The word is derived from the Greek words an, which means “without” and aithesia which means “feeling” The use of medical anesthesia was first reported in 1846 The development of anesthesia has made today’s modern surgical techniques possible • Basic Principles of Anesthesia • “Triad of General Anesthesia”  need for unconsciousness  need for analgesia  need for muscle relaxation and loss of reflexes • Preoperative Evaluation • The preanesthetic evaluation has specific objectives including: - Establishing a doctor-patient relationship, - Becoming familiar with the surgical illness and - coexisting medical conditions, - Anticipating potential complication Developing a management strategy for perioperative anesthetic care, - Obtaining informed consent for the anesthetic plan. The overall goals of the preoperative assessment are to reduce perioperative morbidity and mortality and to allay patient anxiety. • Pre-operative This applied both in evaluation & investigations • General This include the following: 1-General condition of the patient. 2-Psychological condition. ( Specially in major operations). • Specific This include the following: 1-Related to anaesthesia. 2-Related to the surgery. • Medical History 1. Review the chart 2. Review previous records 3. Interview the patient • Demographic Data Height / weight Vital signs Diagnosis History and Physical Exam  Note any abnormalities  Don’t assume that all problems are listed • Steps of the preoperative visit : • Preoperative testing should be performed on a selective basis for purposes of guiding or optimizing perioperative management. • Pre-op Testing Schema Example • Preoperative Laboratory Testing: • only if indicated from the preoperative history and physical examination. • "Routine or standing" pre operative tests should be discouraged • -CBC anticipated significant blood loss, suspected hematological disorder (eg.anemia, thalassemia, SCD), or recent chemotherapy. • -Electrolytes diuretics, chemotherapy, renal or adrenal disorders • -ECG age >50 yrs ,history of cardiac disease, hypertension, peripheral vascular disease, DM, renal, thyroid or metabolic disease. • -Chest X-rays prior cardiothoracic procedures ,COPD, asthma, a change in respiratory symptoms in the past six months. • -Urine analysis DM, renal disease or recent UTI. • -tests for different systems according to history and examination • Disease-based indications  Alcohol abuse  CBC, ECG, lytes, LFTs, PT  Anemia  CBC  Bleeding disorder  CBC, LFTs, PT, PTT  Cardiovascular  CBC, creatinine, CXR, ECG, lytes • Disease-based indications  Cerebrovascular disease  Creatinine, glucose, ECG  Diabetes  Creatinine, electrolytes, glucose, ECG  Hepatic disease  CBC, creatinine, lytes, LFTs, PT • Disease-based indications  Pregnancy (controversial)  Serum B-hCG- 7 days, Upreg 3 days  Pulmonary disease  CBC, ECG, CXR  Renal disease  CBC, Cr, lytes, ECG  RA  CBC, ECG, CX

1. BY,
Dr. Punam Nagargoje
1

2. The word is derived from the Greek words an,
which means “without” and aithesia which
means “feeling”
The use of medical anesthesia was first reported
in 1846
The development of anesthesia has made today’s
modern surgical techniques possible
2

3.  “Triad of General Anesthesia”
 need for unconsciousness
 need for analgesia
 need for muscle relaxation and loss of
reflexes
3

4. Anesthetic drugs and techniques have profound effects
on human physiology. Hence, a focused review of all major
organ systems should be completed prior to surgery.
Goals of the preoperative evaluation is to ensure that the
patient is in the best (or optimal) condition.
Patients with unstable symptoms should be postponed
for optimization prior to elective surgery.
4

5.  The preanesthetic evaluation has specific
objectives including:
- Establishing a doctor-patient relationship,
- Becoming familiar with the surgical illness and
- coexisting medical conditions,
- Anticipating potential complication
5

6. Developing a management strategy for
perioperative anesthetic care,
- Obtaining informed consent for the anesthetic
plan.
The overall goals of the preoperative assessment are to
reduce perioperative morbidity and mortality and to
allay patient anxiety.
6

7.  General
This include the
following:
1-General condition of
the patient.
2-Psychological
condition. ( Specially in major
operations).
 Specific
This include the
following:
1-Related to
anaesthesia.
2-Related to the
surgery.
7

8. MEDICAL HISTORY DEMOGRAPHIC DATA
1. Review the chart
2. Review previous
records
3. Interview the patient
Height / weight
Vital signs
Diagnosis
8

9. History and Physical Exam
 Note any abnormalities
 Don’t assume that all problems are
listed
1. Medications
Routine
medications
at home
Meds ordered in
hospital
2. Lab / x-ray
results
3. Consultations
OLD RECRDS:
1. Available in same
institution
2. Previous
diagnosis
3. Previous
treatment
Old Hospital
Records
Review prior
anesthesia record
Induction doses
Airway
difficulty
Work-up
9

10. I. Problem Identification
II. Risk Assessment
III. Preoperative Preparation
IV. Plan of Anesthetic Technique

11.  Preoperative testing should be performed on a
selective basis for purposes of guiding or
optimizing perioperative management.
11

12. Dr. Andrew Ferguson

13.  only if indicated from the preoperative history and physical examination.
 "Routine or standing" pre operative tests should be discouraged
 -CBC anticipated significant blood loss, suspected hematological
disorder (eg.anemia, thalassemia, SCD), or recent chemotherapy.
 -Electrolytes diuretics, chemotherapy, renal or adrenal disorders
 -ECG age >50 yrs ,history of cardiac disease, hypertension, peripheral
vascular disease, DM, renal, thyroid or metabolic disease.
 -Chest X-rays prior cardiothoracic procedures ,COPD, asthma, a
change in respiratory symptoms in the past six months.
 -Urine analysis DM, renal disease or recent UTI.
 -tests for different systems according to history and examination
13

14.  Disease-based indications
 Alcohol abuse
 CBC, ECG, lytes, LFTs, PT
 Anemia
 CBC
 Bleeding disorder
 CBC, LFTs, PT, PTT
 Cardiovascular
 CBC, creatinine, CXR, ECG, lytes
14

15.  Disease-based indications
 Cerebrovascular disease
 Creatinine, glucose, ECG
 Diabetes
 Creatinine, electrolytes, glucose, ECG
 Hepatic disease
 CBC, creatinine, lytes, LFTs, PT
15

16.  Disease-based indications
 Pregnancy (controversial)
 Serum B-hCG- 7 days, Upreg 3 days
 Pulmonary disease
 CBC, ECG, CXR
 Renal disease
 CBC, Cr, lytes, ECG
 RA
 CBC, ECG, CXR, C-spine (atlantoaxial subluxation)
 AP C-spine, AP odontoid view and lateral flexion and
extention.
16

17.  General & Local examination
 Should focus on evaluation of :
• Upper airway
• Respiratory system
• Cardiovascular system
• other systems’ problems identified from the history
17

18.  Take history of prior
difficulty
 Head and neck
movement (extension)
 Alignment of oral,
pharyngeal, laryngeal
axes
 Cervical spine arthritis or
trauma, burn, radiation,
tumor, infection,
scleroderma, short and
thick neck
18

19. 19

20. Mallampati
Measurements 3-3-2-1 or 1-2-3-3 Patient ‘s fingers
Movement of the Neck
Malformations of the Skull
Teeth
Obstruction
Pathology
20

21. Class I = visualize the soft palate, fauces, uvula, anterior
and posterior pillars.
Class II = visualize the soft palate, fauces and uvula.
Class III = visualize the soft palate and the base
of the uvula.
Class IV = soft palate is not visible at all.
21

22.  Oropharyngeal visualization
 Mallampati Score
 Sitting position, protrude tongue
22

23. 23

24. 1 2
3 4
24

25.  3 Fingers Mouth Opening
 3 Fingers Hypomental Distance. (3 Fingers
between the tip of the jaw and the beginning of the
neck (under the chin)
2 Fingers between the thyroid notch and the
floor of the mandible (top of the neck)
 1 Finger Lower Jaw Anterior sublaxation
25

26.  Skull (Hydro and Microcephalus)

Teeth (Buck, protruded, & loose teeth. Macro and Micro
mandibles)

Obstruction (obesity, short Bull Neck & swellings around the
head and neck)

Pathology (Craniofacial abnormalities & Syndromes e.g.
Treacher Collins, Goldenhar's, Pierre Robin syndromes)
 “Patients with an abnormal airway (including Class III
or IV airway) should be considered at higher risk “.
26

27.  Mouth opening less than 3 cm.
 Limitation of neck movement
 Micrognatia
 Macroglossia
 Protusion of teeth
 Short neck
 Morbid obesity
27

28. Components for evaluating perioperative risk:
• patient's medical condition preoperatively
• extent of the surgical procedure
• risk from the anesthetic
“Most of the work, however, addresses the operative risk
according to the patient's preoperative medical status”
28

29.  To define patient’s condition
 To optimize patient’s medical condition and
future management before surgery
29

30.  Benefits from surgery ←→ Risk of
complications
30

31. medical status mortality
ASA I normal healthy patient without organic,
biochemical, or psychiatric disease
0.06-0.08%
ASA II mild systemic disease with no significant impact
on daily activity e.g. mild diabetes, controlled
hypertension, obesity .
Unlikely to
have an impact
0.27-0.4%
ASA
III
severe systemic disease that limits activity e.g.
angina, COPD, prior myocardial infarction
Probable
impact
1.8-4.3%
ASA
IV
an incapacitating disease that is a constant threat
to life e.g. CHF, unstable angina, renal failure
,acute MI, respiratory failure requiring mechanical
ventilation
Major impact
7.8-23%
ASA V moribund patient not expected to survive 24 hours
e.g. ruptured aneurysm
9.4-51%
ASA
VI
brain-dead patient whose organs are being
harvested
ASA Physical Status Classification System
For emergent operations, you have to add the letter ‘E’ after the classification.
31

32.  High Risk
 Vascular (aortic and major vascular)
 Intermediate Risk
 Intraperitoneal and intrathoracic, carotid, head and
neck, orthopedic, prostate
 Low Risk
 Endoscopic, superficial procedures, cataract, breast,
ambulatory surgery
32

33.  Duke Activity Status Index:
1–4 METS(Eating, dressing, walking around
house, dishwashing)
4–10 METS(Climbing stairs—1 flight, walking
level ground 6.4 km/hr, running short
distance, game of golf)
≥10 METS(Swimming, singles tennis, football)
MET: metabolic equivalent.
1 MET = 3.5 mL of O2 /Kg/min.
33

34. CARDIAC ASSESSMENT
35

35. 36

36. 37

37. Dr. Andrew Ferguson

38. HYPERTENTION IHD CHF
•Determine B.P. control
•Review drugs
•Through history &
physical exam.
•Continue all medication
•No universal guidelines
-if diastolic B.P
>110mmHg-postpone the
case.
•SAFE DRUGS:
•BZD, Opioids, Propofol,
•CAUTION:
•Ketamine
•Pain control is imp.
•Persistent hipertension-
hydralazine or labetalol.
•Determine severity,
progression & functional
limitation.
•Assess CCRF
•Determine functional
status;
-METS
•+ve history MI delayed
at 6 weaks.
•Consultation with the
cardiologist
•Continue all
medications with
antiplatlets( based on
risk)
•AVOID:
•Ketamine, glycopyrolate
•CAUTION:
•Fentanyl/propofol.
•Assess presipitating
factors for heart failure,
confirm control &
management.
•Obtain cardiology
clearence
•Continue all medication
•If on diuretics check
potassium and
electrolytes
•Consider only moderate
sedation
•Minimize fluctuation in
BP and HR
•Carefully administer
fluids
•AVOID:
•Ketamine,
Glycopyrolate, Atropine.
39

39. 40

40. RESPIRATORY ASSESSMENT
41

41.  Age
 Obesity
 Smoking
 Chronic obstructive pulmonary disease (COPD)
 Asthma
42

42. 44

43.  Clinical
characteristics to
consider:
 Smoking, COPD,
recent respiratory
infection, cardiac
disease

44. 46

45.  Smoking cessation
 24 hr: decrease carboxyhemoglobin and eliminates
circulating nicotine
 2-3 day: improve ciliary function
but increase secretion
 1-2 wk: decrease secretion and also benefits the
patient by enhancing ciliary activity
 4-8 wks: decrease the incidence of postop pulmonary
complication.
47

46. ACUTE RESP.
INFECTION
ASTHMA SMOKING COPD
•↑ secretions-↑
chances of
laryngospasm &
bronchospasm
•Postpone untill
pt becoms
asympyomatic
•If elective delay
procedure for at
least 6 wks
•Adequate
hydration
•Otrivine drops as
a nasal
decogesent.
•Determine
severity & efficacy
of current
medication
•If poor control;
•Recent hosp.
•↑ use of inhalers
•Steroids
•Resp.exam.
•Review all pulm.
function test
•Continue all
medications
•USEFUL:
•Ketamine,
Prpofol
•AVOID:
•Morphine
•meperidine
•Ask pt to stop 4
wks before
•Immediate
cessation :
detrimental to ;
-↑ sputum prod.
-nicotine
withdrawl
-restlessness
-anxiety
•Ascultate lungs
& question
regarding the
degree of
dyspnea.
•Similar drug
instructions to
asthmatic pt.
•Determine the
severity & risk
factors for
pulmonary
complications
•Continue all
medications
•Cosult physician
•AVOID:
•Nitrous oxide
inhalation
•CAUTION:
•Opioids
•In severe disease
-minimal
conscious
sedation & LA
48

47.  Patients on oral hypoglycemics:
 Hold any oral agents on day of surgery
 For pts with good control- cover with regular /
rapid acting insulin using sliding scale
 For pts with poor metabolic control-
start continuous insulin infusion [ CII ]
 Pts on insulin:
 Pts with fair metabolic control-
 Hold short acting and give ½ dose of
intermediate acting insulin on day of surgery.
49

48.  Simultaneously infuse 5% dextrose in normal
saline plus kcl at 100ml/hr.
 Check blood glucose level every 4 to 6 hrs
Accordingly adjust the insulin dosage
 For poor controlled pts- start CII.
 Sliding –scale formula
BSL - 140
UNITS REGULAR INSULIN =-----------------
40
BSL = blood sugar level
50

49.  Variable Rate Intravenous Insulin Infusion

Mix 100 U short-acting insulin in 100 mL normal saline (1 U = 1
mL)

Start insulin infusion at 0.5 to 1 U per hour (0.5 to 1 mL per hour)*

Start a separate infusion of 5 percent dextrose in water at 100 to
125 mL per hour

Monitor blood glucose hourly (every two hours when stable) and
adjust insulin infusion rate according to the following algorithm:

BLOOD GLUCOSE LEVEL, MG PER DL (MMOL PER
L)†ACTIONBelow 70 (3.89)

Turn off insulin infusion for 30 minutes, recheck blood glucose
level. If blood glucose level is still below 70, give 10 g glucose and
recheck blood glucose level every 30 minutes until the level is
above 100 (5.56), then restart infusion and decrease rate by 1 U per
hour.

71 to120 (3.94 to 6.67) Decrease insulin infusion rate by 1 U per
hour
51

50. 
121 to 180 (6.72 to 10.0)

Continue insulin infusion as is

181 to 250 (10.1 to 13.89)

Increase insulin infusion rate by 2 U per hour

251 to 300 (13.94 to 16.67)

Increase insulin infusion rate by 3 U per hour

301 to 350 (16.72 to 19.4)

Increase insulin infusion rate by 4 U per hour

351 to 400 (19.5 to 22.2)

Increase insulin infusion rate by 5 U per hour

Above 400 (22.2)

Increase insulin infusion rate by 6 U per hour
Glucose infusion rate can also be increased if tendency toward hypoglycemia
persists.
†—Target blood glucose range is 120 to 180 mg per dL (6.67 to 10.0 mmol per
L).
52

51.  Preoperative :- untreated , uncontrolled, and
recently diagnosed thyroid diseases- should
not go for outpatient sedation
 And warrant prompt medical evaluation
 Question regarding degree of severity & ability
to control
 Goiters – increased difficulty of intubation
 Consider ECG and medical clearence
54

52. HYPOTHYROID HYPERTHYROID
 Have hypodynamic
CVS
 ↑ sensitivity to
anesthetics
 AVOID: ketamine
Atropine , & medications
that ↑ damand of heart
 Maintain regular dose
on day of syrgery.
 Anesthesia is not
contraindicated
 ↑ adrenergic activities –
B blockers
 Introp hypotention- IV
fluids, ↓ level of
anesthesia
 Avoid :
atropine,ketamine
 Safe : N2O, opioids,BZD
55

53.  Daily cortisole production-
15 to 25 mg/d of hydrocortisone
5 to 7 mg/d of prednisolone
 Response to surgery- ↑ 2 to 10 times
 Depression of HPA – less cortisol
 Preoperative :
 History and physical examination
 Question regarding underlying diseases and its
control
56

54. Three strategies;
1. Most common- doubling morning dose on day
of surgery
2. Administration depends on type of surgery
and physiological glucocorticoid production
rate.
3. Clinical judgement to assess for need of
coverage along with baseline dose.
57
Ususl morning dose PLUS 100 mg of hydrocortisone IV before
procedure and 50mg 8 hourly for 24 hrs.taper dose 50% each day untill
it reach to normal dose.

55.  Therapy : 1. Generlised – phenytoin, valproate
2. focal – carbamazepine
 Preoperative :
1. history & physical examination
2. All medications should be continued.
 Perioperative :
 Safe – BZD,[ protective effect]
Propofol [ ↑ seizure threshold ]
ketamine
 Opioids- fentanyl & morphine can be used. 58

56.  Preoperative:
1. Review of symptoms of LD
2. Risk stratification for these pts
child-pugh score system
3. Complete blood count, coagulation profile, LFT
 Perioperative :
 ↓ dose of anesthetics
 Avoid : ketamine , opioids
 With caution: BZD, Propofol
 Safest: inhalation anesthetics- N2O
 Articaine is safer.
59

57. 60

58.  Preoperative
 Assessment of manifestations of CKD and
management
 Evaluate for cardiac & resp. dysfunction
 CBC & KFT
 ECG
 Consultation with nephrologist
61

59.  Perioperative
 Carefully select anesthetics
 Safe : Propofol (low dose), opioids (fentanyl),
barbiturates
 With caution : BZD, Atropine
 Safest : N2O
 Monitor fluid administration closely
 Aviod : RL Prefere NS/ 5% dextrose
 No contraindication for use of LA (but dosage
should be kept minimum)
62

60. 63

61. 64

62.  What to stop (suggestions! - discuss with cons)
 What to keep
 What else to give
65

63.  Diuretics
 unless thiazide for hypertension
 unless severe heart failure
 Insulin & OHA - see hospital diabetic protocol
 Vitamins & iron
 ACEI’s or ARB’s (individual choice)
 depends on procedure/risk of hypotension
66

64.  Antiarrhythmatics
 Antiasthmatics
 Antibiotics
 Antiepelectics
 Antihypertensives
 B blockers
 Calcium chanel blockers
 sedatives
67

65.  Informed consent involves
 discussing anesthetic management plan, alternatives
 potential complication
-Determine what the patient wants to know - Do not
frighten patients
- Start with minor risks
-Proceed to serious risks
69

66. 70

67. 71

68. 72

69.  Anxiolytic and sedation
 Analgesia
 Amnesia
 Hemodynamic stability
 Decrease secretion
 Decrease gastric volume
 Antiemetic
 Facilitate induction of anesthesia.
73

70. MEDICATION ADMINISTRATION ROUTE DOSE (mg)
Lorazepam Oral, IV 0.5–4
Midazolam IV Titration of 1.0–2.5-mg doses
Fentanyl IV Titration of 25–100–µg doses
Morphine IV Titration of 1.0–2.5-mg doses
Meperidine IV Titration of 10–25-mg doses
Cimetidine Oral, IV 150–300
Ranitidine Oral 50–200
Metoclopramide IV 5–10
Atropine IV 0.3–0.4
Glycopyrrolate IV 0.1–0.2
Scopolamine IV 0.1–0.4
74

71.  Describe anesthetic technique available and
risk
 Describe what to expect
 Describe duration and time to return
 Describe postop pain management
 Psychological support
75

72.  Good for amnesia and sedation
 No single drug is best for preop medication
 Deteminant of drug choice and dose
Age and weight
ASA physical status
Prior experience
Patient condition
Elective or emergency
76

73.  Inhibit GABA receptors and have anticonvulasant properties
 Anterograde amnesia
 Can be combined with oral analgesics to add background
analgesia.
 sedative effects and muscle relaxation.
causes respiratory depression
 The action can be reversed with flumazenil.
 Diazepam (valium):
 pain with IM or IV injection
 peak effect 30 mins (oral)
 duration 20 hrs.
 Dose: 0.1-0.2 mg/kg oral.
77

74.  Lorazepam:
 more amnesia 4 times than dizepam.
 slow onset, long duration
 Not appropriate for premedication
 Dose 25-50 ug/kg oral
2mg IM
100-200ug IV.
78

75.  Midazolam (dormicum) :
 water soluble
 not pain on injection
 short duration
 stable hemodynamic
 dose: 0.07-0.15 mg/kg
15mg orally
70-100ug IM
decrease dose with old age
-Can be used for induction 0.1 mg/kg
-can be used as co-induction agent with propofol.
79

76. Caution
 Potentiate with opioid in respiratory
depression
 Psychomotor depression; agitation
 Decrease blood pressure
 Reduce seizure threshold.
80

77.  Female gender
 Non-smoker
 History PONV or motion sickness
 Predicted opioid use
If more than one factor is present preoperatively,
a prophylactic antiemetic should be administered.
82

78. 83

79.  Prevent nausea and vomitting postop for
high risk group
 Give to patient for premedication or
intraoperative period
 Ondansetron
 Droperidol
 Metoclopramide
84

80. PHENOTHIAZINES:
3.Phenothiazine
 Mild sedative
 Antiemetic
 Anti histamine
 Dose: 25-50 mg/kg oral or rectal
25-50mg IM
Trimeperizine tartarate syrup 2mg/kg
for children.
85

81. 4.Ondensetron:
 Selective 5 HT3 blocker
 4mg IV or 8mg oraly .
86

82.  Droperidol ; good antiemetic, sedation ,
 Caution : dysphoria,
decreased BP (adrenergic block)
extrapyramidal sypmtoms (antidopaminergic)
 Dose: 0.01-0.02 mg/kg IM/IV for antiemetic
 0.03-0.14 mg/kg for sedation.
87

83.  NSAIDS
 Long acting NSAIDS give useful background
analgesia for intraoperative and postoperative
opioids to develop an enhanced analgesic
effect.
 Diclofenac 50-100mg orally
 Ketoprofen 100-200mg orally
50mg IM.
 Piroxicam 20-40mg orally.
89

84.  Acts on µ (mu), k(kappa), δ(delta) receptor
 Morphine
 Analgesia
 Respiratory depression
 Myocardial depression
 Nausea and vomitting
 Histamine release
 Caution with asthma patient, spasm of sphinter of
oddi
 not recommend for infant
 Dose: 0.1-0.2 mg/kg IM or IV
 Analgesia last for 4 hours.
90

85.  Meperidine (Pethidine)
 Potency 1/10 of MO
 Less histamine release and respiratory depression
 Dose : 1-2 mg/kg IM or IV (50 to100mg).
 Lasts for 2 to 4 hrs
91

86.  Fentanyl
 No histamine release
 Rapid onset
 Short duration 30 mins
 More potency than MO 100 times
 Incidence of respiratory depression is high
 Dose : 1-2 ug/kg IV or IM or oral ,transmucosal.
92

87. Caution
 Respiratory and myocardial depression:
Hypotension, Nausea and vomitting
 Spasm of sphincter of Oddi
(Fentanyl>MO>pethidine)
 Interfere with pupillary signs
 Flushing
93

88.  Compititive blocker of muscarinic receptors [eg.
Smooth musceles and secretory glands]
 Decrease secretion (antisialogogue)
 Dry airway
 Sedation
 Amnesia
 vagolytic
 Side effects: CNS toxicity, relax of esophageal
sphinter, mydriasis and interfere with sweating.
94

89.  Atropine
 Dose – 0.6mg IM/IV
 Glycopyrolate
 More potent and longer lasting
 Less likely to produce CNS effects
 Dose- 0.2-0.4mg for premedication.
In presence fever avoid anticholinergic premedication
Instead give other drying agents such as
promathazine.
95

90.  Benefitial for patient with risk for
pulmonary aspiration
 Pregnant woman
 GE reflux
 Hiatal hernia
 Morbid obesity
 Chronic renal failure
96

91.  H2 antagonist
 Raise pH of gastric secresions
 May reduce its volume & thus chances of
regurgitation
 Cimetidine 200-400 mg oral /IM/IV
 Peak effect 60 mins
 May prolong other drug effect
 Ranitidine 150-300 mg oral 50-100 mg IV or IM
 Neight before and 1 hr prior to surgery
 No drug interaction
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92.  Proton pump inhibitor
 Inhibit the activity of H+k+ATPase in g.i.t.
 Reduce the secretion of gastric acid
 Omeprazole (losec)
 40 mg oral
 Nonparticulate antacids
 Neutralize gastric pH>3.5
 30 ml 0.3mg oral 30 mins before induction.
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93.  Metoclopramide(plasil)
 Decrease gastric emptying time
 Increase tone of lower esophageal sphincter
 Decrease nausea
 Dose 5-10 mg IV or oral 1 hr before surgery
 Caution: Do not use with gut obstruction patient
Extrapyramidal symptom
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94.  α2-adrenergic agonist(clonidine)
 Sedation
 Decrease anesthetic and opioid requirement
 Decrease sympathetic response
 Dose: 5-20 ug/kg
 Hypotension
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95.  β-adrenergic blocker (atenolol,propanolol)
 Decrease sympathetic response
 Anxiolytic
 May be benefit in CAD patient
 Dose: 50 mg oral
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96.  Petersons principle of oral and maxillofacial
surgery volume I
 Fonseca volume I
 Oral and maxillofacial surgery Clinics of north
america VOL.25 (2013)
 Textbook of oral and maxillofacial surgery.
 LEE’S Synopsis of anesthesia.
 K. D. Tripathi.
 General Medicine –George Mathew.
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97. Thank you
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