Premedication

Benzodiazepines Benzodiazepines produce anterograde amnesia in addition to anxiolysis with minimal sedative effects. Note that benzodiazepines may interfere with the release of cortisol during stressful situations [Kay et. al. Anesth Analg 79: 501, 1994; Arvat et. al. J Endocrinol Invest 25: 735, 2002]. Opiates were initially thought to be an important component of preemptive analgesia, but it turns out that they may sensitize patients to pain [Chu et. al. Clin J Pain 24: 479, 2008]. Clonidine may provide preemptive analgesia, at least when given epidurally. Relative Contraindications to Depressant Premedication Newborn (< 1 year of age) Elderly Decreased level of consciousness Intracranial pathology Severe pulmonary disease Hypovolemia

Antihistamines Antihistamines are occasionally used for their sedative and anti-emetic properties, however beware as promethazine now carries an FDA warning re: apnea and death in children. Diphenhydramine (25-50 mg PO) can be given as prophylaxis for allergic reactions (atopy, dye studies), and should be administered in conjunction with an H2-antagonist (ex. famotidine). Prednisone 50 mg PO may also be added Clonidine

Clonidine, in addition to possibly providing preemptive analgesia when given epidurally, can decrease the incidence of MI [Quintin et. al. Anesth Analg 83: 687, 1996], while also decreasing MAC (in one study, 56 children were randomized to 4 ucg/kg 100 min prior to sevo induction vs. no clonidine, and MAC was reduced from 2.00% to 1.33% [Nishina et. al. Paediatr Anaesth 16: 834, 2006]). Possible side effects of clonidine include bradycardia and dry mouth. Antiemetics Popular antiemetics include ondansetron, dexamethasone, droperidol, metoclopramide, and perphenazine. Disadvantages of routine use include cost and possible orthostatic hypotension Anticholinergics Anticholinergics should not be administered routinely, but rather to produce an antisialogogue effect, sedation/amnesia, or prevent reflex bradycardia. Scopolamine has outstanding antisialogogue properties and produces sedation. Glycopyrrolate (quatenary amine) produces slightly less antisialogogue effect but does not produce sedation as it can't cross the BBB. Atropine is the worst in terms of secretions, and also crosses the BBB. Atropine and scopolamine can produce a central anticholinergic syndrome, which can only be treated with physostigmine, 1-2 mg IV (neostigmine and pyridostigmine do not pass into the CNS). Only atropine can reliably produce an increase in heart rate (in fact, the most common cardiac response to IM glyco or scopolamine is bradycardia, presumably due to a weak cholinergic agonist effect) GI Medication Routine use of H2 blockers is not recommended [Warner et. al. Anesthesiology 90: 896, 1999] but may be a consideration in patients at risk for aspiration (morbidly obese, parturients, GERD, anticipated difficult airway). In elective surgeries, the risk of aspiration is low enough that the cost of routine H2 blockers is not justified [Warner et. al. Anesthesiology 78: 56, 1993]. Furthermore, these drugs do not always work [White PF Anesth Analg 65: 963, 1986] and do not alter the pH of fluid already present Antacids given 15-30 minutes prior to surgery are, by contrast, nearly 100% effective at raising gastric pH to > 2.5. Nonparticulate antacids such as sodium citrate are key as they do not cause pulmonary complications if aspirated. The theoretical

tradeoff for sodium citrate is that gastric volume is actually increased, however data from rats showed that 0.3 cc/kg of aspirate with pH < 1.0 carried a mortality rate of 90%, whereas 1-2 cc/kg of aspirate with a pH > 1.8 carried a mortality rate of 14% [James et. al. Anesth Analg 63: 665, 1984]. Thus, antacids should never be withheld based on volume. Metoclopramide (or cisapride) may be considered as well, although erythromycin may be a better pro-motility agent, as it is an antibiotic as well. It may be particularly useful for emergency cases, and in one case study 100 mg IV 80 minutes before surgery (with 30 cc sodium citrate 30 minutes prior) led to complete gastric emptying (EGD confirmed) in a 56 kg boy [Kopp et. al. Anesthesiology 87: 703, 1997]. Reglan begins working within 1-3 minutes, but may be attenuated by anticholinergics, opioids, or antacids. Keep in mind that complete gastric emptying is an impossibility. Solid food can take up to 12 hours, whereas clear liquids have a 50% emptying time of 12-20 minutes. Fears that ingestion of clear fluids within 2 hours of induction will increase gastric volume significantly are probably unfounded [Warner et. al. Anesthesiology 90: 896, 1999 FREE Full-text at Anesthesiology]. It is acceptable to administer medications with up to 150 cc of water one hour prior to induction. Preoperative (1600 - 2400 the day before) oral nutrition with 800 cc of a carbohydrate-rich beverage does not appear to increase gastric fluid volume or acidity and may reduce insulin resistance postoperatively [Hausel et. al. Br J Surg 92: 415, 2005]. Aspiration occurs in only 1:3200 anesthetics but is associated with 10-30% of all anesthesia-related deaths [Pisegna et. al. J Clin Gastro 39: 10, 2005].

Intravenous Anesthetics Barbituates (H&A) -Thiopental -Methohexital -Thiamylal Benzodiazepin es (H&A) -Diazepam

Onset 30-40 sec

Elimination -10-12 hrs - 3-6 hrs

Pharmicokinetics Redistribution

Advantages/ Use Rapid onset Fast recovery Anesthesia for short procedures. Relative rapid onset Minimal resp and CV

Disadvantages No analgesia Alkaline/Tissue Irritant. Resp & CV depression Low TI OD risk Not a good analgesic Cant produce surgical

3-5 min

-20-40 hrs -2-6 hrs

Demethelated in the Liver. (prolonged t1/2 with cirrosis, etc)

-Midazolam -Lorazepam Dissociative (H&A) -Ketamine -2-3 hrs

depression Preanesthetic Intense analgesia and amnesia Radiological procedures in children, Bronchodilato r Large volume of distribution, highly lipophilic Prevents N/V, quick recovery

analgesia

Dissociative anesthesia (II) unpleasant recovery w/ hallucinations and nightmares

Miscellaneous (H&A) -Etomidate -Propofol

1 min 40-50 sec

4-8hrs 3-6hrs

Hypotension, cv depression, requires mechanical ventilation, discoloration of urine (green) Dose related cardiac depression. Meperidinecardiac depression

Opioids (A) -Morphine -Fentanyl -Meperidine (Demerol) -Sufentanyl

2-7 hrs 3-4 hrs 2-4 hrs

Minimal CV effects at normal dosages

Morgan GE, Mikail MS, Murray MJ. Clinical Anesthesiology McGraw Hill Medical. 2005 Glidden RS. NMS Anesthesiology. Lippincott Williams & Wilkins. 2003.

Drug Name Generic (Trade)

Adult Dose

Onset of Duration Action of Action

Advantages

Cautions

Etomidate (Amidate) 0.3 mg/kg IV push (normal adult dose about 20 mg)

0.5-1 min

3-5 min

Does not alter hemodynamics Commonly causes myoclonus; or intracranial pressure (ICP); no histamine release; generally does not induce apnea; useful for patients pain upon injection; adrenal suppression with multiple trauma and (typically no clinical significance); hypotension (does not alter systemic BP) does not suppress sympathetic response to laryngoscopy; nausea;

vomiting;

lowers seizure threshold;

does not provide analgesia

Ketamine (Ketalar)

1-2 mg/kg slow 0.5-1 IV push (not to min exceed 0.5 mg/kg/min)

5-10 min

Bronchodilatory effects advantageous if hypotension or lung disease present (leaves airway and other protective reflexes intact); rarely used in adults

Reported to increase ICP (avoid with head injury); hallucinations; increases sympathetic tone, potent cerebral vasodilation, cardiovascular stimulation (do not use with ischemic heart disease); emergence delirium common, but more of a concern when used for conscious sedation with painful procedures (approximately 12%) in adults < 65 y

Propofol (Diprivan)

2-3 mg/kg IV push

< 1 min 3-10 min

Provides rapid onset and Causes cardiovascular depression and brief duration; hypotension; respiratory depression is dosecerebroprotective (decreases dependent ICP); amnestic properties; extremely potent

Decrease dose if patient unstable

ASA Physical Status (PS) Classification System* ASA PS Category Preoperative ASA PS 1 Health Status Normal healthy patient Comments, Examples No organic, physiologic, or psychiatric disturbance; excludes the very young and very old; healthy with good exercise tolerance No functional limitations; has a well-controlled disease of one body system; controlled hypertension or diabetes without systemic effects, cigarette smoking without chronic obstructive pulmonary disease (COPD); mild obesity, pregnancy Some functional limitation; has a controlled disease of more than one body system or one major system; no immediate danger of death; controlled congestive heart failure (CHF), stable angina, old heart attack, poorly controlled hypertension, morbid obesity, chronic renal failure; bronchospastic disease with intermittent Has at least one severe disease that is poorly controlled or at end stage; possible risk of death; unstable angina, symptomatic COPD, symptomatic CHF, hepatorenal failure Not expected to survive > 24 hours without surgery; imminent risk of death; multiorgan failure, sepsis syndrome with hemodynamic instability, hypothermia, poorly controlled coagulopathy

ASA PS 2

Patients with mild systemic disease

ASA PS 3

Patients with severe systemic disease

symptoms ASA PS 4

Patients with severe systemic disease that is a constant threat to life

ASA PS 5

Moribund patients who are not expected to survive without the operation

ASA PS 6 A

declared brain-dead patient who organs are being removed for donor purposes

*ASA PS classifications from the American Society of Anesthesiologist

American Society of Anesthesiologists, 1995 ALDRETE SCORE CARD ALDRETE SCORE Able to move 4 extremities voluntarily or on command = 2 Able to move 2 extremities voluntarily or on command = 1 Able to move 0 extremities voluntarily or on command = 0 Able to deep breathe and cough freely = 2 Dyspnea or limited breathing =1 Apneic =0 BP" 20% of Preanesthetic level = 2 BP" 20-50% of Preanesthetic level = 1 BP" 50% of Preanesthetic level = 0 Fully Awake = 2 Arousable on calling = 1 Not responding = 0 Pink = 2 Pale, dusky blotchy, jaundiced, other = 1 Cyanotic = 0 ACTIVITY

RESPIRATION CIRCULATION

CONSCIOUSNESS

COLOR

Nadi normal BBL 1 12 BL 1 2 TH 3 6 TH 7 12 TH REMAJA DEWASA 120 160 80 140 80 130 75 120 75 110 60 100 60 100 140 120 110 100 95 80 80

* Reference: Pediatrics - Harriet Lane - Mosby Year Book, Inc. 1991 Adult - AHFS-95 Drug Information - American Hospital Formulary Service ASHSP - Inc., packages inserts, Micromede Adult Diazepam (Valium) Lorazepam Midazolam (Versed) Morphine Meperidine (Demerol) Fentanyl Sufentinil 2 mg to 10 mg 0.05 mg/kg(maximum dose 4mg) 0.07 mg to 0.08 mg/kg(maximum dose 2.5 mg) 0.025 to 0.2 mg/kg 1 to 1.5 mg/kg 1 mcg to 2 mcg/kg 0.1 to 0.2 mcg/kg Pediatric 0.25 mg/kg 0.03 - 0.05 mg/kg 0.035 mg/kg 0.05 to 0.2 mg/kg 1 to 2 mg/kg 1 mcg to 2 mcg/kg 0.1 to 0.2 mcg/kg