PRE - MEDICATION

DR OKUNOLA O.T
DEPT OF FAMILY MEDICINE
5/10/22
OUTLINE

INTRODUCTION
GOAL OF PREMEDICATION
PHARMACOLOGICAL PREMEDICATIONS
IDEAL PREMEDICANT DRUG
GROUP OF PREMEDICANT
IMPORTANCE AND SIDE EFFECTS
CONCLUSION
 PHARMACOLOGICAL PREMEDICATIONS

 Pre-medication is the administration of drugs before

induction of anaesthesia.
 Premedication is usually given 1-2 hours preoperatively
before induction of anaesthesia
 They can be taken within 2 hours prior to surgery with
sips of water (<30 ml)

 GOALS OF PREMEDICATION

 Reduction of anxiety

 Promotion of amnesia.

 Adequate Analgesia

 Reduction of secretions.

 Reduction of volume and pH of gastric contents

 Reduction of postoperative  nausea and vomiting.

 Facilitate induction of anesthesia.

 Reduction of vagal reflexes to  intubation.

IDEAL PREMEDICANT DRUG

Anxiolytic
Analgesic
Sedative
Amnesic
Safe for patient
Painless during administration
Highly specific
Rapid onset and rapidly cleared
ROUTES OF ADMINISTRATION

 Oral
 Intramuscular
 Intravenous
 Intranasal
 Dermal
 Topical
RECENT PRACTICE OF PREMEDICATION

 The practice of premedication has changed

substantially in recent years.
 The use of strongly sedative drugs,
e.g. morphine and hyoscine, to aid smooth
induction and reduce salivation has been abandoned
with advent of modern intravenous and inhalational
anesthetic agents, with fewer side-effects
and faster action
 The choice of drugs used for premedication depends on
the procedure, patient and anesthetic technique.

 Some patients prefer not to have premedication.

ANXIOLYTICS/ SEDATIVES/HYPNOTICS

Benzodiazepines
.e.g
,diazepam
,midazolam
lorazepam
This drugs also have amnestic effect

Barbiturates
Pentobarbital

Promethazine
BENZODIAZEPINES

Produce anxiolysis, amnesia and sedation 

Act predominantly on GABA receptors in CNS 
Minimal respiratory depression 
Doesn’t cause nausea and vomiting 
Cross placenta barrier and may cause neonatal 
depression
Diazepam

It is a long acting benzodiazepine 

Cn be used as a sole agent in bronchoscopy and 

also as an adjunct in LA
Cirrhosis of the liver leads to up to fivefold 
increase in elimination half life
Dose as a premedicant 
mg orally 0.25-0.5 
0.25mg IM 
Lorazepam

A new and effective sedative, amnesic,anxiolytic 

It has stabilizing effects on cardiovascular and 
respiratory systems
Twice as potent as Midazolam 
Dose for premedication
Oral- 50mcg/kg ,Not more than 4mg (can be given
90mins before anaesthesia
0.03-0.05mg/kg IM
Midazolam

Midazolam is a water soluble benzodiazepine 

Amnesic effects are more potent than sedative effects 
Choice of drug for outpatient surgery and paediatric 
premedication
Capable of crossing the blood brain barrier with 
effects ranging from tranquilization to full
anaesthesia
There is little or no change in ICP with Midazolam 
Midazolam

Usual dose range of 0.15-0.3mg/kg (IV)

In children it is useful as premedication (30 minutes)
preoperatively at
oral dose of 0.5mg/kg
Intranasal Midazolam 0.3mg/kg(quicker
onset of action than oral)
Bromazepam

Can be used as a premedicant in patients with

severe anxiety
Has similar side effects as diazepam
Usually taken orally
comes in 1.5mg and 3.0mg tablets
Has elimination half life of 12-20hrs
Relative contraindications to sedative
premedications

Newborn< 1year
Decreased level of consciousness
Severe pulmonary pathology
Hypovolemia
Airway obstruction
Severe hepatic and renal disease
Analgesics
OPIOIDS
 morphine

 pethidine

 fentanyl citrate.

NSAIDS
• Ketorolac

• Diclofenac
Morphine

An opium alkaloid and a standard potent addictive

analgesic
Causes constipation and urinary retention
Depresses the respiration
Passes through the placenta barrier
Tolerance occur to morphine
Dose 0.1mg/kg
Fentanyl

Potent narcotic analgesics, 100 times more potent than morphine

with rapid onset of action and short duration of action

Metabolised in the liver and excreted through the kidney

Causes respiratory depression which can be treated with

naloxone

Dose- 1mcg/kg
:NOTE
Opioids should be cautiously used in patients with
COPD
Head injury
MAO inhibitor use
Pregnancy
Liver and kidney pathology
Aspiration- risk factors

Extremes of age
Emergency case
Type of surgery
Recent meal
Trauma
Pregnancy
Pain and stress
Depressed level of conciousness
Morbid obesity
Difficult airway
 PREVENTION

FASTING

Reduce gastric volume,increase gastric pH

H2 receptor antagonist-Eg Ranitidine

Proton pump inhibitor- Omeprazole
Antacid

Increase gastric motility

Prokinetic drugs-Metoclopromide
 ANTIEMETICS PROPHYLAXIS

Metoclopramide- commonlyused as antiemetic and

prokinetic agents prior to surgery

Domperidone 10mg oral more preferred

Phenothiazines- Promethazine
Ondasetron

/Highly effective in managing chemotherapy

radiotherapy related vomiting
Dose
4mg IV found effective in preventing post anaesthetic
nausea and vomiting
 METOCLOPRAMIDE

A stable, water soluble antiemetic drug used

parenterally ,orally, and rectally
Its act as a prokinetic agent increasing the gastric emptying
.and peristaltic movement of the gut
Dose 0.15 to 0.3mg/kg IV
Adult dose of 10mg
METOCLOPRAMIDE

MECHANISM OF ACTION
Peripherally -enhancing the stimulatory effects of
acetylcholine on intestinal smooth muscle,
metoclopramide increases lower esophageal sphincter
tone, speeds emptying, and lowers gastric fluid
volume
Centrally -Metoclopramide produces antiemetic effect
by blocking dopamine receptors in the chemoreceptor
trigger zone of the central nervous system
Drugs reducing acid secretions

Ranitidine and Cimetidine are drugs that reduces risk of

gastric regurgitation and aspiration pneumonia

Proton pump inhibitors like Omeprazole are preferred

nowadays

These drugs increases the gastric pH and reduces the

gastric volume
Anticholinergics

Decreases salivary gland and mucosal glands

secretion

GLYCPOPYROLLATE (potent antisecretory)

ATROPINE
SCOPOLAMINlE
 Glycopyrrolate
Glycopyrrolate is a synthetic product that differs from
.atropine in being a quaternary amine compound
The usual dose of glycopyrrolate is one-half that of
.atropine
The premedication dose is 0.005 to 0.01 mg/kg up to 0.2
.to 0.3 mg in adults
Glycopyrrolate for injection is packaged as a solution of
.0.2 mg/mL
Atropine

Atropine is a tertiary amine

As a premedication, atropine is administered
intravenously or intramuscularly in a range of 0.01 to
,0.02 mg/kg
.Adult dose of 0.4 to 0.6 mg
.This provides an antisialagogue effect
Larger intravenous doses up to 2 mg may be required to
completely block the cardiac vagal nerve in treating
.severe bradycardia
Side effects of anticholinergics

CNS toxicity: Atropine produces central anticholinergic

syndrome of the CNS,producing
restlessness,agitation,somnolence and convulsions
Physiostigminie 1-2mg IV reverses the effects when
given with glycopyrolate
Reduction in lower oesophageal sphincter tone
Tachycardia and hyperthermia
Cycloplegia and Mydriasis
Unpleasant Dry mouth
Conclusion

Reducing the morbidity of surgery

-Increasing the quality and decreasing the cost of peri

operative care

To return patient to desirable functioning as quickly as

possible

Preoperative medical optimization significantly reduces the

post op complications
THANK YOU
References

Clinical anaesthesiology Morgan &Millers

www.anaesthesiajounrnal.co.uk