PRE ANAESTHETIC

MEDICATION

JASMINA KV
FINAL YEAR PART II
 CONTENTS

Introduction
Basic plan of preanesthetic preparation
Patient counseling
Premedication
Objectives of premedication
Premedication drug
Premedication for outpatient dental surgery
Premedication for Major Maxillofacial Surgery
Premedication for children
Preoperative instructions
Concurrent medication
Other instructions
 INTRODUCTION

Preoperative preparation is the beginning of

anesthetic process . A good or adequate Preoperative
preparation improves clinical outcomes , increase
patient’s satisfaction and helps to reduce events
subsequently .
BASIC PLAN OF PREANESTHETIC
PREPARATION

The basic plan of preoperative preparation is as

follows:
 Patient’s counseling or psychological preparation
 Premedication
 Preoperative instructions for:

- Fasting guidelines
- Guidelines for administration of current
medication or pre-existing drug therapy .
 PATIENT COUNSELING

Good psychological preparation is often as

effective as pharmacological preparation. Majority of the
patients undergoing surgical procedures have high levels of
apprehension and anxiety. During preoperative visit all the
anticipated surgical events, risks and limitations, benefits and
alternatives of anesthetic procedure should be discussed with
the patient and his relatives.
 PREMEDICATION
Premedication can be defined as ‘preliminary medication’,
drugs with specific pharmacological actions, administered
preoperatively with specific goals to achieve .
1.Selection and dosage of the premedication drugs will depend on the
following:
a. Age of the patient.
b. Weight of the patient.
c. Physical status and type of anesthesia used.
2. Timing of the premedication is decided depending on initial onset, peak
effect and duration of action and the route of administration .
 Objectives of Premedication 10A’s
10A’s
Anxiolysis
Analgesia
Amnesia of perioperative events
Antisialagogue effect
Antiemetic effect
Antacid usage
Allergies
Antiautonomic parasympathetic /
sympathetic reflexes care
Objectives of Premedication
Relief of apprehension or anxiety
or sedation
Smooth induction of G A
Anterograde amnesia
Reduction of salivary and bronchial
secretion
Prevention of nausea and vomiting
Reduction of stomach acidity and
volume
Prophylaxis
Vagolytic action
PREMEDICANT DRUGS
Benzodiazepines:
Action
• sedation
• amnesia
• excellent anxiolysis (but no analgesia)
Adverse effect
• agitation
• restlessness.
• respiratory depression

.
 Midazolam:
Action
• Sedative
• Anxiolytic
• Excellent amnestic .
Dosage
• Intramuscular : 0.07-0.15mg/kg
• Intravenous- 0.03-0.05mg/kg
• Intranasal-0.3-0.4mg/kg
• Oral:sublingual-0.5-0.7mg/kg
• Rectal-0.5-0.75mg/kg

When given intramuscularly, the onset of action is seen within 5 to 10

minutes, with peak effect seen in 30 to 60 minutes.
 Diazepam:
It is considered as “gold standard” with which other drugs are usually compared.

Action
• Anxiolytic
• Amnestic
• Sedative
Ninety percent of the oral dose is absorbed in 30 to 60 minutes in adults
and 15 to 30 minutes in children
Dosage
• Oral- 0.2-0.5mg/kg
• Intravenous-0.04-0.1mg/kg
Contraindication
• Elderly or patients with deranged liver functions,cirrhosis
• Patients with chronic liver failure/low serum albumin
• Children below 12years .
Flumazenil:
Action
• sedative

• amnestic

Dose is 0.1 to 0.5 mg. It is a short-acting drug and

requires to be given in infusion form.
Other sedative and hypnotic agents

Barbiturates:
e.g. secobarbital-dose 50 to 200 gm orally
pentobarbital dose 50 to 200 gm orally
Butyrophenones:
Dose IV or IM 2.5 to 7.5 mg
Phenothiazine:
They are always used with opioid analgesic agents.
Commonly used drugs in this group
promethazine
perphenazine
chlorpromazine
“Lytic cocktail” once popular combination for dental
anesthesia, consisted of
50 mg pethidine
25 mg promethazine
10 mg chlorpromazine. With advent of new drugs
this combination is now abandoned .
Promethazine
Dose:10 to 25 mg orally in similar doses given IM or IV.
Action :antisialagogue, antihistaminic and sedative effect.

Trimeperazine tartrate
Dose : 3 to 4 mg/kg 2 hours preoperatively

Diphenhydramine:
Dose : 50 mg orally.
 ANALGESIC AGENTS

OPIODS
Action: sedative and analgesic action rather than anxiolytic.
euphoria
Adverse effect:
Respiratory depression,
Postoperative nausea and vomiting
Cardiovascular depression.
Spasm of sphincter of Oddi, rapidly lead to upper quadrant pain.
Flushing, dizziness and miosis (pupillary constriction).
Morphine:
• Morphine is well absorbed after IM injection with onset of
analgesia after 15 to 30 minutes
• Peak effects are seen in 45 to 90 minutes,with analgesia
lasting for 4 hours.
• Morphine may cause orthostatic hypotension, pruritus,
respiratory depression, nausea and vomiting. It is habit
forming and addictive drug.
Fentanyl:
It is 50 to 125 times more potent than morphine.
Dose : 1 to 2 μgm/kg.
Onset : 30 to 60 seconds
Duration of action :30 to 60 minutes
It can be used intranasally, orally and also transdermally as patches.
Pethidine
Dose : 50 to 100 mg IM/IV.
Duration of action : 2 to 4 hour
Buprenorphine:
Dose: 3 to 6 μgm/kg, IM/IV.
ANTICHOLINERGIC AGENTS

Anticholinergic agents used for premedication include atropine,

glycopyrrolate and scopolamine. Actions common to
anticholinergic agents are:

1. Vagolytic effects
2. Antisialagogue actions
3. Sedation and amnesia
 Vagolytic effects
• Atropine, glycopyrolate and scopolamine increase heart
rate by blocking acetylcholine action on muscarinic
receptors in SA node
• Atropine is more effective than glycopyrrolate and
scopolamine in increasing heart rate and is very useful in
preventing intraoperative bradycardias resulting from
vagal stimulation or stimulation of carotid sinus.
Antisialagogue actions:
• It includes drying of salivary, gastric, tracheobronchial
and secretions of sweat glands.
• Glycopyrrolate is more potent and longer-acting drying
agent and is less likely to increase heart rate.
• Scopolamine is more effective antisialagogue than
atropine.
• All three drugs take about 20 to 30 minutes for drying
action. Hence, should be given 30 minutes prior to
planned procedure.
Sedation and amnesia
• Scopolamine has good amnesic and sedative action.
• In elderly subjects, it is better to use glycopyrrolate instead of
atropine.
Side effects
1. Pupillary dilatation and cycloplegia. This could be harmful in glaucoma
patients.
2. Tachycardia and cardiac arrhythmias.
3. Delirium, confusion, and restlessness.
4. Inspissations of existing secretions in trachea and bronchi.
5. Increase in body temperature.
Dose: Atropine—0.12 mg/kg.
Glycopyrrolate—0.044 mg/kg.
Aspiration Prophylaxis
• Used to alter gastric pH and fluid volume.
• Drugs include:
Histamine receptor (H2 receptor) blocking agents,
Gastrokinetic drugs
Antacid
Anticholinergic drugs
Histamine receptor blocking agents

• Cimetidine, ranitidine and famotidine are the commonly used H2

receptor blockers.
• These drugs raise the gastric pH by blocking histamine-mediated
secretions of gastric hydrogen ion.
• The drug regimen started night before surgery is usually more
effective in raising gastric pH than single dose preoperatively, on
the day of surgery. As with most of the drugs, parenteral
administration produces more rapid onset of action than the oral
route.
Doses
Cimetidine (adult dose): 150 to 300 mg orally or parenterally
60 to 90 minutes prior to surgery and repeated 8 hourly.
Ranitidine (adult dose):
50 to 100 mg orally, 50 to 100 mg parenterally, on the night before
surgery and 1 hour prior to surgery. Action lasts for about 9 to 10
hours.
Famotidine:
40 mg at bedtime and 40 mg on the morning of surgery. Onset
occurs in 1 hour and persists for 10 to 12 hours. The drug is
administered orally.
Gastrokinetic drugs (Metoclopramide):

• It is a dopamine antagonist, that stimulates upper GI motility,

increases gastroesophageal sphincter tone and relaxes pylorus and
duodenum.
• It has been shown to reduce gastric fluid volume and reduce risk of
aspiration.
• At times it can precipitate extrapyramidal reactions.
• Also rapid injection can cause abdominal cramping.

Dose:
Orally 10 mg 30 to 60 minutes prior to surgery. Parenterally 5 to
20 mg given over 3 to 5 minutes, 15 to 30 minutes prior to surgery
Antacids:
• These are used to neutralize the pH of gastric fluid already present in
stomach.
• A single dose of clear antacid given 15 to 30 minutes prior to anesthesia is
effective in raising gastric fluid pH above 2.5.
• 30 ml of 0.3 mg sodium citrate solution is commonly used for this purpose.
• Indicated conditions include :
obesity
pregnancy
diabetic patients
alcoholics
patients on long term steroid therapy
ascites
hiatus hernia
patients with history of gastroesophageal reflux, etc.
Antiemetics:
• For major maxillofacial surgeries, it is advisable to give
antiemetics as during surgical procedure, some amount of
blood enters stomach that can irritate the stomach mucosa and
induce vomiting postoperatively.
• The drugs used as antiemetics include, droperidol,
metoclopromide, phenothiazine like prochlorperazine and
ondansetron. Prochlorperazine is the most common.
• Phenothiazine is used to prevent nausea and vomiting.
• Ondansetron is given 4mgm IV or 8mgm orally or IV
preoperatively. The effect lasts for 4 to 8 hours.
Premedication for Outpatient Dental Surgery

• All patients need to receive anticholinergic agent either atropine

or glycopyrrolate 30 minutes prior to the procedure and
diazepam 0.25 mg/kg orally on night before surgery to reduce
anxiety.
• For short procedure under local anesthesia, diazepam can be
given orally in similar doses 60 to 90 minutes prior to the
procedure to allay anxiety.
• For procedures which require longer periods of drilling, etc.
instead of diazepam, midazolam may be given (0.05 to 0.1
mg/kg) IM 30 minutes prior to surgery.
• If patient is already in pain, then preoperatively pethidine (1.5
mg/kg), fentanyl 100 mg, pentazocine 0.5 to 0.6 mg/kg may be
added to midazolam. But this does delay the recovery time.
Premedication for Major Maxillofacial Surgery

• Along with atropine or glycopyrrolate, pethidine and

promethazine (50 + 25 mg) should be given 30 minutes
prior to surgery.
• Instead of pethidine, pentazocine or buprenorphine (3
mg to 6 mg/kg) or fentanyl may be given.
Promethazine helps in drying secretions, sedation and
act as antiemetic. It also prevents histamine release
after opioids.
Premedication for Children

• Anticholinergic premedication becomes mandatory.

• But most of the children have fears or phobias of needle
pricks. So, syrup trimaperazine or promethazine or midazolam
intranasally or orally (0.6mg/kg) should be given.
• Once sedated, anticholinergic agents should be given IM/IV.
Ketamine hydrochloride is also a popular drug for children.
But, it is mainly used as sedative.
Preoperative Instructions

Fasting Guidelines
 Clear fluids: Apple juice, coconut water, water, tea and coffee
without milk.
 Nonclear fluids: Milk (breast milk, formula milk), orange
juice, etc.
Concurrent Medication or Pre-existing
Drug Therapy
Antihypertensive
• All antihypertensive except monamine oxidase(MAO)
inhibitors should be continued till the day of surgery.
• The usual morning dose should be given with sip of
water and postoperatively as soon as orals would be
resumed.
• Sudden withdrawal of these drugs can precipitate
hypertensive episode during preoperative period.
Angina prophylaxis:
• These drugs should also be continued in
perioperative period. Or else, it can precipitate
ischemic episode.
• If oral route is not available, transdermal patch of
glyceryl trinitrate is to be placed on chest wall or
forehead. Effect usually lasts for almost 24 hours.
 Psychotropic drugs :
• Major tranquilizer and tricyclic antidepressants have
anticholinergic side effect. In the presence of catecholamines and
under anesthesia, they potentiate ventricular tachyarrhythmias.
Also, sudden withdrawal can precipitate severe reactions. Hence
the drugs to be continued till the day of surgery with extreme
caution in mind.Avoid adrenaline in local infiltration.
• Lithium is known to potentiate action of muscle relaxants used in
anesthesia. They should be omitted 48 to 72 hours prior to
surgery. Patients should be shifted on some other drugs on
consultation with psychiatrist.
• MAO inhibitors also should be discontinued 2 to 3 weeks before
surgery. They adversely react with opioid analgesics and can give
rise to cardiovascular instability.These patients too, should be
shifted on some other drugs on consultation with psychiatrist.
 Antiparkinsonism drugs
• Drugs like levadopa, potentiates Ventricular
arrhythmias. Hence, it is prudent to omit these drugs 24
hours prior to surgery.
• If stopped for longer period, there would be
reappearance of Parkinson symptoms and there is
definite risk of aspiration. So, the drugs need to be
restarted as soon as possible in postoperative period.

Anticonvulsants
• These drugs also to be continued till the day of surgery.
• Sudden withdrawal of drugs can precipitate convulsions
in postoperative period.
 Alcohol: It should be stopped prior to surgery.
There is possibility of acute alcohol withdrawal
symptoms in postoperative period. Patients should
be given good dose of benzodiazepine sedation.
Antidiabetic or hypoglycemic agents: All oral
antidiabetic drugs to be stopped on the day of
surgery. Restarted as soon as patient switches back
to orals. If oral route is not available, patient should
be switched over to crystalline insulin and managed
on ‘sliding scale.’
In case of insulin dependent diabetic,
morning dose to be omitted and managed on
‘sliding scale’ with intravenous insulin, on
consultation with physician.
 Antituberculous therapy: Aminoglycosides
potentiate action of muscle relaxants. These drugs to be
omitted on the day of surgery, to be restarted in
postoperative period.

Antibiotics: All antibiotics can safely be given.

Steroids: Long term steroid therapy calls for replacement

during anesthesia, either with short-acting hydrocortisone or
long-acting dexamethasone

Contraceptive pills and other hormones:

Ideally, estrogen containing pills should be stopped at least 4
weeks before major elective procedure. But for minor surgery,
routine of contraceptive pills need not be disturbed.
Hormone replacement therapy (HRT):
The hormones content of these pills are very
low. It does not require any alteration in schedule
of this drug.
Progesterone (Postponement) pill:
Needs no alteration in schedule of this
Other Instructions
Smoking: Ideally should be stopped 4 to 6 weeks
prior to the surgery to decrease the incidence of
postoperative pulmonary complications.
Dentures: Chances of aspiration of loose dentures
or slipping from the position can cause obstruction
of the airway
 Cosmetics: Lipsticks, nail varnishes and other cosmetics
may interfere with observation of cyanosis or pallor and may
also interfere with estimation of oxygen saturation. Patients
are instructed to defer their use.
Artificial limbs: Should be removed as metal component
of the artificial limb may induce electrical burns.
Artificial eyes and contact lenses: Dislodgements can
cause corneal abrasions or injury to surrounding delicate
structures of eye. Removal is a must.
Hearing aids: Should be kept in place so as to maintain
effective communication with the patient.
Emptying the bladder: Prior to surgery, ensure that the
patient‘s bladder is emptied. Patient should be accompanied
by a responsible adult, who will also escort him home,
specially important in ambulatory surgery
REFERENCE
 TEXTBOOK OF ORAL AND MAXILLOFACIAL SURGERY
-NEELIMA ANIL MALIK
 INTERNET
THANK YOU