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

 Sedation and anxiolysis  Analgesia and amnesia  Antisialagogue effect 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-- pneumonic

 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

 Anxiety  %  55 % in one study  Counselling  Drugs

 Drug, route  Choose so that the peak action time is at their entry into the operating room

 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

 Oxazepam  Temazepam  Triazolam  Alprazolam

 Sedation  Anticholinergic  Antiemetic  Diphenhydramine – oral dose of 50 mg

 Previous  Morphine and pethidine IM  Now fentanyl IV

 Where we need analgesia  Ortho  IV and arterial lines  Decrease anaesthetic requirements  But respiratory depression, Sphincter of Oddi, PONV – problems

 Popular in ether days  Now only in  Ketamine  Fibreoptic intubation

 Traction of ocular muscles  Second dose of scoline  Propofol, fentanyl, halothane  Atropine and glyco pyrollate  But – problems  central anticholinergic syndrome, tachycardia, blocking sweat glands ??

 Clonidine  in doses of 2.5 to 5 µg/kg – oral  sedation,  prevent hypertension and tachycardia from endotracheal intubation and surgical stimulation  Hypotensive anaesthesia  IM,IV – OK

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

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

 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

 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

 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

 Sedation  Anxiolysis  Antiemesis  Alpha blocker  Anticholinergic

 Steroids  Antibiotics  Insulin  Methadone

 Infective endocarditis prophylaxis  Probable contamination  Immunosupressed  Diabetic  On steroids  Cephalosporin –ok around one hour prior  Vancomycin 2 hours prior  Tourniquet !! Give antibiotics before inflation

 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

 Beta blockers  Thyroxine  Statins  And the other dugs he /she is taking for systemic illness

 Heparin  Warfarin  Clopidogrel  When to use and stop – guidelines are there

 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

 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

 Vagolysis  Anticholinergic  Anxiolysis  Oral/ nasal/SL routes  IM ??

 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

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

 Nasal transmucosal ketamine 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

 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 )

 Goals  Factors  Route  Drugs -- benzo, opioids, anticholinergics, promethazine, clonidine, aspiration,antiemetics others  Paediatric

Thank you all