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Dr . S. Parthasarathy MD., DA., DNB, MD ( Acu ), Dip. Diab . DCA, Dip. Software statistics PhD ( physio ) Mahatma Gandhi medical college and research institute – Puducherry – India . Premedication . Sedation and anxiolysis Analgesia and amnesia Antisialagogue effect

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premedication

Dr. S. Parthasarathy

MD., DA., DNB, MD (Acu),

Dip. Diab. DCA, Dip. Software statistics

PhD (physio)

Mahatma Gandhi medical college and research institute – Puducherry – India

Premedication

why we need

Sedation and anxiolysis

Analgesia and amnesia

Antisialagogueeffect

To maintain hemodynamic stability, including decrease in autonomic response

To prevent and/or minimize the impact of aspiration

To decrease postoperative nausea and vomiting

Prophylaxis against allergic reaction

VAAAAAS--

Why we need ??

pneumonic

before we write

Patient age and weight

Physical status

Levels of anxiety and pain

Previous history of drug use or abuse

History of postoperative nausea, vomiting or motion sickness

Drug allergies

Elective or emergency surgery

Inpatient or outpatient status

Familiarity with drugs

Before we write !!
psychology

Anxiety

40 -80 %

55 % in one study

Counselling

Drugs

Psychology
when to administer

Drug , route

Choose so that the peak action time is at their entry into the operating room

When to administer
benzodiazepines

Sedation

Anxiolysis

No nausea

but

No analgesia

Excess sedation, paradoxical agitation

especially in Old age ??

oral, IV, spray midaz,

oral diazepam .Lorazepam

Sublingual – midaz can be used

Benzodiazepines
other drugs

Oxazepam

Temazepam

Triazolam

Alprazolam

Other drugs
antihistaminics h1

Sedation

Anticholinergic

Antiemetic

Diphenhydramine – oral dose of 50 mg

Antihistaminics (H1)
opioids

Previous

Morphine and pethidine IM

Now fentanyl IV

Opioids
opioids and

Where we need analgesia

Ortho

IV and arterial lines

Decrease anaesthetic requirements

But respiratory depression, Sphincter of Oddi, PONV – problems

Opioids ++ and ---
antisialogogues

Popular in ether days

Now only in

Ketamine

Fibreoptic intubation

Antisialogogues
reduction in vagal relexes clinical scenario

Traction of ocular muscles

Second dose of scoline

Propofol, fentanyl, halothane

Atropine and glycopyrollate

But – problems

central anticholinergic syndrome, tachycardia, blocking sweat glands ??

Reduction in vagalrelexes(clinical scenario)
adrenergic agonists

Clonidine

in doses of 2.5 to 5 µg/kg – oral

sedation,

prevent hypertension and tachycardia from endotracheal intubation and surgical stimulation

Hypotensiveanaesthesia

IM,IV – OK

Adrenergic Agonists
aspiration

pH of 2.5 and a volume of 25 ml

Danger zone

Ranitidine , famotidine, nizatidine are H2 blockers

Aspiration
antacids

Nonparticulate antacid 0.3 M sodium citrate

Colloid antacid suspension

Immediate , no lag time

Increase volume,

with food ??

Antacids
omeprazole

Intravenous doses of 40 mg 30 minutes before induction have been used.

Oral doses of 40 to 80 mg must be given 2 to 4 hours before surgery to be effective

Other PPIs – used

Omeprazole
gastrokinetic agents

Gastrokinetic agents are useful because of their effectiveness in reducing gastric fluid volume.

Metoclopramide

Increased gastric emptying – but no guaranteed emptiness of stomach

Antiemetic

No change in pH

Gastrokinetic Agents
at the end antiemesis

Many anesthesiologists prefer not to administer antiemetics as part of a preoperative regimen, but believe that antiemetics should be administered intravenously just before they are needed at the conclusion of surgery.

Droperidol, metoclopramide, ondansetron, and dexamethasone

At the end ?? Antiemesis
promethazine

Sedation

Anxiolysis

Antiemesis

Alpha blocker

Anticholinergic

Promethazine
antibiotics

Infective endocarditis prophylaxis

Probable contamination

Immunosupressed

Diabetic

On steroids

Cephalosporin –ok around one hour prior

Vancomycin 2 hours prior

Tourniquet !! Give antibiotics before inflation

Antibiotics
steroids

consider treatment in any patient who has received corticosteroid therapy for at least 1 month in the past 6 to 12 months.

80 mg 6 hourly

Why ??

300 mg / day – maximal daily production to stress

Steroids
other premedicants to continue

Beta blockers

Thyroxine

Statins

And the other dugs he /she is taking for systemic illness

Other premedicants to continue
deep vein thrombosis

Heparin

Warfarin

Clopidogrel

When to use and stop – guidelines are there

Deep vein thrombosis
in a child

parental presence on induction of anesthesia

an increase in heart rate and skin conductance levels in mothers

Oral midaz better than parent and the combined is not very superior

IV midaz – wait for 4.8 minutes

Intranasal – 10 minutes

In a child ??
benzodiazepines in paediatrics

Lorazepam

slow onset and offset of action, and therefore is better used for inpatients

Diazepam

immature liver function that would lead to a prolonged half life

Benzodiazepines in paediatrics
pediatric vs adult patients

Vagolysis

Anticholinergic

Anxiolysis

Oral/ nasal/SL routes

IM ??

pediatric vs. adult patients
pediatrics

Upto 6 months – no problem in parental separation

6 months to 5 years -- maximal psychological problem and anxiety

5 years and above – easy to convince

Pediatrics
dexmed premed

Intranasal dexmedetomidine produces more sedation than oral midazolam when children were separated from their parents and at induction of anesthesia

Dexmed premed
ketamine

Nasal transmucosalketamine at a dose of 6 mg/kg is also effective in sedating children within 20 to 40 minutes before induction of anesthesia.

Oral ketamine, IM ketamine , IV ketamine

Ketamine
patches for venipuncture

EMLA cream

(eutectic mixture of local anesthetic),

is a mixture of two local anesthetics (2.5% lidocaine and 2.5% prilocaine).

ELA-Max (4% lidocaine) ,

Ametop (4% tetracaine )

The S-Caine Patch (eutectic mixture of lignocaine and tetracaine – 70 mg of each drug/ patch )

Patches for venipuncture
summary

Goals

Factors

Route

Drugs -- benzo, opioids, anticholinergics, promethazine, clonidine, aspiration,antiemetics others

Paediatric

Summary