Premedication

1. 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

2. 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

3. 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 !!

4. Anxiety 40 -80 % 55 % in one study Counselling Drugs Psychology

5. Drug , route Choose so that the peak action time is at their entry into the operating room When to administer

6. 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

7. Oxazepam Temazepam Triazolam Alprazolam Other drugs

8. Sedation Anticholinergic Antiemetic Diphenhydramine – oral dose of 50 mg Antihistaminics (H1)

9. Previous Morphine and pethidine IM Now fentanyl IV Opioids

10. Where we need analgesia Ortho IV and arterial lines Decrease anaesthetic requirements But respiratory depression, Sphincter of Oddi, PONV – problems Opioids ++ and ---

11. Popular in ether days Now only in Ketamine Fibreoptic intubation Antisialogogues

12. 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)

13. 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

14. pH of 2.5 and a volume of 25 ml Danger zone Ranitidine , famotidine, nizatidine are H2 blockers Aspiration

15. Nonparticulate antacid 0.3 M sodium citrate Colloid antacid suspension Immediate , no lag time Increase volume, with food ?? Antacids

16. 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

17. 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

18. 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

19. Sedation Anxiolysis Antiemesis Alpha blocker Anticholinergic Promethazine

20. Steroids Antibiotics Insulin Methadone They are not premedicants in strict sense but we use

21. 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

22. 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

23. Beta blockers Thyroxine Statins And the other dugs he /she is taking for systemic illness Other premedicants to continue

24. Heparin Warfarin Clopidogrel When to use and stop – guidelines are there Deep vein thrombosis

25. 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 ??

26. 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

27. Vagolysis Anticholinergic Anxiolysis Oral/ nasal/SL routes IM ?? pediatric vs. adult patients

28. 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

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

32. 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

33. 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

36. Goals Factors Route Drugs -- benzo, opioids, anticholinergics, promethazine, clonidine, aspiration,antiemetics others Paediatric Summary

37. Thank you all