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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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