PERI-OPERATIVE MEDICATIONS

PSYCHOLOGICAL PREMEDICATION:
Pre-operative counseling/interview (surgeon/anesthesiologist)
Many Studies support that support that personal contact is more effective than
educational literature (booklets etc.) or no visit.
Reality is that time and other factors (e.g. patients condition trauma etc). May not
lend themselves to this practice.

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGICAL PREMEDICATION:
- TYPICALLY ADMINISTERED PARENTERALLY (OCC. ORALLY) PRIOR TO
ADMINISTRATION OF ANESTHESIA

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:
GOALS:
- MULTIFACTORIAL!
-Two sets Primary + secondary
-Sumarized as best drug or drug combination to achieve desired goals of
pharmacologic premedication based upon individual surgeon and
anesthesiologist experience, and according to psychological and physiological
condition of patient
-I want to be asleep before being trasnported to the O.R. This is neither
desirable nor safe!

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:
PRIMARY GOALS:
-Anxiety relief anxe.. Or hypnotic
-amnesia antegrade preferred by patient
-Antisialagogue effect drying up secretions, particularly saliva
-Sedation
-Elevation of gastric fluid pH make it less acidic
-reduction of gastric fluid volume
-reduction of anesthetics requirements
-Attenuation of SNS reflexes (prevention of ANS reflexes)
-Prophylaxis against allergic reactions anti histamines

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:

SECONDARY GOALS:
-reduction of cardiac vagal activity (anticholinergics)
-ease of induction of anesthesia
-post-operative analgesia (parenterally administered opiods) patient fear #1
= PAIN!
-prevention of PONV (parenterally administered anti-emetics) Patient fear
#2 PONV

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:
DETERMINANTS OF DRUG CHOICE AND DOSE:
Patient age/weight
Physical status/pre-existing conditions
Allergies/previous adverse experiences with drugs used pre-operatively
allergy hives (very unusual for codine)
ADR - nausea
Level of anxiety
Tolerance for depressant agents
opioid analgesics
have a much higher tolerance for the drugs
Elective or emergency surgery?
In-patient or out-patient surgery?

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:

THE RANGE OF DRUGS USED:

Choice of anesthesia general vs. LMAC (+/- spinal)
Length of procedure
-Many determinants that go into the drug choice etc

-Classes of drugs
Antibiotic
Anti-emetic agents
Anticholinergics agents
H2 receptor antagonists and antacids
Alpha-2 receptro agonists
Hypnotics/sedatives
Opioid analgesics
antihistamines

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:

ANTIBIOTICS:
-obviously no anesthetic agents, but often part of pre-operative medication list!
-Their use is not universal for prophylaxis!!
-surgical care improvement project SCIP A national quality partnership of
organizations committed to improving the safety of surgical care through the
reduction of post-operative complications. (ultimate goal = save lives by 25%
reduction in incidence surgical complications by 2010)
-Several indicators e.g. infection, VTE etc.
-Their use is not universal for prophylaxis !!
-dirty wounds
-contaminated wounds
-implants
-potential dead space surgery
youve cut something out of the body, and leaving a space there
blood fills the area, potential for abscess and antibiotic growth

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:
ANTIBIOTICS:
3 MEASURES RELATE TO PERI-OPERATIVE USE OF ANTIBIOTICS:
-SCIP INF 1 = PROPHYLACTIC ANTIBIOTIC RECIEVIED WITHIN 1
HR. PRIOR TO SURGICAL INCISION
-SCIP INF 2 = PROPHYLACTIC ANTIBIOTIC SELECTION FOR
SURGICAL PATIENTS ( SEE AND KNOW HANDOUT!!)
-SCIP INF 3 = PROPHYLACTIC ANTIBIOTICS DISCONTINUED
WITHIN 24 HRS. OF SURGERY END TIME

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:

ANTIEMETIC AGENTS:
Anticholiergics (muscarinic antagonists)
-Antihistamines
-Histamine/dopamine 2-receptor antagonists, including butyrophenones
-Antipsychotics
-5-hydroxytyptamine receptor antagonists
-steroids

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:

ANTICHOLINERGIC AGENTS:
--Routine use not necessary!
--Most common reasons for use:
-1. antisialigogue effect
-2. sedative and amnesic effects
-3. anti-relfex bradycardic effects

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:

ANTICHOLINERGIC AGENTS:
ANTISIALAGOGUE EFFECT:
-reduction of secretions during general anesthesia (GET vs LMA)
-of particular importance in intra-oral procedures, bronchospcopies
-Not required for LMAC/regional cases!
- Most currently inhaled GAs DO NOT excessively stimulate upper airway/GI
secreta, so use is falling!

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:
ANTICHOLINERGIC AGENTS:
ANTISIALAGOGUE EFFECT:
- Scoplamine (hyoscine) >>>>Atropine! (3x more potent + sedative effects too)
-glycopy..

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:

ANTICHOLINERGIC AGENTS:
SEDATIVE AND AMNESIC EFFECTS:
Scoplamine and atropine = tertiaty amines
Potent ability to cross lipid barriers (CNS)
Scopalamine >>>> atropine (8x more)
Effects enhanced with other sedatives, e.g. opioids etc.
Glycopyrrolate cannot easily cross BBB (quarternay ammonium)

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:

ANTICHOLINERGIC AGENTS:
ANTI-REFLEX BRADYCARDIC EFFECTS:
- REVIEW YOUR PHYSIOLOGY NOTES IF THIS IS A MYSTERY TO
YOU!
- RB is predictable response to elevated B.P.
- Most common agent = atropine (glycopyyrolate ALT)
- Particularly necessary in pediatrics (increased vagal activity/tone)

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:

ANTICHOLINERGIC AGENTS:
UNDESIRABLE SIDE EFFECTS:
- CNS toxicity (central anticholinergic Syndrome)
- Tachycardia
- Lower esophageal sphincter relatxation
- Mydriasis and cycloplegia
- Elevation of body temperature
- Drying of airway secretions
- Too much the pt runs the risk of anelectasis and infection

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:

ANTICHOLINERGIC AGENTS:
UNDESIRABLE SIDE EFFECTS:
CNS TOXICITY:
-delerium/prolonged somnolence after anesthesia
Scopolamin >>Atropine. Not with glycopyrrolate (BBB)
Reversed with physostigmine (15-60 mcg/kg

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:

ANTICHOLINERGIC AGENTS:
UNDESIRABLE SIDE EFFECTS:
TACHYCARDIA:
-Particularly undersirable in pts. With Atrial Fibrillation and mitral stenosis
-Scopolamin/glycopyrrolate << atropine
Note that these drugs also have weakc cholinergic effect
?

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:

ANTICHOLINERGIC AGENTS:
UNDESIRABLE SIDE EFFECTS:
LOWER ESOPHAGEAL SPHINCTER RELAXATION:
-leads to potential for aspiration pneumonitis/gerd
EBM does not support this, however!

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:

ANTICHOLINERGIC AGENTS:
UNDESIRABLE SIDE EFFECTS:
MYDRIASIS AND CYCLOPLEGIA:
-could interfere with drainage of aqueous humor from anterior chamger of eye
-increased risk for glaucoma patient? Drops prn

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:

ANTICHOLINERGIC AGENTS:
UNDESIRABLE SIDE EFFECTS:
ELEVATION OF BODY TEMPERATURE:
-Due to suppression of sweat gland function (cholinergic inervation via SNS)
-Particularly undesirable in pts with elevated BMR (E.G.???)

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:

ANTICHOLINERGIC AGENTS:
UNDESIRABLE SIDE EFFECTS:

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:
H2 RECEPTOR ANTAGONISTS: e.g. CIMETIDINE, RANITIDINE
- Increase gastric fluid pH >2.5 (less risk of aspiration pneumonitis if
inhaling fluid with higher pH)
- Studies show that 40-80% of adults undergoing elective surgery have
gastric fluid pH <2.
- Particular indications for use:
- Parturients (labor)
- GERD
- Obesity
- Anxious patients (
- ANS neuropathy (gastroparesis)
- Cardiovascular (susceptable to silent MI)
- Autonomic neuropathy of the GI (gastroparesis)
- Can be administered P.O or I.V., But use is not routine!

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:

H2 RECEPTOR ANTAGONISTS: e.g. CIMETIDINE, RANITIDINE

-not 100% effective !

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:

H2 RECEPTOR ANTAGONISTS: e.g. CIMETIDINE, RANITIDINE

-Ranitidine may be better to prevent A. P. in cases > 3 hrs. .

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:

H2 RECEPTOR ANTAGONISTS:
SIDE EFFECTS: (CIMETIDINE > RANITIDINE) (used to treat stomach
ulcer)

-Mild CNS sedation

-Decreased hepatic blood flow and therefore hepatic function (anesthetic
drugs, e.g. amids, propanolol, succynil choline, Beta blockers)
-Increased airway resistance (unapposed H1 receptor mediated
Bronchoconstriction) So what??
-Make it more diificult to intubate a pt
-Cardiac dysrhythymias

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:

H2 RECEPTOR ANTAGONISTS:
SUMMARY:

-These drugs are not substitutes for good anesthetic technique (cuffed
Endotracheal tube/ prevention of aspiration etc.)

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:
ANTACIDS: e.g. SODIUM CITRATE
Nearly 100% effective in elevating gastric pH (if administered up to 3 mins.
Prior to induction)
-primary advantage of H2 antagonists = no lag time associated at time of
administration
Cause increase in gastric volume
May delay gastric emptying (i.e. more time needed

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:

METOCLOPRAMIDE: D2 Receptor agonist (TEST QUESTION)

Accelerates gastric emptying (relaxes pyloric sphincter and increases upper GI
motility) = note atropine will negate this effect!

May decrease gastric Volume (.

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:

METOCLOPRAMIDE:
SIDE EFFECTS: THE GOOD, BAD AND UGLY!
-Mild anti-emetic effect (Dopamin AGONISM Good!
-Abdominal cramping if admin..
-..
-..

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:

ALPHA 2 AGONISTS: e.g. CLONIDINE

-primary use is to attenuate ANS reflex responses, e.g.:
-increase BP
-increase HR
-Therefore useful in surgical trauma and intubation

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:

HYPNOTICS & SEDATIVES:

Benaodiazepines
Barbiturate
Btyrophenones
opioids

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:

HYPNOTICS & SEDATIVES:

BENZODIAZEPINES: Potency: Iorazepam > Midazolam > Diazepam
USES:
-antegrade amnestic effects while producing minimal sedation/
cardiopulmonary depression (e.g. Lorazepam, midazolam)
-anti-anxiety effects, particularly night before surgery (e.g. Diazepam,
Flurazepam, Temazepam, Triazolam)

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:
HYPNOTICS & SEDATIVES:
BENZODIAZEPINES:
USES:

So loazepam is good!

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:

HYPNOTICS & SEDATIVES:

BENZODIAZEPINES:
DISADVANTAGES:
-atypical prolonged sedation (some patients)
-Long half-lifes, related to active metabolites (primarily diazepam) 20-35 hrs.
-potential other drug interactions, e.g. diazepam with cimetidine (delayed
clearance of diazepam for blood stream) . Less likely with newer agents

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:

HYPNOTICS & SEDATIVES:

BUTYROPHENONES: e.g. DROPERIDOL
USES:
Antiemesis (for high risk procedures for PONV Ophth/Gyne)
Sedation

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:

HYPNOTICS & SEDATIVES:

BUTYROPHENONES: e.g. DROPERIDOL
DISADVANTAGES: MANY!
-Dysphoria/fear of death/ refusal of procedure
-Extra-pyramidal (dopaminergic receptor blockade)
-Given at end of procedure to prevent PONV

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:

HYPNOTICS & SEDATIVES:

OPIOIDS: e.g. morphine, meperidine,
USES:
-Analgesia/sedation (esp. useful if invasive procedures need to be done as part of anesthetic plan,
e.g. spinal, insertion of monitors, e.g. Swan Ganz catheter etc.)
-Minimal increases in HR as a result of surgical stimulation
-Note that sedative effects are minimal; analgesia predominates!
-In general, potentiated by antihistamines (anti H1)

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:

HYPNOTICS & SEDATIVES:

OPIOIDS:
DISADVANTAGES:
- Respiratory depression (medulla oblongata)

- Othostatic hypotension (peripheral SM relaxation)

- PONV (CTZ stimulation) note role of recumbency!
- Smooth muscle constriction: - urinary retention, choleduchocuodenal
sphincter spasm, constipation
- Pruritis (itching?)

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:

ANTIHISTAMINES: MANY AGENTS! PROMETHAZINE IS VERY

COMMON!
USES: e.g. hydroxyaine, dipenhydramine, chloral hydrate

-Sedation (weak)

-Antiemesis
-Prophylaxis (allergic reactions)

PERI-OPERATIVE MEDICATIONS
PHARMACOLOGIC PREMEDICATION:

ANTIHISTAMINES: MANY AGENTS! PROMETHAZINE IS VERY

COMMON!
DISADVANTAGES:

Drowsiness

PERI-OPERATIVE MEDICATIONS
FASTING BEFORE ELECTIVE SURGERY:

FOR ELECTIVE SURGERY: NPO (non per os) after MN

-Minimizes gastric volume at time of induction
-keep in mind that even with NPO status, complete gastric emptying cannot
be guaranteed: - foods pass through stomach @ undpredictable rates
- water and crystalloids have a 50% GET of 12-20 mins
- liquid boluses (150mls.) may stimulate peristalsis and GET
-relevance for p.o. medications prior to surgery?
e.g. usual a.m. medicaitons with sip water p.o
pre-operative .

PERI-OPERATIVE MEDICATIONS
FASTING BEFORE ELECTIVE SURGERY:
FOR ELECTIVE SURGERY: NPO (non per os) after MN
Caution with pts. At known risk for slower GETs :
- DM
- obese
- other GI disease
- certain drugs including opioids!

PERI-OPERATIVE MEDICATIONS
FASTING BEFORE ELECTIVE SURGERY:

FOR EMERGENT SURGERY: NPO asap!

-if truly life-threatening (i.e. not foot/ankle surgery usually!), anti-emetic and
H2 antagonist should be given

PED vs MV
THE CAR WON!
AND THE PT.
LIVED!

PERI-OPERATIVE MEDICATIONS
RECOMMENDED PRE-OPERATIVE MEDICATION FOR ADULTS
BEFORE ELECTIVE SURGERY:

Timing is key for pre-operative administration:

- pt. interview by anesthesiologist night before sx.
- BDZ (p.o) night before sx. For insomnia
- BDS (p.o) 1-2 hrs. pre-op + 150 mls H20 (increases G.E.)
(or use opioid instead of BDZ this will delay G.E.)
-
- ..
- ..
- ..

PERI-OPERATIVE MEDICATIONS
RECOMMENDED PRE-OPERATIVE MEDICATION FOR ADULTS
BEFORE ELECTIVE SURGERY:
DRUGS THAT :
-decrease vagal activity (atropine/glycopyrrolate)
Protect against PNV (e.g. droperidol)
Provide post-operative analgesia
Should be administered I.V. at a time just preceding desired effect

PERI-OPERATIVE MEDICATIONS
RECOMMENDED PRE-OPERATIVE MEDICATION FOR PEDIATRIC
PATIENTS BEFORE ELECTIVE SURGERY:
Like adults, medication should be tailored to unique requirements of each
child
Age is also important pre-schoolers suffer most from separation anxiety (<1
yr old is less problematic)
- Parents may need to accompany child to O.R. (parent attitude/behavior is
also important
- In general, P.o. >> i.v. / i.m. But exceptions, e.g:
- Barbiturate p.r.
- Atropine i.v. (immediately prior to induction
- Use of flavored masks