Is anxiolytic premedication
advisable before ambulatory surgery, and what agents are appropriate?
Because the goal of anesthesia for ambulatory
surgery is to permit early discharge
to home, there was concern that the administration of short-acting anxiolytic
or analgesic premedication might delay recovery from anesthesia and thereby
prolong time in the postanesthesia care unit (PACU) with a resultant delay in
patient discharge. However, no sig-nificant differences in recovery times can
be demonstrated after short-acting premedicants have been administered. The
effects of more potent and longer-acting anesthetics and the surgical procedure
itself contribute in a more significant fashion to the recovery time before a
patient may be dis-charged. However, although time to discharge, a gross
meas-urement, may remain unaffected, tasks that require fine coordination and
speedy reaction times may still be deleteri-ously affected.
Many patients experience anxiety in the
immediate preoperative period, and pharmacologic management is quite
acceptable. The administration of either diazepam, 5–10 mg orally, 1–2 hours
before surgery or midazolam, 1–2 mg intravenously, after an intravenous
catheter is placed before surgery can ameliorate distress if deemed desirable.
The amnestic effect of intravenous midazolam is powerful, and patients may not
remember having seen their surgeon. Midazolam can also be given orally,
although much larger doses are required because of first-pass hepatic
degradation (0.5–1 mg/kg orally). Opioid premedication may contribute to the
incidence of postop-erative nausea and vomiting.
Preoperative oral doses of clonidine, a
centrally acting α2-adrenergic agonist have been used to provide sedation, reduce anesthetic requirements, and decrease episodes of
hypertension and tachycardia during intubation and mainte-nance of anesthesia.
Side-effects of this class of drugs may include dryness of the oral cavity,
hypotension, as well as undesirable sedation extending into the postoperative
period. Relaxation techniques have been taught preoperatively to patients and
may aid in the reduction of anxiety level. Instruction of these techniques,
however, is time-consuming and requires patient motivation, and is therefore
usually reserved for selected patients with extreme phobias.
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