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

2.  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

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

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

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

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

7.  Oxazepam  Temazepam  Triazolam  Alprazolam

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

9.  Previous  Morphine and pethidine IM  Now fentanyl IV

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

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

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

13.  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

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

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

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

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

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

19.  Sedation  Anxiolysis  Antiemesis  Alpha blocker  Anticholinergic

20.  Steroids  Antibiotics  Insulin  Methadone

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

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

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

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

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

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

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

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

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

32.  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

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 )

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

37. Thank you all