Preoperative Medications Goals of Pre-op Medication

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Preoperative Medications Goals of Pre-op Medication

  1. 1. Preoperative Medications
  2. 2. Goals of Pre-op Medication <ul><li>Optimize physical condition </li></ul><ul><li>Relief of anxiety </li></ul><ul><li>Relief of pain </li></ul><ul><li>Amnesia </li></ul><ul><li>Facilitate induction </li></ul>
  3. 3. Goals (con’t) <ul><li>Facilitate smooth operative course </li></ul><ul><li>Facilitate smooth wake-up </li></ul><ul><li>Antiemetic effect </li></ul><ul><li>Prophylaxis against aspiration </li></ul>
  4. 4. Psychological Preparation <ul><li>Pre-op visit lays the foundation </li></ul><ul><ul><li>Trust and confidence are essential </li></ul></ul><ul><ul><li>Be efficient, informative and reassuring </li></ul></ul><ul><ul><li>More effective than sedatives </li></ul></ul>
  5. 5. Psychological Prep (con’t) <ul><li>All patients have some anxiety </li></ul><ul><ul><li>May be outwardly calm, inwardly terrified </li></ul></ul><ul><li>Patients on sedatives have more anxiety </li></ul>
  6. 6. Preoperative Medication <ul><li>Should be individualized </li></ul><ul><li>Give for specific indications </li></ul><ul><li>Monitoring should be appropriate </li></ul>
  7. 7. Contraindications to Sedation <ul><li>Poor physiologic reserve </li></ul><ul><li>Extremes of age </li></ul><ul><li>Head injury </li></ul><ul><li>Hypovolemia </li></ul>
  8. 8. Routes of Administration <ul><li>Oral (60-90 minutes) </li></ul><ul><li>Intramuscular (30-60 minutes) </li></ul><ul><li>Intravenous </li></ul><ul><li>Rectal </li></ul><ul><li>Nasal </li></ul><ul><li>Dermal </li></ul>
  9. 9. Specific Drugs and Dosages <ul><li>Know drugs in each class </li></ul><ul><li>Know characteristics of class </li></ul>
  10. 10. Benzodiazepines <ul><li>Anxiolysis </li></ul><ul><li>Amnesia </li></ul><ul><li>Sedation </li></ul><ul><li>Anti-convulsant </li></ul><ul><li>All effects are dose-dependent </li></ul>
  11. 11. Benzodiazepines <ul><li>Minimal respiratory depression </li></ul><ul><li>Minimal cardiovascular depression </li></ul><ul><li>Work well with opioids </li></ul><ul><li>Few side effects </li></ul>
  12. 12. CNS Action <ul><li>Sedation </li></ul><ul><ul><li>Enhancement of GABA </li></ul></ul><ul><li>Anxiolytic </li></ul><ul><ul><li>Glycine mediated inhibition of brain stem </li></ul></ul><ul><li>Amnesia </li></ul><ul><ul><li>Unknown mechanism </li></ul></ul>
  13. 13. Specific Benzodiazepines <ul><li>Diazepam (standard) </li></ul><ul><ul><li>Pain on injection </li></ul></ul><ul><ul><li>Active metabolites </li></ul></ul><ul><ul><li>Good anticonvulsant </li></ul></ul><ul><ul><li>Used as P.O.. pre-op </li></ul></ul>
  14. 14. Specific Benzodiazepines (con’t) <ul><li>Lorazepam </li></ul><ul><ul><li>Slow onset, long duration </li></ul></ul><ul><ul><li>Profound amnesia </li></ul></ul><ul><ul><li>Not good for outpatients </li></ul></ul>
  15. 15. Specific Benzodiazepines (con’t) <ul><li>Midazolam </li></ul><ul><ul><li>No irritation or phlebitis </li></ul></ul><ul><ul><li>2-3x potent as diazepam </li></ul></ul><ul><ul><li>Rapid onset, rapid metabolism </li></ul></ul><ul><ul><li>Excellent short-term amnesia </li></ul></ul><ul><ul><li>Given IV prior to surgery </li></ul></ul><ul><ul><li>Given P.O.. to children </li></ul></ul>
  16. 16. Barbiturates <ul><li>Sedative </li></ul><ul><li>Dose dependent respiratory depression </li></ul><ul><li>Less safe than benzodiazepines </li></ul><ul><li>Do not give to patients with porphyria </li></ul>
  17. 17. Butyrophenones (Droperidol) <ul><li>Dopamine antagonist </li></ul><ul><li>Appear calm and tranquil </li></ul><ul><ul><li>Inner terror is reported </li></ul></ul><ul><ul><li>High rate for refusing surgery </li></ul></ul><ul><li>Alpha blockade </li></ul><ul><li>Excellent anti-emetic </li></ul>
  18. 18. Other Sedatives <ul><li>Hydroxyzine </li></ul><ul><ul><li>Used to augment opioids </li></ul></ul><ul><li>Diphenhydramine </li></ul><ul><ul><li>Histamine blocker </li></ul></ul><ul><ul><li>Sedative and anticholiergic </li></ul></ul>
  19. 19. Other Sedatives (con’t) <ul><li>Phenothiazines </li></ul><ul><ul><li>Used to augment opioids </li></ul></ul><ul><li>Chloral hydrate </li></ul><ul><ul><li>P.O.. pre-op for elderly patients </li></ul></ul>
  20. 20. Opioids <ul><li>Produce analgesia </li></ul><ul><li>Useful prior to painful procedure </li></ul><ul><li>Establish baseline analgesia </li></ul><ul><li>Reduce anesthetic requirements </li></ul><ul><li>Comfort upon awakening </li></ul><ul><li>Work well with sedatives </li></ul>
  21. 21. Problems with Opioids <ul><li>Respiratory depression </li></ul><ul><li>Orthostatic hypertension </li></ul><ul><li>Histamine release (morphine) </li></ul><ul><li>Shift in CO 2 response curve </li></ul>
  22. 22. Problems with Opioids (con’t) <ul><li>Occasional dysphoria </li></ul><ul><li>Nausea and vomiting </li></ul><ul><li>Pruritus </li></ul><ul><li>Sphincter of Oddi spasm </li></ul>
  23. 23. Opioid Premedication <ul><li>Usually given IV in holding area </li></ul><ul><ul><li>Monitor pulse oximetry </li></ul></ul><ul><li>Fentanyl lollipop </li></ul><ul><li>Nasal sufentanil </li></ul><ul><li>Oral codeine </li></ul>
  24. 24. Prophylaxis for Aspiration <ul><li>Who is at risk? </li></ul><ul><li>Full stomach (all emergencies) </li></ul><ul><li>Pregnancy </li></ul><ul><li>Obesity </li></ul><ul><li>Diabetes </li></ul><ul><li>Hiatal hernia / reflux </li></ul>
  25. 25. Prophylaxis / Aspiration (con’t) <ul><li>Critical values </li></ul><ul><ul><li>Volume > 25 ml. </li></ul></ul><ul><ul><li>pH < 2.5 </li></ul></ul>
  26. 26. Prophylaxis / Aspiration (con’t) <ul><li>NPO Guidelines </li></ul><ul><ul><li>NPO after midnight </li></ul></ul><ul><ul><ul><li>Tradition of strict enforcement </li></ul></ul></ul><ul><ul><ul><li>Now being challenged </li></ul></ul></ul><ul><ul><ul><li>Clear liquids may be o.k. </li></ul></ul></ul><ul><ul><ul><li>Dehydration and hypoglycemia </li></ul></ul></ul>
  27. 27. Pharmacologic Preparation <ul><li>Reduce gastric volume </li></ul><ul><li>Increase gastric pH </li></ul><ul><li>Increase gastric motility </li></ul>
  28. 28. Anticholinergics <ul><li>Atropine / Robinul </li></ul><ul><li>Probably not effective </li></ul><ul><li>Relax lower esophageal tone </li></ul><ul><li>Have CV side effects </li></ul>
  29. 29. Histamine-Receptor Antagonists <ul><li>Cimetidine / Ranitidine </li></ul><ul><li>Reduce gastric acid secretion </li></ul><ul><ul><li>Increase gastric pH </li></ul></ul><ul><li>Few side effects </li></ul><ul><li>Give H.S. and A.M.. </li></ul>
  30. 30. Histamine Receptor Antagonists (con’t) <ul><li>Cimetidine </li></ul><ul><ul><li>Slows metabolism of other drugs </li></ul></ul><ul><li>Ranitidine </li></ul><ul><ul><li>More effective </li></ul></ul><ul><ul><li>Does not alter hepatic function </li></ul></ul>
  31. 31. Antacids <ul><li>Neutralize stomach acids </li></ul><ul><li>Onset is rapid </li></ul><ul><li>Increase gastric volume </li></ul><ul><ul><li>Antacid can be aspirated </li></ul></ul><ul><li>Use only non-particulate antacids </li></ul>
  32. 32. Metoclopramide <ul><li>Gastrokinetic agent </li></ul><ul><ul><li>Increases upper GI motility </li></ul></ul><ul><ul><li>Increases G.E. sphincter tone </li></ul></ul><ul><ul><li>Relaxes pyloris and duodenum </li></ul></ul>
  33. 33. Metoclopramide (con’t) <ul><li>Has antiemetic properties </li></ul><ul><li>May be offset by atropine or opioids </li></ul><ul><li>Combine with H 2 antagonist </li></ul><ul><li>Do not use on bowel cases </li></ul>
  34. 34. Antiemetics <ul><li>Emesis is cause for admission </li></ul><ul><ul><li>Treatment is cost effective </li></ul></ul><ul><li>Treat high risk patients </li></ul><ul><ul><li>History of N and V </li></ul></ul><ul><ul><li>Ophthalmologic surgery </li></ul></ul><ul><ul><li>Gyn procedures </li></ul></ul><ul><ul><li>Obesity </li></ul></ul>
  35. 35. Antiemetics (con’t) <ul><li>Droperidol </li></ul><ul><ul><li>Effective in low dose </li></ul></ul><ul><li>Metoclopramide </li></ul><ul><ul><li>Antiemetic effect in addition to reduction in gastric volume </li></ul></ul>
  36. 36. Antiemetics (con’t) <ul><li>Ondansetron </li></ul><ul><ul><li>Highly effective new drug </li></ul></ul><ul><ul><li>Very expensive </li></ul></ul><ul><ul><li>Good rescue drug </li></ul></ul>
  37. 37. Anticholinergics <ul><li>Antisialagogue </li></ul><ul><ul><li>Glycopyrrolate </li></ul></ul><ul><ul><li>Ophthalmic procedures </li></ul></ul><ul><ul><li>ENT procedures </li></ul></ul><ul><li>Vagolytic effect </li></ul><ul><ul><li>Atropine </li></ul></ul>
  38. 38. Anticholinergics (con’t) <ul><li>Sedation and amnesia </li></ul><ul><ul><li>Scopolamine </li></ul></ul><ul><li>See Barash for side effects </li></ul>
  39. 39. Clonidine <ul><li>Antihypertensive </li></ul><ul><ul><li>Alpha-2 blocker </li></ul></ul><ul><li>Produces sedation </li></ul><ul><li>Reduces anesthetic requirements </li></ul><ul><li>Acute withdrawal causes rebound </li></ul>
  40. 40. Other Pre-op Medications <ul><li>Antibiotics </li></ul><ul><ul><li>Ordered by surgeon </li></ul></ul><ul><ul><li>Protocol for valvular heart disease </li></ul></ul><ul><ul><li>Give slowly </li></ul></ul>
  41. 41. Other Preop Medications (con’t) <ul><li>Steroids </li></ul><ul><ul><li>Adrenals may be suppressed up to one year after taking steroids </li></ul></ul><ul><ul><li>Hydrocortisone 100 mg IV </li></ul></ul>
  42. 42. Other Preop Medications (con’t) <ul><li>Insulin </li></ul><ul><ul><li>Agree on plan prior to surgery </li></ul></ul><ul><ul><li>Always start IV with dextrose prior to giving insulin </li></ul></ul>
  43. 43. Other Preop Medications (con’t) <ul><li>Insulin (con’t) </li></ul><ul><ul><li>Treatment plans </li></ul></ul><ul><ul><ul><li>No insulin </li></ul></ul></ul><ul><ul><ul><li>1/2 dose of insulin </li></ul></ul></ul><ul><ul><ul><li>Insulin infusion </li></ul></ul></ul>
  44. 44. Pediatric Considerations <ul><li>Always approach a child as if you will have to do him/her again </li></ul><ul><li>Use oral medication where possible </li></ul><ul><li>Consider needs of the parent </li></ul>
  45. 45. Small Infants <ul><li>Separation not a problem </li></ul><ul><li>High vagal tone </li></ul><ul><ul><li>Consider anticholinergic </li></ul></ul>
  46. 46. Preschool Children <ul><li>Separation extremely traumatic </li></ul><ul><li>Use oral premedication </li></ul><ul><ul><li>Versed </li></ul></ul><ul><ul><li>Fentanyl </li></ul></ul><ul><li>Anticholinergic after asleep </li></ul><ul><li>Avoid cyclobrutane </li></ul>
  47. 47. Older Children <ul><li>Assess level of anxiety </li></ul><ul><li>Include in decision making </li></ul><ul><li>Premedicate as appropriate </li></ul><ul><li>Pre-op visit extremely important </li></ul>

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