Premedication Before Anesthesia for Elective Surgery
Core Recommendation
Long-acting anxiolytic drugs should be avoided, particularly in the elderly, and routine sedative premedication is not recommended for most adult patients undergoing elective surgery. 1
Anxiolytic Premedication
General Approach
- Preoperative education and structured patient information programs ("Surgery School") should be the first-line approach to reduce anxiety rather than pharmacologic anxiolysis 1
- Long-acting sedative premedication should be avoided within 12 hours of surgery because it impairs immediate postoperative recovery by delaying mobility and oral intake 1
- Patients receiving oral anxiolytics demonstrate psychomotor function impairment 4 hours postoperatively, reducing their ability to ambulate, eat, and drink 1
Benzodiazepines: Use With Caution
- In elderly patients (≥65 years), benzodiazepines should be avoided due to increased risk of cognitive impairment, delirium, and falls per the American Geriatrics Society Beers Criteria 1
- If anxiolysis is absolutely necessary, short-acting anxiolytics such as 1-2 mg midazolam can be given in selected cases to facilitate regional anesthesia before general anesthesia induction 1
- Short-acting intravenous drugs (fentanyl combined with small incremental doses of midazolam or propofol) can be titrated carefully under monitoring to facilitate epidural or spinal analgesia placement 1
Alternative Anxiolytics
- Melatonin (tablets or sublingual) provides effective preoperative anxiolysis with few side effects compared to placebo and is equally effective to midazolam with high-grade quality evidence 1
- Melatonin may also provide postoperative anxiolysis benefits 1
Multimodal Analgesic Premedication
Gabapentinoids: NOT Routinely Recommended
- Preoperative gabapentinoids (gabapentin, pregabalin) are NOT recommended for routine use in elective surgery 1
- While single preoperative doses decrease postoperative pain and opioid consumption, these benefits are offset by increased postoperative sedation, dizziness, and visual disturbances 1
- If used in selected cases, limit to a single lowest preoperative dose with dose adjustment for elderly patients and those with renal dysfunction 1, 2
NSAIDs: NOT Recommended Preoperatively
- Preoperative nonsteroidal anti-inflammatory drugs are NOT recommended 1
Acetaminophen (Paracetamol)
- Preoperative acetaminophen should be dose-adjusted according to extent of resection 1
- Timing should achieve optimal pharmacodynamic effect coinciding with surgery onset 1
Antiemetic Premedication
Routine Use NOT Recommended
- Routine preoperative use of antiemetics to reduce pulmonary aspiration risks is NOT recommended in patients without apparent increased risk 1
- Preoperative droperidol and ondansetron are effective in reducing postoperative nausea and vomiting but should not be given routinely 1
Selective Use
- Preoperative hyoscine (scopolamine) patches can be used in patients with high risk for postoperative nausea and vomiting but should be avoided in the elderly 1
Preoperative Fasting Guidelines
Standard Fasting Periods
- Clear liquids: 2 hours before anesthesia 1
- Solids and light meals: 6 hours before anesthesia 1
- These guidelines apply to healthy patients undergoing elective procedures and do not guarantee complete gastric emptying 1
Carbohydrate Loading
- Carbohydrate loading is recommended the evening before surgery and 2-4 hours before induction of anesthesia 1
- This improves perioperative insulin resistance, though evidence for reduced length of stay is unclear 1
- Type 2 diabetes patients can receive carbohydrate loading; Type 1 diabetes or active gastroesophageal reflux is a relative contraindication in the 2-4 hour period before surgery 1
Aspiration Prophylaxis
NOT Routinely Recommended
- Preoperative antacids are not routinely recommended as the literature does not sufficiently demonstrate reduced morbidity or mortality from pulmonary aspiration 1
- Anticholinergics to decrease pulmonary aspiration risks are NOT recommended 1
- Combination therapy with histamine-2 receptor antagonists plus gastrointestinal stimulants (metoclopramide) effectively reduces gastric volume and acidity but lacks outcome data 1
Thromboembolism Prophylaxis
Mechanical and Pharmacologic Prophylaxis
- All patients should receive mechanical thromboprophylaxis with well-fitted compression stockings 1
- Pharmacological prophylaxis with low-molecular-weight heparin (LMWH) or unfractionated heparin is recommended 1
- Once-daily LMWH is as effective as twice-daily administration 1
- Epidural catheters should not be placed or removed within 12 hours of heparin administration 1
Key Clinical Pitfalls
- Avoid the outdated practice of routine benzodiazepine premedication, especially in elderly patients where cognitive impairment and delirium risks outweigh anxiety reduction benefits 1
- Do not administer gabapentinoids routinely despite their opioid-sparing effects, as sedation and visual disturbances impair early recovery 1
- Ensure proper timing of premedication administration when used—medications must reach peak effect at the appropriate perioperative moment 1
- Prioritize non-pharmacologic anxiety reduction through structured preoperative education programs rather than defaulting to sedative medications 1