Pengelolahan operasi dimulai dengan persiapan operasi dengan preoperasi fisik pasien dan pemilihan obat-obatan yang spesifik

sebagai komponen managemen anastesi sebagai obat sebelum operasi. Idealnya, semua pasien harus bebas dari periode preoperatif seperti kecemasan, sedasi tetapi mudah ....... Dan sepenuhnya kooperatif. Table 13-17 Primary Goals of Pharmacologic premedication - Relief anxiety - Sedation - Amnesia - Antisialagogue effect - increase in gastric fluid PH - decrease in gastric fluid volume - Attenuation of sympathetic nervous system reflex responses - decrease in anesthetic requirements - prophylaxis againt allergic reactions Table 13-18 Secondary Goals of Pharmacologic Premedication Decrease in cardiac vagal activity-- better achieved with the intravenous injection of an anticholinergic (atropine) just before the time of anticipated need Facilitation of induction of anesthesia -- not necesary in view of the availability of potent intravenous induction dregs Postoperative analgesia -- better achieved with neuraxial opioids or the painful surgical stimulus (preemptive analgesia) and/ or just before awakening Prevention of postoperative nausea and vomiting -- better achieved with the intravenous injection af an antiemetic just before awakening versus withholding treatment and treating the symptoms if necessary Table 13-19 Drugs and dDose Used for Pharmacologic Premedication before Induction of Anesthesia* Classification Drug Thypical Adult Dose Route of (mg) Administration Benzodiazepines Midazolam 1 - 2,5 IV Diazepam 5 - 10 Orally, IV Lorazepam 0,5 - 2 Orally, IV Opioids Morphine 5 - 15 IV Fentanyl 25 - 100 g IV Antihistamines Diphenhydramine 12,5 - 25 Orally, IV 2 - Agonists clonidine 0,1 - 0,3 Orally, Transdermal** Antiemetics Droperidol 1,25 IV Dolasetron 12,5 IV Ondansentron 4 IV Anticholinergics Atropin 0,3 - 0,6 IV

H2 antagonists

Antacids Proton pump inhibitors Gatrointestinal stimulants * Doses are to be titrated to patient's condition age ** 24 hours for full effect

Glycopyrrolate Cimetidine Ranitidine Famotidine Nonparticulate Omeprazole Pantoprazole Metoclopramide

0,1 200 - 300 150 20 - 40 15 - 30 mL 20 40 10

IV Orally Orally Orally Orally Orally IV Orally, IV

Table 13 - 20 Determinats of Drug Choice and Dose Patients age and weight Physical Status Level of anxiety Tolerance of depressant drugs Previous adverse experience with drugs used for preoperative medication Allergies Elective or emergency surgery Inpatient or outpatient surgery Table 13-21 Is Depressant Pharmacologic Premedication Indicated? No Yes Newborn (<1 year of age) Cardiac surgery Elderly Cancer surgery Decreased level of consciousness Coenxisting pain Intracranial pathology Regional anesthesia Severe pulmonary disease Hypovolemia Table 13-22 Comparative Effect of Anticolinergics Administered Intramusculary as Pharmacologic Premdication Atropine Scopolamine Glycopyrroplate Antisialagogue + +++ ++ Sedative and amnesic effect + +++ 0 Central nervous system toxicity + ++ 0 Relaxation of lower esophageal ++ ++ ++ sphincter Mydriasis and Cycloplegia + +++ 0

Table 13-23 Undesirable Side Effects of Anticholinergics Central nervous system toxicity Tachycardia Relaxation of the lower esophageal sphincter Mydriasis and cycloplegia Increase in body temperature Drying of airway secretions Increased physiologic dead space