Premedication
Syed Raashid Andrabi
GOALS
• To relieve anxiety
• To produce haemodynamic stability.
• To induce sedation.
• To produce analgesia and amnesia.
• To decrease chances of aspiration.
• To control oral and respiratory secretion.
• To prevent PONV
• To control infection
To Decrease anxiety and
fear
• The best way to do this is by non-
pharmacological means
• Psychotherapy
• Assure the patient
• Explain about anesthesia
To Decrease anxiety and produce
sedation
• Benzodiazepines most commonly used
drugs.
• Most frequently drugs used
• Lorazepam
• Midazolam
To produce hemodynamic
stability
• Clonidine was recommended for
hypertensive patient in past but not
used now a days.
• It produces dry mouth and bradycardia.
• It is providing analgesia when given
epidurally .
• It can decrease the chnces of MI.
To provide analgesia
• Opioids are given intra-venously just before
induction to provide analgesia.
• Naturally occurring –morphine ,codeine,thebaine
• Semi- synthetic –
heroin,Dihydromorphine,oxymorphine,Pentamorp
hine
• Synthyetic-
Buterophenol,Levorphenol,pentazocine,Pethidine
,Fentanyl,alfentanil,sufentanil,remifentanil,Tram
adol,Buprenomorphine,
To decrease chances of
aspiration
• Patient should be fasting for 8 hrs for solid
food and 3-4 hrs for clrear fluids which
include water and juices without pulp.
• Tea and coffee are considered as unclear
fluids For children-6-8 hrs for solid food
and 2-3 hrs of fasting for clear fluids is
consideres as sufficient.
• For infants-fasting for 3-4 hrs and 2 hrs for
water is sufficient.
• Current recommendations for
gastricprokinetics –
Metclopromide ,rantidine should be
employed only for patients who are at
high risk aspiration.
To control oral and
respiratory secretion
• Anticholinergics-
Atropine,Glycopirolate,Scopolamine .
• Anticholinergics can cause dry mouth which
can be troublesome to patients therefore
they should be used only when required.
• Glycopyrrolate is a pref erred
anticholinergic over atropine and
scopolamine because it does not crosses the
blood-brain barrier
To prevent PONV
• Hyoscine
• Ondansetron/Granisteron/Dolasteron
• Metclopromide
To control infection:
• The timing of antibiotic should be adjusted so that
the peak blood levels are achieved at the time of
skin incision. Therefore,antibiotic prophylaxis must
be given within 60 minutes before skin incision.
• Vancomycin is used to treat infections caused by
bacteria
Antisialagogues
• Glycopyrrolate injection is used before and during
surgery to lessen mouth, throat, or stomach
secretion (eg, saliva, stomach acid).
• Glycopyrrolate is an anticholinergic medication. It
works by blocking the activity of a chemical
messenger (acetylcholine) in the brain.
• Glycopyrrolate(selective peripheral action)
acts rapidly, longer acting, potent antisecretory
agent, prevents vagal bradycardia effectively.
• Atropine is a prescription medicine used
to treat the symptoms of low heart rate
(bradycardia), reduce salivation and
bronchial secretions before surgery or
as an antidote for overdose of
cholinergic drugs or poisoning.
Atropine may cause serious
side effects including:
• fast heart rate,
• high pressure in the eye (glaucoma),
• abdominal blockage (pyloric
obstruction),
• worsening urinary retention, and
• mucus in your airways
common side effects of
Atropine include:
• Dry mouth,
• Blurred vision,
• Sensitivity to light,
• Lack of sweating,
• Dizziness,
• Nausea,
• Loss of balance,
• Hypersensitivity reactions (skin rash), and
• rapid heartrate
Lorazepam
• It is a new benzodiazepine drug.
• It is an effective tranquilizing drug ,decreases
anxiety, fear & tension.
• it is a sedative and amnesic.
• The drug is absorbed in GIT tract and other
body tissues.
• It is twice potent than midazolam.
• It is mostly used for patients undergoing
lengthy procedures.
• It is less lipophilic.
• Premedication
• Adults: 0.05 mg/kg (3.5 mg for an average 70 kg man).
• Acute anxiety
• Adults: 0.025-0.03 mg/kg
• Patients with renal or hepatic impairment
• Lower doses may be sufficient in these patients
Contraindications
• Hypersensitivity to the active substance.
• Sleep apnea syndrome.(serious sleeping disorder in
which breathing repeatedly stops & starts)
• Myasthenia gravis. (A weakness and rapid fatigue of
muscles under voluntary control caused by
breakdown communication between nerves and
muscles).
• Severe hepatic insufficiency.(loss of liver function)
• Lorazepam 4 mg/ml solution for injection is not
recommended for out-patient use unless the patient is
accompanied
• The elimination half-life is about 12-16 hours when
given intramuscularly or intravenously
Complications
• Drowsiness
• Blurred vision
• Confusion
• Decrease urine output
• Dry mouth
• Convulsion
• Dark urine
• Fatigue
Midazolam
• It is three times potent than diazepam.
• It decreases anxiety, fear & tension.
• it is a sedative and amnesic.
• Clear, colorless to pale yellow solution with a pH
in the range of 2.9 - 3.7.
• Midazolam is a short acting sleep-inducing active
substance.
• Adults below the age of 60
• 1-2 mg i.v. given 5 to 10 minutes before the
beginning of the procedure.
• Adults over 60 years of age
• chronically ill patients, the dose must be reduced
to 0.5-1.0 mg and given 5-10 minutes before the
beginning of the procedure.
Contraindications
• Hypersensitivity to Midazolm
• Severe respiratory insufficiency or acute
respiratory depression.
Advantages
• Water based preparation ,so injection
will be painless.
• Elimination half life is 2- 3 hrs
• Reversal with flumazenil
Complications
• Incidence of apnea
• Respiratory depression
• Hypotension
Diazepam
• Diazepam is an anxiolytic, anticonvulsant and
central muscle-relaxant.
• Diazepam is used to relieve anxiety and provide
sedation in severe acute anxiety or agitation
patients.
• Preparation is oil based ,so injection is painful.
• Elimination half is prolonged 30-60hrs
• Usual Adult Dose for Muscle Spasm
• ORAL: 2 to 10 mg orally 3 to 4 times a day
• PARENTERAL: 5 to 10 mg IM or IV, then 5 to 10
mg IM or IV in 3 to 4 hours if necessary.
• Usual Adult Dose for Seizures
• ORAL: 2 to 10 mg orally 2 to 4 times a day
RECTAL:
• Initial dose: 0.2 mg/kg
• Usual Adult Dose for Endoscopy or Radiology Premedication
• PARENTERAL:
Cardioversion: 5 to 15 mg IV once 5 to 10 minutes before the
procedure
Endoscopic Procedures:
IV: Usually less than 10 mg
• Usual Adult Dose for Light Anesthesia
• PARENTERAL:
Preoperative Medication: 10 mg IM once before surgery
• Usual Geriatric Dose for Seizures
• ORAL:
• Initial dose: 2 to 2.5 mg orally once to 2 times a
day
• RECTAL:
Initial dose: 0.2 mg/kg rectally
• Usual Geriatric Dose for Muscle Spasm
• ORAL:
• Initial dose: 2 to 2.5 mg orally once to 2 times a
• Usual Pediatric Dose for Seizures
• ORAL:
6 months and older:
Initial dose: 1 to 2.5 mg orally 3 to 4 times a day
• RECTAL:
2 to 5 years:
Initial dose: 0.5 mg/kg rectally,
• 6 to 11 years:
Initial dose: 0.3 mg/kg rectally
• 12 years and older:
Initial dose: 0.2 mg/kg rectally
Phenergan
• Phenergan is a prescription medicine used to treat
the symptoms of allergic conditions, nausea,
vomiting, motion sickness, pre- and post-operative
sedation as well as obstetric sedation.
• Phenergan belongs to a class of drugs called
Antihistamines, 1st Generation, Antiemetic Agents.
Phenergan
• It may cause serious side effects including:
• severe drowsiness,
• weak or shallow breathing,
• confusion,
• agitation,
• Nightmares,
• seizures (convulsions),
• fast or slow heartbeats,
• fever,
• chills,
• sore throat,
• mouth sores,
• red or swollen gums,
• very stiff or rigid muscles,
• high fever,
• sweating,
DOSAGE AND
ADMINISTRATION
• Phenergan (Promethazine HCl) Suppositories are contraindicated for
children under 2 years of age
• Allergy
• The average dose is 25 mg
• Motion Sickness
• The average adult dose is 25 mg taken twice daily
• Nausea And Vomiting
• Pre- And Postoperative Use
• 12.5- to 25-mg doses for children and 50-mg doses for adults the
night before surgery produces a quiet sleep.
CHLORO -PROMAZINE
• Thorazine is a prescription medicine used to
treat the symptoms of
Schizophrenia, Psychotic Disorders, nausea
and vomiting, anxiety before
surgery, intraoperative sedation etc.
• Thorazine may be used alone or with other
medications.
Serious side effects
• uncontrolled muscle movements in your face,
• stiffness in your neck,
• tightness in your throat,
• trouble breathing or swallowing,
• lightheadedness,
• confusion,
• agitation,
• feeling jittery,
• trouble sleeping
• weakness,
• breast swelling or discharge,
• convulsions (seizure),
• yellowing of the skin or eyes (jaundice),
• fever,
• chills,
• mouth sores,
• skin sores,
• sore throat,
• cough,
• very stiff (rigid) muscles,
• high fever,
• sweating,
• confusion,
• fast or uneven heartbeats, and
• tremors
DOSAGE
• Adults
• The 100 mg and 200 mg tablets are for use in severe
neuropsychiatric conditions.
• Psychotic Disorders — Increase dosage gradually until
symptoms are controlled.
• Acute schizophrenic— I.M.: 25 mg If necessary, give
additional 25 to 50 mg injection in 1 hour. Increase
subsequent I.M. doses gradually over several days
• Nausea and vomiting — oral: 10 to 25 mg
• Intractable hiccups — oral: 25 to 50 mg
• Thorazine (chlorpromazine) should generally not
be used in pediatric patients under 6 months
• Severe behavioral problems — Outpatients—
select route of administration according to severity
of patient's condition and increase dosage
gradually as required. Oral: 1 / 4 mg/ body weight
• Nausea and Vomiting —
• Dosage and frequency of administration should be
adjusted according to the severity of the symptoms
and response of the patient.
• The duration of activity
following intramuscular administration may last up to
12 hours. Subsequent doses may be given by the same
route if necessary.
•
• Oral: 1 / 4 mg/ bodyweight
• Rectal: 1 / 2 mg/body weight
• When given I.V., dilute to at least 1 mg/mL and
administer at rate of 1 mg per 2 minutes.
Triclofos
• Triclofos is a hypnotic.
• It is converted in the body into an active
compound which works in the brain to induce
sleepiness.
• It decreases the time taken to fall asleep and
increases sleep duration.
Side effects
• nausea and vomiting
• Drowsiness
• Abdominal pain
• Decreased appetite
• Headache
• Spinning sensation
• Confusion
• Skin rash
• Diarrhea
Contra-indications of
Triclofos
• Hepatic impairment
• Renal impairment
• Cardiac failure
Dose
• 30-50 mg / kg /bw
