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Fasting Recommendations

INGESTED MATERIAL MINIMUM FASTING PERIOD, (hr)
Clear liquids 2
Breast milk 4
Infant formula 6
Nonhuman milk 6
Light meal (toast and clear liquids) 6

Co-existing Disease indications- Management of preexisting drug therapy

  1. Antihypertensive: to be continued and morning dose to be taken Patient on MAO inhibitors – Discontinued before 3 weeks
  2. Oral hypoglycemic – For minor surgery (<20 min) continue, omitting morning dose
  3. For major surgery-switch over to insulin 48 hrs before surgery
  4. Oral anticoagulants to be stopped 1 week before and switch over to low mol. Wt heparin, which is stopped one day before surgery.
  5. Oral contraceptivesQ estrogen containing pills to be stopped 4 wks before surgery.
  6. Only progesterone pills need not be stopped
  7. Antianginal to be continued
  8. Lithium: to be stopped 48-72 hrs before surgery
  9. Steroid: If patient has taken steroid for more than 1 week in last 1 year intraoperative steroid replacement is necessary
  10. Aspirin:Q to be stopped 7 days before surgery (low dose 48 hrs before)
  11. Anti tubercular drugs: To be continued but assessment of liver function tests is mandatory
  12. Anticholinesterases: Continue in reduced doses
  13. Aminoglycosides and tetracycline: switch over to other antibiotic 48 prior to surgery.

Anesthetic indications

  1. Classification of premedicants
    1. Narcotic – Morphine, pethidine, fentanyl, Alfentanyl
    2. Tranquilizers
      1. Phenothiazine – Chlorpromazine, Promethazine
      2. Benzodiazepine – Diazepam, Midazolam
    3. Sedative hypnotics – Barbiturates
    4. Neuroleptics – Haloperidol
    5. Anticholinergics – Atropine, Glycopyrrolate
    6. Antiemetics – Metoclopramide, Ondansetron
    7. H2 receptor blockers – Ranitidine and famotidine
  2. Premedication
     
    AIM: To
    1. Relieve anxietyQ
    2. Reduce Chances of aspirationQ
    3. Control of secretionsQ
    4. Prevent post op. nausea & Vomiting
    5. Control infection
    6. Provide analgesiaQ
    7. Induce sedationQ
    8. Promote hemodynamic stability
    9. Amnesia
  3. Aim of premedication 
    1. Relieve anxiety
      1. Non-pharmacological measures
        • Assurance
        • Relaxation
      2. Pharmacological
        • Lorazepam (night before surgery 2mg/70kg)
        • Midazolam (i/m or i/v 1-2 hrs before surgery) 0.03 mg/kg
    2. Reduce chances of aspiration
      1. Decreasing Chances of aspiration
      2. For food & unclear fluids 8 hrs fasting is required
      3. For clear fluids 3 hrs. fasting is enough
        • Ranitidine (given night before surgery)
        • Sodium citrate (just before surgery)
        • Omeprazole
        • Metoclopramide (also Reduce N & V) 0.15 mg/kg
    3. To Reduce the secretions
      1. Atropine
      2. Glycopyrrolate
      3. Scopolamine
    4. Nausea & vomiting
      1. Droperidol
      2. Metoclorpramide
      3. Ondansetron 4-8 mg
    5. To reduce infection
       
      Antibiotics are to be given 1-2 hr before surgery
    6. Analgesia : Opioids
       
      To be given in preop. Room, not in ward, only used to attenuate cardiovascular response to intubation, not given routinely.
    7. Induce sedationQ (Use Benzo diazepam)
    8. Promote hemodynamic stability (Use opioids)
    9. Amnesia (Use Benzo diazepam)

Benzodiazepine acts at alpha unit of  GABA receptor predominately, barbiturates acts at other sites (AIIMS Nov 08)

  1. Anti Cholinergics

 

Atropine

Glycopyrrolate

Scopolamine

Antisialagogue

+

++

+++

Sedation & Amnesia

0

0

+++

CNS toxicity

++

0

++

 

Doses of atropine:
  1. For premedication: 0.01 mg/kg.
  2. Along with neostigmine for preventing muscarinic side effects: 0.02 mg/kg.
  3. Vagolytic dose: 2 mg (0.04 mg/kg).
Dose of glycopyrrolate for premedication is 0.005 mg. Along with neostigmine is 0.01 mg/kg
 
Pulmonary Function Test
 
Bed side test
  1. Match test; match stick to be blown off from 15 cm distance
  2. Auscultation over trachea during forced expiration; if breath sounds are audible >6 sec. airway obstruction is positive
  3. Able to blow a balloon
  4. Breath holding time: normal >25 seconds 15-25 borderline <15 sec significant




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