PREOPERATIVE SEDATION AND PREMEDICATION IN PEDIATRICS

DR NIDA FATIMAJAWAHARLAL NEHRU MEDICAL

COLLEGE,AMU ALIGARH

objectives

• Sedation and premedication• Why? --Aims of premedication!• When?• How?• Drugs for premedication!• Routes for administration!• Side effects & complications!

• Whole family is under Stress.• Parental Anxiety• SEPARATION ANXIETY• <6m- no separation anxiety• 6m- 5yrs -more regression after separation• 2-6years -↑ in anxiety than older child-5X

Introduction

Kids not small adults • Respiratory functions• Hepatic functions poorly developed• Renal functions• Cardiovascular-heart rate dependent • Apnoeic events related to Gestational age.• ANS and reflexes – poorly developed

•Great variation in recommendations.•Sedative -omitted for neonates and sick infants.•child's age, body weight, drug history, allergic status and medical or surgical conditions •Avoid needles!!•Oral premedication ≠ risk of aspiration pneumonia

Pediatric consideration

What does “put to sleep” really meanWill I be awaken during operation?Will I move during Operation?Am I going to die?Will I be naked totally.Concerns of mutilation and tortureNeedle phobia

Fear of Unknown-older kids

1. Narrative information 2. Orientation tour to O.T’s3. Role rehearsal using dolls 4. Puppet shows/ Videos of O.R5. Communication 6. Consent

Pre-op preparation programs

• Allay Anxiety & fear.• Reduce saliva and airway secretions.• Enhance the hypnotic effects of general

anaesthesia.• Reduce postoperative nausea & vomiting.

AIMS OF PREMEDICATION

• Attenuate vagal reflexes.• Produce amnesia.• ↓ volume & ↑pH of gastric contents.• Attenuate sympathoadrenal responses. • ↓amount of drug produce-unconsciousness.• Provide analgesia before surgery.

• Untreated severe GERD • Recent apnea history• Congenital airway anomalies -macroglossia,

micronathia, etc.• Extreme Tonsillar hypertrophy• Mitochondrial or metabolic disease

Specific risks

Greater risk for aspiration Low gastric pH High residual volumes

Type Fasting time (hrs)Clear liquids 2Breast milk 4

Infant formula 6Solid (fatty or fried) foods 8

Preoperative fasting

• Vital signs –H.R, R.R, B.P, temperature• Pulse oximetry• ETCO2 • Accurate weight• Focused physical exam-ECG, rate & rhythym.• Renal or hepatic functions.

Pre-sedation assessment

Drugs options for sedation

• Narcotics: Morphine, fentanyl• Benzodiazpines: Diazepam, Midazolam• Ketamine• Barbiturate: Thiopentone, Methohexital• Propofol• Clonidine, Dexmedetomidine• Chloral hydrate

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. Advantages Disadvantages

Oral painless slow onset

IM reliable painful, threatening, sterile abscess

Rapid onset

Rectal rapid, reliable painful defaecation

Irregular/delayed Absorption

Nasal reliable uncomfortable,Desaturation

Transoral,

Muco oral reliable slow onset, nauseaVomiting, desaturation

IV most reliable Painful, threatening

Routes of administration Route of administration Advantages Disadvantages

Oral painless slow onset

IM

Rapid onsetreliable

painful, threatening, sterile abscess

Rectal rapid, reliable painful defaecationIrregular / delayed absorption

Route of administration

Advantages Disadvantages

Nasal reliable uncomfortable, Desaturation

Transoral,

Muco oral reliable slow onset, nausea,Vomiting,

desaturation

IV

most reliable Painful, threatening

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Doses of drugs commonly used:

Drug Dose mgm/kg. Route

Barbiturates

• Methohexital 20-30 10% rectal, • Thiopentone 20-30 rectal

Doses of drugs commonly used

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Benzodiazepines

Diazepam oral 0.1-0.3 Iv 0.1-0.3 Im not recommended Rectal 0.2-0.3

Midazolam oral 0.5-0.75 Iv 0.05-0.15 Im

0.05-0.15 Rectal 0.5-0.75 Nasal 0.2-0.5 Sublingual 0.2-0.5

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• KETAMINE Oral 6-10 mgs Iv 1-3 Im 2-8 Rectal 10-15 Nasal 3-5

Sublingual 3-5

•1.PATIENT• Age, sex, body wt, physical condition, psychological status.

•2.PROPOSED SURGERY• Nature of op. , site of op., posture during surgery, duration of Op ,etc

FACTORS AFFECTING CHOICE OF PREMEDICANT DRUG

• 3. Availability- adequate preoperative and postoperative nursing care

• 4. Surgical and anaesthetic management available

FACTORS AFFECTING CHOICE OF PREMEDICANT DRUG

IDEAL STRATEGY• eliminates the pain, discomfort,& physiologic

abnormalities,• helps intubation expeditiously, • minimizes traumatic injury to the newborn,• Complete Cardiopulmonary stability• has no adverse effects• Rapid induction and emergence

• Midazolam - 0.3–0.5 mg/kg, 15 mg maximum• oral route-preferred-less traumatic than i.m• requires 20–45 min for effect, bitter • Smaller doses of midazolam in combination with oral ketamine (4–6 mg/kg)• Chloral hydrate 20 to 75 mg/kg max 2 g

Oral gastric/sublingual/transmucosalsedatives

• uncooperative patients, intramuscular Midazolam-0.1–0.15 mg/kg, 10 mg maximum or Ketamine (2–3 mg/kg) with Atropine (0.02 mg/kg) may be helpful.

Intramuscular sedatives

• Rectal midazolam- 0.5–1 mg/kg, 20 mg max• Rectal methohexital-25–30 mg/kg of 10% sol

administered in cases while the child is in the parent’s arms.

Rectal sedatives

• Sufentanil 1-2 µgkg-1 ,• midazolam 0.2-0.3 mgkg-1 • Ketamine 2-3mgkg-1

• unpleasant,• potential neurotoxicity of nasal midazolam.• Nasal dexmedetomidine has also been used by

some clinicians.

Nasal sedatives

• Use of topical analgesia if possible– EMLA, LMX, Synera (>3 years)-use care to follow

age and duration guidelines– New product on market called Zingo (>3 as well)

being trialed at several pediatric institutions• Take time to find best site• Secure well!

IV access

• Lollipop: Fentanyl-Actiq, 5–15 mcg/kg• Fentanyl levels continue to rise intraop and

contribute to postoperative analgesia.

Other routes:

Sedation Scoring Scale Description

1 Awake

2 Awake, Calm and quiet

3 Drowsy, readily responds to verbal gentle stimuli

4 Asleep, slowly responds to verbal/gentle stimuli

5 Asleep, not readily arousable.

SCORING SYSTEMS OF EFFICIENCY OF PREMEDICATION

• Reduces- bradycardia during induction. • reduces-hypotension in neonates and infants <3m• prevent secretions –bronchial and salivary. • Secretions-patients with URIs or ketamine. • Atropine orally (0.05 mg/kg), i.m, rectally.

Anticholinergics

• Atropine, 0.01-0.02 mg/kg i.m or i.v• Glycopyrollate ,0.01mg/kg i.m/i.v-does not cross

BBB, no confusion • Scopolamine (0.005-0.01 mg/kg)-sedating effect

of 5 to 15 times> atropine• adjuvant to ketamine anesthesia-antisialagogue

and central sedative effects

Analgesics

• Pain alleviation -goal of all caregivers.• Pain at intubation -disturbs physiologic homeostasis• analgesic reduces the pain and discomfort of

intubation.• Ideally - rapid onset, short duration, no adverse effects on respiratory mechanics, and predictable pharmacokinetic properties.

• Neonates-very sensitive to respiratory depressant effects of opioids-rarely used.

• Opioids-Used in children.• Opioids + sedatives , dose adjusted to avoid

serious respiratory depression. • Other analgesics:• Acetaminophen, tramadol, butorphanol,

codeine, pentazocine.

• Opioids-m/c used → Fentanyl• Oral-10 to 15 μg/kg. = 1-2 μg/kg i.v / nasal• children blunts physiologic disturbances-

endotracheal suctioning, ↓pulmonary arterial pressure & systemic hypertension.

• Remifentanil-rapid onset of action and an ultrashort duration of action

Antihistaminics

• Central antiemetic action • Sedation • Anxiolysis • H2 receptor antagonism• ά – adrenergic anatagonism • Anticholenergic properties • Potentiation of opiod analgesia

•

• Antihistamine, antiemetic, and sedative activity,• Weaker sedative than Diazepam• Best premedication for Ketamine• Competes for H1 receptor sites on effector cells• Prevents histamine-mediated responses• preoperative sedation and as an analgesic

adjunct

Promethazine

ANTI-EMETICS

1.Metoclopramide–0.15-0.20 mg/kg iv2.Ondansetron-0.10-0.12 mg/kg iv3. Droperidol 0.05-0.075 mg/kg.4. Dexamethasone 0.1-0.2 mg/kgCombination of metocopramide, ondansetron,

dexamethasone etc.

α2 Agonist

• dose-related sedation • attenuates the hemodynamic response to

intubation in combination with atropine.• Clonidine oral 3-4 µg/kg • Dexmedetomidine-safety not established in

pediatric age group.

Suppress cardiovascular system

Respiratory side effects (decreased ventilation)

Hard to monitor effects

Side effects of individual drugs

DISADVANTAGES OF PREMEDICATION

Adverse effects • Opioids- acute chest wall rigidity-preterm and

term infants, nausea and vomiting • Midazolam- intranasal-potential neurotoxicity• cardiovascular collapse after regional anesthesia

toxicity• paradoxical effect with behavioral changes and

agitation and hiccups

• Methohexital- hiccups, apnea, airway obstruction, laryngospasm , cardio-respiratory arrest

• Chloral hydrate- metabolic acidosis, renal failure, and hypotonia

• Phenothiazines- dystonic reactions • Ketamine- hallucinations, nightmares, and

delirium • Codeine-seizure

No premedication• Intubation without premedication may• be acceptable during :• infants with upper airway anomalies such as

Pierre Robin sequence.• during resuscitation• after acute deterioration or critical illness

Thanks!!