Premedication in private practice does not work except with the first case in the morning when anaesthetist and surgeon work at the same nursing home. The scheduled time is disturbed due to:
- Transport difficulties
- Either the surgeon or anaesthetist delayed in the previous case
- Patients relatiives not present
- Patient sent for special exam for ureteric stone or some X-ray investigation needed
- Delay by the theatre staff, equipment
Hence one can depend on premedication on the 1st case only. The rest of the schedule has to be conducted with IV premedication + inductions. Injection Atropine, which was prescribed ½ hour before, does not help in modern practice. It was a must for open drop ether anaesthesia where suppression of salivary secretion was essential. Injection atropine of dryness and some may even start thinking that some extraordinary complications is taking place due to drying and rapid action of the heart and feverish sensation. The olden days premedication for stealing the thyroid in thyrotoxicosis do not apply as they are never taken on table unless sympathetic activity is totally suppressed with anti thyroid drugs.
With IV medication one is assured of
Full administration of drug in system (leaky syringes used by nurses)
Only one injection prick patient feels. This is important in children, as they are very uncooperative for the 2nd injection.
Premedication for infants either by oral or by injection has to be given by ½ hours before induction is by inhalation method. Delayed action like I.V. atropine may not act immediately and appearance of secretion due to endotracheal tube narrow the air passages by secretions.
For patients who are anxious a 10 mg. Diazepam at night or even a tab of diazepam early morning will alleviate the problem.
In patients where induction dose of Thiopentone is likely to be dangerous heavy premedications or basal narcosis is a must, like mitral stenosis patients. Avoid atropine for tachycardia it produces. In very sick and poor risk patients it is better to avoid any premedication.
In some public hospitals the order of patients to be taken for surgery is not known and hence the ward sister gives the injection atropine to all patients at 7.30am as patients are scheduled for surgery at 8.00am (which normally does not start till 8.30 or 9.00 am). The system is followed for years together as anaesthetist insist on atropine ½ hour before. They do not mind delaying the induction till ½ hour is over after injection of atropine is given. I do not understand the rationale behind this plan. Is it because you do conduct less cases in the day and leave early for home? Or is it to show your domination? Nobody is bothered about the suffering of the patient.
Vagolytic action of atropine in pharmacologic doses to prevent vagal arrest is doubted and hence insistence of giving it ½ hour before surgery is sheer ignorance, as IV atropine acts immediately it can certainly replace IM as drying effect is not necessary for IV induction and intubation. If it is given that the 1st drug to be followed by Thiopentone or even mixed with thiopentone (sometimes produces precipitate which dissolves) also acts before scoline and prevents the Cholinergic effect of scoline.
In one infant for congenital cataract the surgeon had prescribed atropine drops in the eye. He did not order oral or sub cut atropine. On arrival we found that atropine drops had produced complete systemic effect with facial flushing tachycardia and dry mouth. Induction with open drop could be take up immediately without injection atropine
Premedication Schedule – never works in private practice except the first case. As you are likely to be delayed, surgeon’s arrival, preparation of OT due to previous operation.
