NMB agent
Verapamil (Isoptin)	IV	2–5 min	<  10 min	30–60 min	Calcium channel blocker
	PO	30 min	1–2 h	3–7 h
Vitamin K (Aquamephyton)	IM, IV, SC	1–3 h	—	6–48 h	Water-soluble vitamin
Warfarin (Coumadin)	PO	Up to 5–7 d	—	2–5 d after therapeutic dose reached	Anticoagulant

ACE, Angiotensin-converting enzyme; DDAVP, 1-deamino-8-d-arginine vasopressin; ET, endotracheal tube; IM, intramuscular; INH, inhalation; IO, intraosseous; IOP, intraocular pressure; IV, intravenous; NMB, neuromuscular blocker; NPH, neutral protamine Hagedorn; PO, by mouth; SC, subcutaneous; SL, sublingual.

Adapted from Nagelhout JJ, Plaus KL. Handbook of nurse anesthesia. 5th ed. St. Louis, MO: Saunders; 2014.

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