Done by : Dr.

Mahmoud al-Mustafa
Osama Noubani
Pre operative medications
• Many drugs are routinely administered by
anesthesiologists perioperatively to protect
against aspiration pneumonitis, to reduce the
incidence of nausea and vomiting, Relief
anxiety, amnesia, analgesia and to reduce
anesthetic requirements
 Aspiration
• Aspiration of gastric contents is a rare,
potentially fatal event that can complicate
anesthesia.
• Based on an animal study, it is often stated that
aspiration of 25 mL of volume at a pH of less
than 2.5 will be sufficient to produce
aspiration pneumonia.
Risk factors:
• Full stomach
• Intestinal obstruction
• Hiatal hernia
• Obesity
• Pregnancy
• Reflux disease
• Emergency surgery
• Inadequate depth of anesthesia
• Many approaches are employed to reduce the
potential for aspiration perioperatively.
• Sellick's maneuver: (cricoid pressure): Brian
Arthur Sellick (1918–1996)was a British
anesthesiologist. He was known for cricoid
pressure he described in 1961.
Risks
• Cricoid cartilage fracture
• Airway obstruction
• Esophageal rupture in situations of rapid
increase in gastric pressure (i.e., vomiting)
• Cervical spine or laryngeal trauma when
significant manipulation of the head occurs.
Histamine Receptor blockers
• Clinical uses:
• Suppression of allergic reactions and
symptoms of URTI (eg, urticaria,
rhinitis,conjunctivitis)
• Vertigo, nausea, and vomiting (eg,motion
sickness, Ménière’s disease)
• Sedation, suppression of cough
 H2 receptor antagonists
These agents competitively inhibit histamine binding to H2 receptors,
thereby reducing gastric acid output and raising gastric pH
Clinical uses:
• Treatment of peptic ulcer disease
• Decrease gastric PH (ZE syndrome).
• Prevention of stress ulceration in critically ill patients.
• By decreasing gastric fluid volume and hydrogen ion content, H2
blockers reduce the perioperative risk of aspiration pneumonia.
These drugs affect the pH of only those gastric secretions that occur
after their administration.
• H2 blockers should be given at bed time and
again 2hrs prior to surgery
• Dose adjustment in patients with significant
renal impairment
Side effects:
• Rapid IV injection of cimetidine has been found
to cause hypotenstion, bradyarrhythmias,
cardiac arrest in critically ill patients.
• Cimetidine was also found to cause
hepatotoxicity, interstitial nephritis,
granulocytopenia, thrombocytopenia.
• Changes in mental status in elderly patients, and
may cause seizures.
• Drug interactions:
Cimetidine binds CYTP450 and thus slows the
metabolism of some drugs: lidocaine,
warfarin, phenytoin, phenobarbital..

Ranitidine is a weak inhibitor and famotidine,

nizatidine don't affect the enzyme)
 Antacids
Mechanism of action:
• Antacids neutralize the acidity of gastric fluid by providing
a base (usually hydroxide, carbonate, bicarbonate, citrate,
or trisilicate) that reacts with hydrogen ions to form water.
• They provide protection against the harmful effects of
aspiration pneumonia by raising the pH of gastric contents.
• They have immediate effect.
• They raise intragastric volume.
Types of antacids:
• Particulate: Aluminum and magnesium hydroxide
• Nonparticulate antacids: sodium citrate or sodium bicarbonate.

• Aspiration of particulate antacids produces abnormalities in lung

function compared with the non-particulate antacids which
produce much less damage if aspirated.
• Furthermore, non-particulate antacids mix with gastric contents
better than particulate solutions.
• Timing is critical, as non-particulate antacids lose their
effectiveness 30–60 min after ingestion.
• Dosage: The usual adult dose of a 0.3 M solution of
sodiumcitrate—Bicitra (sodium citrate and citric
acid) orPolycitra (sodium citrate, potassium citrate,
andcitric acid)—is 15–30 mL orally, 15–30 min
prior to induction.

• Drug interaction: The rate of absorption of digoxin,

cimetidine,and ranitidine is slowed, whereas the rate
of phenobarbital elimination is quickened.
 Metoclopramide
• Metoclopramide acts peripherally as a cholinomimetic (ie, facilitates
acetylcholine transmission at selective muscarinic receptors) and
centrally as a dopamine receptor antagonist.
• Its action as a prokinetic agent in the upper gastrointestinal (GI) tract is
not dependent on vagal innervation but is abolished by anticholinergic
agents.
• By enhancing the stimulatory effects of acetylcholine on intestinal
smooth muscle, metoclopramide increases lower esophageal sphincter
tone, speeds gastric emptying, and lowers gastric fluid volume.
• Metoclopramide does not affect the secretion of gastric acid or the pH
of gastric fluid.
• Metoclopramide produces an antiemetic effect by blocking
dopamine receptors in the chemoreceptor trigger zone of the central
nervous system.
• Side effects:
• Abdominal cramps if given rapidly (CI in intestinal obstruction).
• Hypertensive crisis in patients with pheochromocytoma, by
triggering catecholamine release.
• Sedation, nervousness, and extrapyramidal signs from dopamine
antagonism (eg, akathisia) are uncommon and reversible..
• Dosage:
An adult dose of 10–20 mg of metoclopramide (0.25 mg/kg) is
effective orally, intramuscularly, or intravenously (injected
over 5 min).
The onset of action is much more rapid following parenteral
(3–5 min) than oral (30–60 min) administration.
Renal adjustment is needed.
 PPI
Mechanism of action:
These agents bind to the proton pump of parietal cells in the gastric mucosa
and inhibit secretion of hydrogen ions.
Clinical uses:
Peptic ulcer disease, GERD, ZE syndrome.
Side effects:
• GI upset (N, constipation, abdominal pain)
• Myalgia
• Anaphylaxis, angioedema.
• Long-term use has also been associated with gastric enterochromaffin-like
cell hyperplasia and an increased risk of pneumonia secondary to bacterial
colonization in the higher pH environment.
• Dose:
Omeprazole 20mg
Lansoprazole 15mg
(Decreased in severe liver impairment).
• Drug Interactions
PPIs can interfere with hepatic P-450 enzymes, potentially
decreasing the clearance of diazepam, warfarin, and
phenytoin. Concurrent administration can decrease
clopidogrel (Plavix) effectiveness, as the latter medication is
dependent on hepatic enzymes for activation.
PPI V.S H2-blockers
 PONV
• Without any prophylaxis, PONV occurs in
approximately 20–30% of the general surgical
population and up to 70–80% in patients with
predisposing risk factors.
 5HT3 receptor antagonists
• Serotonin, 5-hydroxytryptamine (5-HT), is
present in large quantities in platelets and the
GI tract (enterochromaffin cells and the
myenteric plexus).
• It is also an important neurotransmitter in
multiple areas of the central nervous system.
• There are at least seven receptor types, most with multiple subtypes.
• The 5-HT3 receptor mediates vomiting and is found in the GI tract and
the brain (area postrema).
• The 5-HT2A receptors are responsible for smooth muscle contraction
and platelet aggregation
• The 5-HT4 receptors in the GI tract mediate secretion and peristalsis,
• the 5-HT6 and 5-HT7 receptors are located primarily in the limbic
system where they appear to play a role in depression.
• All except the 5-HT3 receptor are coupled to G proteins and affect
either adenylyl cyclase or phospholipase C, effects of the 5-HT3
receptor are mediated via an ion channel.
Cardiovascular
• Vasoconstriction in the arterioles and veins throughout the body
except the heart and skeletal muscle.
• Heart: it’s vasodilatory effect is endothelium dependent; following
injury, it causes vasoconstriction.
• Modest and transient increases in cardiac contractility and heart rate
may occur immediately following serotonin release; reflex
bradycardia often follows.
• Pulmonary and renal vasculatures are very sensitive to the
vasoconstrictive effects of 5HT
• Respiratory
Contraction of smooth muscle increases airway
resistance. Bronchoconstriction from released
serotonin is often a prominent feature of
carcinoid syndrome
• Gastrointestinal
Direct smooth muscle contraction (via 5-HT 2
receptors) and serotonin-induced release of
acetylcholine in the myenteric plexus (via 5-HT 3
receptors) greatly augment peristalsis. Secretions
are unaffected.  
• Hematological
Activation of 5-HT2 receptors causes platelet
aggregation.
Mechanism of action:
• Ondansetron (Zofran), granisetron (Kytril), and dolasetron
(Anzemet) selectively block serotonin 5-HT 3 receptors, with little
or no effect on dopamine receptors.
• 5-HT 3 -receptor antagonists are generally administered at the end
of surgery
Side effects:
• They do not appear to cause sedation, extrapyramidal signs, or
respiratory depression.
• The most commonly reported side effect is headache.
• Prolong the QT interval on the electrocardiogram.
• This effect may be more frequent with dolasetron, although it has
not been associated with any adverse arrhythmias.

• Decrease the dose in liver failure

 Neurokinin-1 receptor antagonists (Aripitant)

• NK 1 antagonists inhibit substance P at central

and peripheral receptors.
 DEXAMETHASONE
• Dexamethasone should be given at induction
as opposed to the end of surgery, and its
mechanism of action is unclear.
• doses as small as 4 mg has been shown to be
as effective as ondansetron in reducing the
incidence of PONV
 Others:
• Transdermal scopolamine has been used
effectively, although it may produce central
anticholinergic effects (confusion, blurred
vision, and dry mouth).
• Acupuncture, acupressure, transcutaneous
electrical stimulation of the P6 acupuncture
point
 I. Anxiolytics / Sedative /
Hypnotic :

 – Benzodiazepines (still commonly used)

· Diazepam
· Lorazepam
· Midazolam
· Alprazolam
– Barbiturates (not used much)

· Secobarbital
· Pentobarbital
 Benzodiazepines :

 Produce anxiolysis, amnesia and sedation

Act predominantly on GABA receptors in the
CNS.
Minimal respiratory and cardiac depression

Do not produce nausea and vomiting

They are not analgesics

Crosses placental barrier and may cause

neonatal depression
 Comparison of pharmacologic
variables of benzodiazepines:
Diazepam Lorazepa Midazola
m m
Dose equivalent 10 1-2 3-5
(mg)

Time to peak 1-1.5 2-4 0.5-1

effect after oral
dose
(hr)
Elimination half 20-40 10-20 1-4
life (hr)

Clearance 0.2-0.5 0.7-1.0 6.4- 11.1

(mL/kg/min)

Volume of 0.7-1.7 0.8-1.3 1.1-1.7

 Opioid analgesics

Fenyanyl
Morphine ?
Pethidine ?
 Clonidine:

• An imidazoline derivative with predominantly alpha2

adrenergic agonist activity.
• It is highly lipid soluble and readily penetrates the blood–brain
barrier and the placenta.
• Studies indicate that binding of clonidine to receptors is
highest in the rostral ventrolateral medulla in the brainstem
(the final common pathway for sympathetic outflow) where it
activates inhibitory neurons.
• The overall effect is to decrease sympathetic activity,
enhance parasympathetic tone, and reduce circulating
catecholamines.
• its analgesic effects, particularly in the spinal
cord, are mediated entirely via pre- and
possibly postsynaptic alpha2 adrenergic
receptors that block nociceptive transmission.
• local anesthetic effects when applied to
peripheral nerves and is frequently added to
local anesthetic solutions.
• Clinical uses:
• Antihypertensive (decreases sympathetic tone, SVR, HR, BP)
• adjunct for epidural, caudal, and peripheral nerve blocks (it
causes segmental block, but when added to local anesthetics, it
prolongs the duration of anesthetic and analgesic effects)

• Unlabeled/investigational uses of clonidine include serving as

an adjunct in premedication, control of withdrawal syndromes
(nicotine, opioids, alcohol, and vasomotor symptoms of
menopause),
•  
Side effects:
• Common: Sedation, dizziness, dry mouth,
bradycardia
• Abrupt DC (<1m) may cause withdrawal
symptoms: rebound hypertension, agitation,
and sympathetic over activity.
Drug interactions:
• Use with caution in patients on BB
• Can mask the symptoms of hypoglycemia in
diabetic patients
• Additive sedative effect to anesthetic agents.
 PREMEDICATION IN OBSTRETIC
ANAESTHESIA
•Progesterone delays gastric emptying
•Patients are at risk of aspiration due to –gravid
uterus
•Drugs esp opioids
• Opioids and BZD may cause adverse effect on neonate
• Amnesia – woman may not be able to remember her
birthing experiences
 PREMEDICATION IN OBSTRETIC
ANAESTHESIA
•Progesterone delays gastric emptying
•Patients are at risk of aspiration due to –gravid
uterus
•Drugs esp opioids
• Opioids and BZD may cause adverse effect on neonate
• Amnesia – woman may not be able to remember her
birthing experiences
• H2-blockers
• Anti-acids
 PREMEDICATION IN PAEDIATRIC
PATIENTS
• Premedication in infants-
• Infant less than 6 months don’t require sedative
premedication
•Antisialogouges no longer required in
neonate
•Premedication in children-
• Aims –
• To get calm and comfortable child in
operating room
• To decrease secretions
• To obtund vagal reflexes
Modern Trends in Paediatric
Preparation and Premedication

Whole family is under Stress

Anxiety increased by mis information
and Preconceived ideas
Psychological stress -
Long behavioural
disturbances
 Steps of
preparation

Psychological
Premedication
Preparation of Whole Family
Advantages
Ease of Induction
Increased tolerance to stress
Decreased long lasting
behavioural effects.
Preoperative visit by
Anaesthesiologist

Positively affects quality of induction

Allowing child choices
Smooth induction decreases 50-70%
of postoperative emotional changes.
 Parental Presence

Makes sense.
Induction less frightening to child
but more frightening to the anaesthetist.
Less amount of drugs.
Less postoperative behavioral
problems.
 Psychological consequences
of Anaesthesia and Surgery.
Acute: at the time of emergence from anaesthesia.
Calm arousal
Arousable
Abrupt arousal
Excited
emergence

Quiet to sleep, quiet to

arouse, Screaming going
down screaming coming up
Chronic: Some changes continue to
adulthood.
Factors- Age, Stability of family, cultural
patterns, socio economic situations.
 Introduction

•  Whole family is under Stress.

•  Parental Anxiety
•  SEPARATION ANXIETY

•  <6m- no separation anxiety

•  6m- 5yrs -more regression after separation
•  2-6years -↑ in anxiety than older child-5X
Fear of Unknown is common

Older Child is concerned about

What does “put to sleep” really
mean?
Will I be awaken during operation?
Will I move during Operation?
Am I going to die?
Will I be naked totally?
Concerns of mutilation and torture
 KIDSKids
ARE not
NOTsmall
SMALL ADULTS
adults
•  Respiratory functions
•  Hepatic functions poorly developed
•  Renal functions
•  Cardiovascular-heart rate dependent
•  Apnoeic events related to Gestational age.

• ANS and reflexes – poorly developed

 PediatricCONSIDERATIONS
PEDIATRIC consideration

•Great variation in recommendations.

•Sedative -omitted for neonates and sick infants.
•child's age, body weight, drug history, allergic
status and medical or surgical conditions
•Avoid needles!!
•Oral premedication ≠ risk of aspiration pneumonia
 Anticholinergics
Anticholinergics

•  Reduces- bradycardia during induction.

•  reduces-hypotension in neonates and infants <3m

• prevent secretions –bronchial and salivary.

•  Secretions-patients with URIs or ketamine.
•  Atropine, 0.01-0.02 mg/kg i.m or i.v
•  Glycopyrollate ,0.01mg/kg i.m/i.v-does not cross
BBB, no confusion
•  Scopolamine (0.005-0.01 mg/kg)-sedating effect
of 5 to 15 times> atropine
• adjuvant to ketamine anesthesia-antisialagogue
and central sedative effects
 Antihistaminics
Antihistaminics

• Central antiemetic action

• Sedation
• Anxiolysis
• H2 receptor antagonism
• ά – adrenergic anatagonism
• Anticholenergic properties
• Potentiation of opiod analgesia
 ANTI-EMETICS
Anti-Emetics
1.Metoclopramide–0.15-0.20 mg/kg iv
2.Ondansetron-0.10-0.12 mg/kg iv
3. Droperidol 0.05-0.075 mg/kg.
4. Dexamethasone 0.1-0.2 mg/kg
Combination of metocopramide, ondansetron,
dexamethasone etc.
Metoclopramide is contraindicated in
patients under 1 year of age and should be
used with caution in patients under 5 years
Fentanyl
100 times more potent than morphine
High degree of solubility
Penetrates Blood Brain Barrier
Intermittently used – termination of action is due
to redistribution
Effects lasts for 30-45 minutes
Cause chest wall and glottic contracture and
respiratory depression
Dose 0.5 to 1.0mcgm/kg slowly – titrate.
Transmucosal Fentanyl (Lozenges or Lollipops),
Oralet.
Dose 15-20 mcgm/kg.
Good absorption from mucosa.
Child narcotized with in 15-30 minutes
Complications: nausea, vomiting, desaturation
Advantages: Long slow decline in Blood
concentration improves analgesia.
Rigidity of thoracic muscles avoided
Rich good absorptive surface.
 Midazolam – Most Popular
sedative
Soluble in water
No pain at iv or im
B- elimination is 106minutes vs 18hrs diazepam
Good for short procedures
Route: iv, im, orally, sublingually, nasally and
rectally. It produces anterograde and retrograde
amnesia produces calm, compliant child.
Respiratory Depression is common in elderly but
not in children. It can occur if combined with
other drugs.
Study: Fraction of midazolam available
compared with iv administration:
Iv-1.0, im-0.9, nasal-0.6, Rectal-0.4 to
0.3
0.5,oral-
 Nasal-0.2 to 0.3 mgm /kg.
Effective, uncomfortable
Effect in less than 10-
15minutes.
Neurotoxicity can occur in intranasal
administration of drugs.
Children prefer sublingual than nasal.
Rectal-0.5-1.0 mgm/kg. Satisfactory level of
sedation and anxiolysis in less than 15-20minutes.
Children does not fall asleep even with 3mgm/kg
 Midazolam
Sublingual – rapid uptake, Bitter taste is very
difficult to suppress.
Given with sweetening agents orally dose 0.5
to
0.75 mgm/kg. Satisfactory sedation in 10-15
minutes, peak effect at 20-30 minutes.
.
Benzodiazepines

Diazepam oral 0.1-0.3

Iv 0.1-0.3
Im not recommended
Rectal 0.2-0.3

Midazolam oral 0.5-0.75

Iv 0.05-0.15
Im 0.05-0.15
Rectal 0.5-0.75
Nasal 0.2-0.5
Sublingual 0.2-0.5
 KETAMINE
Excellent analgesic and amnesic agent
Route: iv, im, oral, rectal, nasal (4-6mgm)
Increase in HR, BP, CMRO2, IOP, ICP
Increase in airway secretions
Contraindicated in URI ??
No sure protection in full stomach
Emergence delerium
Sedatives or narcotics reduce hallucinations but
increase sedation levels.
Oral Admn: 6-10mgm/kg with orange juice
with 0.02-0.04 mgm/kg atropine gives
excellent results in 10-15minutes .
KETAMINE
It is not known if dreaming occurs with oral
Ketamine\
Some tried oral ketamine 3-6 mgm/kg with
midazolam 0.25-0.5 mgm/kg with profound
sedation.
Increase in oral dose can result in more success
rate but adverse reactions like vomiting and
profound sedation can happen.
Involuntary movements can occur..
 BARBITURATES
Child is sedated in parents lap. No need of
parental presence in induction.
Methohexitone: rectally 20-30mgm/kg , 10%
solution.
Produces a state of slight to deep sedation.
Absorption is fast but irregular.
Seizures in temporal lobe epilepsy.
Airway obstruction and Apnoea can occur.
Monitoring is very much essential.
Thiopentone: Rectally 30mgm/kg.
Used in epilepsy.. Children sleep longer. These are
best premedicants provided the baby is monitored.
 Doses of drugs
commonly used:

Drug Dose mgm/kg. Route

Barbiturates

Methohexital 20-30 10% rectal,

Thiopentone 20-30 rectal

EMLA
Lidocaine+ Prilocaine
Occlusive dressing for 30-60minutes.
For venepuncture, Lumbar Puncture or before
skin infiltration.
If large dose is used - Methhaemogobinaemia
Mucosal surfaces avoided
Accidental ingestion or contact with eyes should be
avoided.
Children may chew the dressing with absorption of the
drug.
One Study of children aged 6-12 years found that N2O is
superior to EMLA
 Conclusion
Preoperative visit from an anesthesiologist
greatly reduces patient anxiety than preoperative
sedative drugs.
Children, aged 2–10 years who experience
separation anxiety, may benefit from
premedication
Patients who will undergo airway surgery or
extensive airway manipulations benefit from
preoperative administration of anticholinergics to
reduce airway secretions before and during
surgery.
 Case Report A rare self-mutilating post-
operative behavioral change in a 3-
year-old child
General anesthesia or sedation is mandatory even for minor
surgery in children especially if they are below 5 years of age for
oblivion. It’s mandatory not only for intraoperative period but
also to omit the psychological impact that may adversely affect
the children postoperatively. We report a case of post-operative
behavioral change where a 3-year-old child applied a straight
incision over his forehead to mimic the surgery that he learnt
intraoperatively while drainage of small abscess of his own great
toe carried out on him without anesthesia or sedation.
Postoperative behavioral changes in Chinese children undergoing hypospadias repair
surgery: A prospective cohort study

• A prospective cohort of 177 children aged 2‐

12 years scheduled for hypospadias repair
surgery from 2016 to 2017 was studied. 
•  Conclusions For children undergoing hypospadias
repair surgery in our institution, approximately three
in five showed postoperative behavioral changes,
which could persist for several weeks. In addition to a
younger age and a higher maternal education, an
emotional temperament is associated with a high
incidence of negative postoperative behavioral
changes. It is important to recognize that there are
factors that are associated with an increased incidence
of negative postoperative behavioral changes
Child behaviour after anaesthesia: associated risk factors M Karling ([email protected]),1 H
Stenlund,2 B H¨aggl ¨of3 1.Division of Anaesthesia, University of Ume˚a, Sweden
2.Department of Public Health and Clinical Medicine, University of Ume˚a, Sweden
3.Epidemiology and Child and Adolescent Psychiatry, University of Ume˚a, Sweden
• Abstract Aim: To identify hospital care factors which are associated
with problematic behaviours in children after hospitalization.
Method: A cohort of 340 children ages 2–13 was studied in
connection with elective procedures which included anaesthesia.
Data collected: sociodemograhic, type of procedure, anaesthesia
induction technique and premedication. Staff and parents assessed
child anxiety at induction of anaesthesia, pain, anxiety and nausea
in recovery room and hospital ward. Parents assessed their child’s
pain and nausea and the behaviour measured with the Post Hospital
Behavioural Questionnaire two weeks after hospitalization. Results:
One-third (34.4 %) of the children developed at least one
problematic behaviour, measured by the PHBQ subscales.
• Conclusion: Pain at home but not in hospital is
a strong risk factor for the onset or worsening
of problematic behaviour after childhood
hospitalization, which included anaesthesia.
Proactive interventions are suggested to
prevent this by improving pain treatment at
home.
 Behavioural Problems
following
anaesthesia and surgery:
Meyers Eckenhoff Hannallah
General anxiety 45% 23% 66%
General regression 33% 19% 5%
Enuresis 28% 26% 37%
Sleep anxiety 34% 32% 65%

Eating Disturbances 33% -- --

The role of anaesthetist is very crucial.