Pengelolahan operasi dimulai dengan persiapan operasi dengan preoperasi fisik pasien dan pemilihan obat-obatan yang spesifik sebagai komponen managemen anastesi sebagai obat sebelum operasi. Idealnya, semua pasien harus bebas dari periode preoperatif seperti kecemasan, sedasi tetapi mudah ....... Dan sepenuhnya kooperatif.

Table 13-17 Primary Goals of Pharmacologic premedication- Relief anxiety- Sedation- Amnesia- Antisialagogue effect- increase in gastric fluid PH- decrease in gastric fluid volume- Attenuation of sympathetic nervous system reflex responses- decrease in anesthetic requirements- prophylaxis againt allergic reactions

Table 13-18 Secondary Goals of Pharmacologic PremedicationDecrease in cardiac vagal activity-- better achieved with the intravenous injection of an anticholinergic (atropine) just before the time of anticipated need Facilitation of induction of anesthesia -- not necesary in view of the availability of potent intravenous induction dregsPostoperative analgesia -- better achieved with neuraxial opioids or the painful surgical stimulus (preemptive analgesia) and/ or just before awakeningPrevention of postoperative nausea and vomiting -- better achieved with the intravenous injection af an antiemetic just before awakening versus withholding treatment and treating the symptoms if necessary

Table 13-19 Drugs and dDose Used for Pharmacologic Premedication before Induction of Anesthesia*Classification Drug Thypical Adult Dose

(mg)Route of Administration

Benzodiazepines MidazolamDiazepamLorazepam

1 - 2,55 - 100,5 - 2

IVOrally, IVOrally, IV

Opioids MorphineFentanyl

5 - 1525 - 100 µg

IVIV

Antihistamines Diphenhydramine 12,5 - 25 Orally, IVα2 - Agonists clonidine 0,1 - 0,3 Orally,

Transdermal**Antiemetics Droperidol

DolasetronOndansentron

1,2512,54

IVIVIV

Anticholinergics Atropin 0,3 - 0,6 IV

Glycopyrrolate 0,1 IVH2 antagonists Cimetidine

RanitidineFamotidine

200 - 30015020 - 40

OrallyOrallyOrally

Antacids Nonparticulate 15 - 30 mL OrallyProton pump inhibitors

OmeprazolePantoprazole

2040

OrallyIV

Gatrointestinal stimulants

Metoclopramide 10 Orally, IV

* Doses are to be titrated to patient's condition age** 24 hours for full effect

Table 13 - 20 Determinats of Drug Choice and DosePatients age and weightPhysical StatusLevel of anxietyTolerance of depressant drugsPrevious adverse experience with drugs used for preoperative medicationAllergiesElective or emergency surgeryInpatient or outpatient surgery

Table 13-21 Is Depressant Pharmacologic Premedication Indicated?No YesNewborn (<1 year of age) Cardiac surgeryElderly Cancer surgeryDecreased level of consciousness Coenxisting painIntracranial pathology Regional anesthesiaSevere pulmonary diseaseHypovolemia

Table 13-22 Comparative Effect of Anticolinergics Administered Intramusculary as Pharmacologic Premdication

Atropine Scopolamine GlycopyrroplateAntisialagogue + +++ ++Sedative and amnesic effect + +++ 0Central nervous system toxicity + ++ 0Relaxation of lower esophageal sphincter

++ ++ ++

Mydriasis and Cycloplegia + +++ 0

Table 13-23 Undesirable Side Effects of AnticholinergicsCentral nervous system toxicityTachycardiaRelaxation of the lower esophageal sphincterMydriasis and cycloplegiaIncrease in body temperatureDrying of airway secretionsIncreased physiologic dead space