PREMEDICATION

Introduction
Preoperative medication consists of :
 psychological
 pharmacological preparation.

How the patient should be like before

entering OT:
 free from apprehension
 sedated
 arousable
 cooperative.
 Goals of preoperative
medication
 Relief of anxiety
 Sedation
 Amnesia
 Analgesia
 Drying of airway secretions
 Prevention of autonomic reflex response
 Reduction of gastric fluid volume and
increased pH
 Antiemetic effects
 Reduction of anesthetic requirements
 Facilitation of smooth induction of anesthesia
 Prophylaxis against allergic reactions.
 Psychological preparation

Non-pharmalogical antedote to
apprehension :

 preoperative visit
 interview
 Adminstration of
premedication :
 1-2 hr before the surgery
 night before.

Prescribed medications:
 2 hours prior to surgery
 small sip of water (<30 ml) orally
 Ideal premedicant drug :

 Anxiolytic
 Analgesic
 Sedative
 Amnesic
 Safe for patient
 Painless and easy to administer
 Highly reliable and specific
 Rapid onset and rapidly cleared
 Free of side effect and interaction with other
drugs
 Should not produce undue depression of
cardiovascular, respiratory and central nervous
system
 Relative contraindications to
sedative premedication :
 New born < 1 year, elderly
 Decreased level of consciousness, intracranial
pathology
 Severe pulmonary pathology
 Hypovolemia
 Airway obstruction or airway surgery, sleep
apnea
 Severe hepatic and renal disease
 Rapid sequence induction
 Obstetric anesthesia
 Recent practice of
premedication :
Morphine and hyoscine has been abandoned
with:

 Modern intravenous and inhalational

anesthetic agents
 Increasing use of day-case surgery
 Same-day admissions
 Changes to the surgical list ,making the
timing of drug delivery difficult
 The choice of drugs used for premedication
depends on the procedure, patient and
anesthetic technique.

 Some patients prefer not to have premedication.

 Potential benefits may be outweighed by potential

problems especially with day-case surgery.

 Reviews found no evidence of a difference in

time to discharge from hospital following adult
day surgery in patients who received anxiolytic
 Group
of
preanesthetics
 I. Anxiolytics / Sedative /
Hypnotic :

 – Benzodiazepines (still commonly used)

 · Diazepam
 · Lorazepam
 · Midazolam
 · Alprazolam
 – Barbiturates (not used much)
 · Secobarbital
 · Pentobarbital
 Benzodiazepines :

 Produce anxiolysis, amnesia and sedation

 Act predominantly on GABA receptors in the
CNS.
 Minimal respiratory and cardiac depression
 Do not produce nausea and vomiting
 They are not analgesics
 Crosses placental barrier and may cause
neonatal depression
 Comparison of pharmacologic
variables of benzodiazepines:
Diazepam Lorazepa Midazola
m m
Dose equivalent 10 1-2 3-5
(mg)

Time to peak 1-1.5 2-4 0.5-1

effect after oral
dose
(hr)
Elimination half 20-40 10-20 1-4
life (hr)

Clearance 0.2-0.5 0.7-1.0 6.4-11.1

(mL/kg/min)

Volume of 0.7-1.7 0.8-1.3 1.1-1.7

distribution
 Diazepam
 Can be used as a sole agent as for cathetrisation,
cardioversion, bronchoscopy etc and as an adjuvant
to LA
 Cirrhosis of liver leads to upto fivefold increase in
elimination half- life
 Doses :
0.25 to 0.5 mg/kg orally
0.25 mg/kg IM
0.3 to 0.6 mg/kg IV as an inducing agent
Dose requirements decrease 10% per decade of
patient’s age.
 Flumazenil, is effective in reversing the sedative
 Lorazepam
 A new and effective sedative/amnesic/anxioloytic
 Has stabilising effect on cardiovascular and respiratory
systems
 Twice as potent as midazolam.
 used for lengthy procedures where prompt
emergence not desirable
 Obesity prolongs the sedative effects of Lorazepam.
 Dose for premedication :
 Oral – 50 µg/kg, not more than 4 mg (can be given 90
min before anesthesia)
 0.03–0.05 mg/kg IM
 Sedation : 0.03–0.04 mg/kg IV
 Midazolam

 Water soluble benzodiazepine with painless

administration
 Amnesic effects are more potent than
sedative effects.
 choice of drug for out patient surgery and
pediatric premedication
 Capable of crossing the BBB with effects
ranging from tranquillization to full anesthesia.
 Respiratory depressant
 Hazardous in hypovolemic patients.
 Midazolam
 Patients with decreased intracranial
compliance show little or no change in ICP
with midazolam
 Usual dose : 0.15 to 0.3 mg/kg IV
 Lesser dose to be used in elderly and obese
patients
 0.5 to 0.75 mg/kg orally produces anxiolysis
and degree of tranquillity within 30 min
 Pediatric dose : 0.1 mg/kg IV or IM
 Intranasal midazolam 0.3 mg/kg has quicker
onset of action than oral midazolam.
 II. Opioid analgesics
 – Morphine
 – Pethidine
 – Fentanyl

They differ in duration of action ; can be given

parentally.

• administered preoperatively for sedation

• control hypertension during tracheal intubation
• analgesia
 For preoperative analgesia, the use of IV
fentanyl is preferred :
• rapid onset
• short duration

 Fentanyl is also available as transdermal

patches.
 Morphine
 An opium alkaloid and a standard potent
addictive analgesic/hypnotic/sedative/anxiolytic
 May lead to GI spasm, biliary tract spasm,
even renal tract spasm.
 Causes constipation and urinary retention
 Depresses respiration both in rate and depth
 Passes through placental barrier
 Tolerance occur to morphine
 1mg of IV morphine ≈ 4 mg of oral morphine
 Dose : 1.0 – 2.5 mg IV
 Morphine

 Morphine should be carefully used in :

 Extremes of ages
 Respiratory cripples
 Hypothyroidism and hypopituitarism
 Liver and kidney pathology
 In patients with increased ICP
 Pregnancy
 Patients treated with MAO inhibitors
 Fentanyl
 Potent narcotic analgesic ; 100 times more potent
than morphine
 Metabolised in liver and excreted through urine
and feces
 Respiratory depression and rigidity of respiratory
muscles which can be satisfactorily treated
with naloxone
 Less nausea and vomiting
 Can be used along with droperidol for
neuroleptanalgesia
 Cautious use in patients with COPD, head injury
and patients on MAO inhibitors
 Dose : 1-5 µg/kg IV
 III. Anticholinergic drugs

Three drugs are in use as preanesthetic :

 – Atropine
 – Hyoscine

 – Glycopyrrolate

While the first two are tertiary amines that

cross the BBB, glycopyrrolate is a
quateranry amine which does not cross BBB
and is not absorbed from GI tract
 Doses :
• Atropine 0.3 – 0.4mg IV :
has vagal inhibition, CNS stimulations

• Hyoscine 0.4 mg IV :
more antisialogogue action with less vagal
inhibition and causes sedation and amnesia,
so avoided in elderly patients

• Glycopyrrolate (dose 0.1 – 0.3 mg IV) :

has no central action, longer duration of
action, and less tachycardia
 Clinical effects of
anticholinergics
 Antisialogogue effects : Glycopyrrolate and
hyoscine are more potent than atropine, reduce
secretions and bradycardia after succinylcholine

 Sedative and amnesic effect : In combination

with morphine, hyoscine produces powerful
sedative and amnesia effects

 Prevention of reflex bradycardia : Atropine is

used to prevent oculocardiac reflex in eye surgery
and is used to prevent halothane bradycardia
 Comparitive effects of
anticholinergics :
Atropine Hyoscine Glycopyrrola
te
Antisialogogue + +++ ++
effect
Sedative and + +++ 0
amnesic effects
Central nervous + ++ 0
system toxicity
Relaxation of ++ ++ ++
gastro-
oesophageal
sphincter
Mydriasis and + ++ 0
cycloplegia
Increased heart +++ + ++
rate
 Side effects of
anticholinergics :
 CNS toxicity : Atropine produces central
anticholinergic syndrome of the CNS, producing
restlesness, agitation, somnolence and
convulsions.
Physostigmine 1-2 mg IV reverses the effects
when given with glycopyrrolate
 Reduction in lower oesophageal sphincter
tone
 Tachycardia & Hyperthermia
 Mydriasis and cycloplegia
 Unpleasant and excessive drying of mouth
 IV. Antiemetics
 – Ondansetron
 – Metoclopramide – most commonly
used
 – Phenothiazines – Promethazine
used
Antihistamnies and antiemetics enhance gastric emptying
and are used to prevent nausea, vomiting in patients which is
the single most common factor delaying recovery in patients.
Additional usage includes :
 Sedative property
 Ondansetron
 Highly effective in management of vomiting
related with chemotherapy and radiotherapy
 Used for prevention of PONV in a dose of 4
mg IV
 In children, a dose of 0.1 mg/kg upto 4 mg may
be used in vomiting prone children
 Elimination half life is 3.5 to 4 h in adults
 Side effects include headache, constipation,
diarrhoea, sedation, a sense of flushing, warmth
and so on.
 Metoclopramide
 A new stable, water soluble antiemetic drug used
parenterally, orally and even rectally
 Dose : 0.15 to 0.3 mg/kg IV, effect lasts for 12h
 Increases the rate of gastric emptying, and
causes some increase in peristalsis of gut
 May be used in emergency anesthesia
 Indicated in patients with hiatus hernia, obese,
parturients and duodenal ulcer.
 Acts both centrally and peripherally
 Metoclopramide
• Central Action : Acting as dopamine antagonist, acts
on medullary vomiting center, producing anti-emetic
effect.
• Peripheral Action : Enhances gastric emptying so
that gastric components are passed earlier, preventing
gastric aspiration.
NOTE : Atropine should be withheld until
induction of anesthesia as it blocks effects of
metoclopramide

 Side effects include abdominal cramps following

rapid IV injection, occasional neurological
 V. Prevention of pulmonary
aspiration :
 No drug or combination is absolutely reliable in
preventing the risk of aspiration
 Patients with no apparent risk of aspiration, these
drugs are not recommended
 Cimetidine and Ranitidine are the two drugs in
common clinical use which when used as
premedication may increase the gastric pH higher
than 2.5 and decrease the gastric volume < 25
mL
 Factors predisposing to
aspiration :
 Emergency surgery
 Inadequate anesthesia
 Abdominal pathology
 Obesity
 Opioid premedication
 Neurological deficit
 Lithotomy
 Difficult intubation/airway
 Hiatal hernia
Summary of fasting recommendations to
reduce the risk of pulmonary aspiration :

Ingested material Minimum fasting

period ( hrs)
Clear liquids 2

Breast milk 4

Infant formula 6

Non human milk 6

Light meal (toast and clear liquids) 6

 Reduce the secretion of acid into the stomach
by about 70% by blocking the effect of histamine
on receptors in the stomach wall
 Used for prevention of acid aspiration
syndrome

Ranitidine seems to be better than

cimetidine due to:
 its longer duration of action
 its lower incidences of side effects and drug
interactions
 Doses : Cimetidine – 400 mg (PO)
Ranitidine – 150 mg (PO), 90 to 150
min before induction of anesthesia
 Also effective when given IV 45 to 60 min
before induction, but are unable to influence
acid already present in the stomach, which
depends on gastric emptying

 Oral sodium citrate 15-30 minutes before

induction can also be used for this purpose
 Premedication in pediatric
patient :
 Includes age-specific psychological
preparation and an emphasis on oral
medications when sedation is desired.
 Topical anesthetic creams are often prescribed
for children before cannulation
 A. Psychological factors in pediatric
patients:

1.Age : most important factor in the success of

preoperative visit and interview
2.Children who do not ask questions during
preoperative interview may be masking high
levels of anxiety
3.It may be helpful to have the parents
accompany these children to the operating
room for children who wish to take active part
in anesthesia
 B. Pharmacological preparation
for pediatric patient :
Their use is controversial. (Oral premedication
is preferred for patients without IV access.)
1. Midazolam (0.5 – 0.75 mg/kg) in a flavored
oral preparation produces sedation.
Roohafza, honey etc can be used as effective
flavoring agents. Intranasal midazolam has
faster onset but causes nasal burning.
2. Paracetamol syrup - 5-10mg/kg
10-15mg/kg rectally produces analgesic
effects.
3. Ketamine (5 – 10 mg /kg) prescribed 20 to 30
min before induction facilitates smooth
separation from parents
4. Opiods : In the absence of an IV catheter,
transmucosal administration of fentanyl
(lollipop) is effective in producing sedation.
 Preoperative Surgical Antibiotic
Prophylaxis :
 Indications :
• Contaminated and clean contaminated procedures
• Clean procedures when infection would be catastrophic
(device implants)
• Prevention of endocarditis
• Prevention of infection in immunocompromised patients

 Antibiotic selection :
Cephalosporins (against skin microbes)
Vancomycin (anerobic and gram-negative microbes)
 Timing :
• 1 hour prior to incision
• 2 hours before incision for vancomycin
• Prior to tourniquet inflation
• Redose after two half lives (Cefazolin has half-
life of 2 hours so redose if surgical procedure >
4 hours)

 Beta-Lactam allergy :
Vancomycin or Clindamycin
Preop Medication instruction
guideline :
Medication to be continued on day of
Surgery :
 Anti hypertensive
 Diuretics
 Cardiac medication
 Antidepressant – antianxiety
 Thyroid, asthma medication
 Steroids (oral & inhaled)
 Medications to be discontinued
before surgery :

 Aspirin : * 7 days before surgery

 NSAIDs : * 48 hrs before plastic retinal

surgery
 Oral hypoglycemic drugs : * on the day of

surgery
 Insulin : * 1/3rd dose in morning

 Warfarin : * 4 days before surgery

 Heparin : * 4 – 6 hrs before surgery

 MAO inhibitors : * 2 weeks before surgery

 Conclusion
 Preoperative visit from an anesthesiologist
greatly reduces patient anxiety than preoperative
sedative drugs.
 Children, aged 2–10 years who experience
separation anxiety, may benefit from
premedication
 Patients who will undergo airway surgery or
extensive airway manipulations benefit from
preoperative administration of anticholinergics to
reduce airway secretions before and during
surgery.
S

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