Modern Trends in Paediatric
preparation and Premedication
Dr. P. Narasimha Reddy, MD, DA
Professor & Head
Department of Anaesthesiology
Narayana Medical College,
After this lecture the Anesthesiologist must be
able to recognise
Various risk factors for pre-op anxiety
Various psychological effects of surgery &
Standards of pre-medication
Monitoring the patient under sedation
Various levels of sedation,
Various drugs, doses, routes &
Modern Trends in Paediatric
Preparation and Premedication
Whole family is under Stress
Anxiety increased by mis information
and Preconceived ideas
Psychological stress - Long
Work of Leigh, Belton and SmithModified Anaethetic Practice.
General: Guilt, (inability to protect the
child), loss of control, separation
anxiety,Can I manage? Financial.
Surgical: Failure of proceedure,
Anaesthetic: Pain, Brain damage, death.
Staff Reactions: Miscommunication,
apparent lack of concern and paternalism.
Some Thing is going to happen
Fantasies, hidden fears (more
Truthful announcement of
Avoid Medical Jargon
Between ages of 6months to 5years more
regression after separation
Between ages of 2-6years five fold increase in
anxiety than older child
No familiarity with medical team
Loss of self identity, autonomy, control and
Individualisation of approach
Pre-op Anxiety - predictors
Lack of pre-medication
Fear of Unknown is common to
Older Child is concerned about
What does “put to sleep” really
Will I be awaken during operation?
Will I move during Operation?
Am I going to die?
Will I be naked totally?
Concerns of mutilation and torture
Needle Phobia - Rice summarised
perception of needle phobia
Needle is perceived as direct threat
to body integrity.
Scratching my bones or pushing it
all the way in
Needle Phobia-decades of
inadequate postoperative analgesia
Anything is better than needle.
Frank and truthful disclosure of anticipated events.
Paediatric Play therapy
Encouraging physical expression
Use of toy tools and art material.
Pre-operative preparation programs
of Anaesthesia and Surgery.
Acute: at the time of emergence from anaesthesia.
Eckenhoff, Kneale and Dripps showed – fear of
disfigurement is significant factor in emergence.
Quiet to sleep, quiet to arouse, Screaming going
down screaming coming up
Chronic: Some changes continue to
Factors- Age, Stability of family, cultural
patterns, socio economic situations.
Psychological consequences of Anaesthesia
Behavioural Problems following
anaesthesia and surgery:
The role of anaesthetist is very crucial.
“Little in medicine is tainted with antiquity
more than the sight of a waiting, fearful
screaming child being taken from the arms
of his mother and carried fighting to an
anaesthetic room. There he is held
forcefully on a table and a mask
unceremoniously thrust on his face while he
battles and screams into oblivion”.
Preoperative visit by
Positively affects quality of induction
Allowing child choices
Smooth induction decreases 50-70% of
postoperative emotional changes.
Induction less frightening to child
but more frightening to the anaesthetist.
Less amount of drugs.
Less postoperative behavioral problems.
Numerous combinations of drugs
Now premedication is primarily to
Calm, sedated, with spontaneous
respiration with obtunded autonomic
Modern preoperative regimens- often
painless, rapid anxiolysis with rapid
Universal needle phobia must be weighed
against global threat of suffocation by
EMLA made insertion of iv cannulae, LP
Induction in the lap of the mother is
Parent sent out after induction.
Pre-op preparation programs
Orientation tour to O.T’s
Role rehearsal using dolls
Coping education &
Safe sedation of children requires a
Appropriate drugs depending on age,
life saving equipment.
Written in 1985
Rewritten in 1992
Monitoring guidelines by Anaesthetist.
Proper drug in proper dosage.
Medically controlled state of depressed
‘allows protective reflexes to be maintained, ability
to maintain spont. Resp. independently and
continuously and permits appropriate response to
physical or verbal stimuli’.
DEEP SEDATION (Procedural sedation)
Deep sedation is defined as medically controlled
state of depressed consciousness or
unconsciousness from which patients are not
easily aroused. May be accompanied by a partial
or complete loss of protective reflexes and
includes inability to maintain a patent airway
independently and respond purposefully to
physical verbal stimuli.
Conscious sedation may change to deep sedationMonitor with Pulse oximeter.
SCORING SYSTEMS OF EFFICIENCY
Awake, Calm and quiet
Drowsy, readily responds to
verbal gentle stimuli
Asleep, slowly responds to
Asleep, not readily arousable.
None, no displayed fear or apprehension
Little or minimal expression of fear or
Moderate expression of fear/apprehension
Excessive expression of fear/apprehension
2 Mildly resistant, requires minimal or no restraint
3 resistant, requires active restraint
Excellent cooperative or asleep
slight fear or crying, quiet
- moderate fear/crying, not
quiet with reassurance
- Crying with need for
Preparation of Whole Family
Ease of Induction
Increased tolerance to stress
Decreased long lasting behavioural
Drugs and routes of
Morphine - Duration of action 3-4Hrs, iv,
im sc, s/l and or rectally
Usual dose 0.1 to 0.2mg/kg
For painful procedures
Rectal Admn: delayed, irregular absorption
and Respiratory depression
100 times more potent than morphine
High degree of solubility
Penetrates Blood Brain Barrier
Intermittently used – termination of action is due
Effects lasts for 30-45 minutes
Cause chest wall and glottic contracture and
Dose 0.5 to 1.0mcgm/kg slowly – titrate.
Transmucosal Fentanyl (Lozenges or Lollipops),
Dose 15-20 mcgm/kg.
Good absorption from mucosa.
Child narcotized with in 15-30 minutes
Complications: nausea, vomiting, desaturation
Advantages: Long slow decline in Blood
concentration improves analgesia.
Rigidity of thoracic muscles avoided
Rich good absorptive surface.
Benzodiazepines: Very useful family of drugs in
0.1 to 0.3 mgm/kg iv or oral.
im erratic absorption, very painful
Respiratory Depression- Combined with other
Disadvantages – long action, painful iv injection
CNS depression common than midazolam
Midazolam – Most Popular sedative
Soluble in water
No pain at iv or im
B- elimination is 106minutes vs 18hrs diazepam
Good for short procedures
Route: iv, im, orally, sublingually, nasally and
rectally. It produces anterograde and retrograde
amnesia produces calm, compliant child.
Respiratory Depression is common in elderly but
not in children. It can occur if combined with
Study: Fraction of midazolam available compared
with iv administration:
Iv-1.0, im-0.9, nasal-0.6, Rectal-0.4 to 0.5,oral36
Nasal-0.2 to 0.3 mgm /kg.
Effect in less than 10-15minutes.
Neurotoxicity can occur in intranasal
administration of drugs.
Children prefer sublingual than nasal.
Rectal-0.5-1.0 mgm/kg. Satisfactory level of
sedation and anxiolysis in less than 15-20minutes.
Children does not fall asleep even with 3mgm/kg
Sublingual – rapid uptake, Bitter taste is very
difficult to suppress.
Given with sweetening agents orally dose 0.5 to
0.75 mgm/kg. Satisfactory sedation in 10-15
minutes, peak effect at 20-30 minutes.
Note: Drugs capable of decreasing cytochrome
P3A isoenzymes like Erythro, Dilti, itracono,
ranitidine, cimeti, and even grape juice, may
increase serum concentration.
They must be asked to gulp as much as possible ,
other wise refusing or spitting is possible.
Excellent analgesic and amnesic agent
Route: iv, im, oral, rectal, nasal (4-6mgm)
Increase in HR, BP, CMRO2, IOP, ICP
Increase in airway secretions
Contraindicated in URI
No sure protection in full stomach
Sedatives or narcotics reduce hallucinations but
increase sedation levels.
Oral Admn: 6-10mgm/kg with orange juice or
Rasna with 0.02-0.04 mgm/kg atropine gives
excellent results in 10-15minutes .
It is not known if dreaming occurs with oral
Some tried oral ketamine 3-6 mgm/kg with
midazolam 0.25-0.5 mgm/kg with profound
Increase in oral dose can result in more success
rate but adverse reactions like vomiting and
profound sedation can happen.
Involuntary movements can occur..
These are best for babies with diapers . Child is
sedated in parents lap. No need of parental
presence in induction.(Jeffcoate)
Methohexitone: rectally 20-30mgm/kg , 10%
Produces a state of slight to deep sedation.
Absorption is fast but irregular.
Seizures in temporal lobe epilepsy.
Airway obstruction and Apnoea can occur.
Monitoring is very much essential.
Thiopentone: Rectally 30mgm/kg.
Used in epilepsy.. Children sleep longer. These are
best premedicants provided the baby is monitored.
NSAID, no resp. depression
Dose - 0.5to1mgm/kg.
Route-oral, im and iv too
Careful in Renal problems, Asthmatics,
Occlusive dressing for 30-60minutes.
For venepuncture, Lumbar Puncture or before skin
If large dose is used - Methhaemogobinaemia
Mucosal surfaces avoided
Accidental ingestion or contact with eyes should be
Children may chew the dressing with absorption of the
One Study of children aged 6-12 years found that N2O is
superior to EMLA
Doses of drugs commonly
Irregular absorption - In some patients, fast absroption and
in some slow absorption
- Faecal material present
-Ph of the drug
-Expelling of the drug by the patient.
=If administered hih in rectum,First Pass effect come into
p-lay but where as if administered low in rectum the first
pass effect is avoided, due to difference in venous drainage.
It is not well accepted by older patients.
Radical Changes in paediatric fasting
Winternitz- association between Acid and clinical
syndrome of Pulmonary aspiration
Mendelson-Pathophysiology of Pulm. Aspi.
Changed to Regional , awake intubation
Development of cuffed ET,
suxameth/Barbiturates/Cricoid Pr./Crash Induction
Period of fasting were instituted.
Research directed to methods to decrease risk by
use of antacids(now clear)
Increase gastric motility(metclopramide)
Children are increasing risk vs. adults
Elective patient have Ph less than 2.5 with gastric
resudual volume more than 0.4ml/kg. But these
Values are not relavent in clinical pracitse.
Factors that increase aspiration
3.Bowel Obst. 4.Opiods
7.Prior oesophageal surgery
8.Difficult airway 9.Lack of Experience in
Metclopramide increase lower oesophageal
Sphincter tone and promote gastric emptying.
Delaying the operation (if possible) can decrease
the problem .
Gastric fluid 1ml/kg on admission after 4hrs.
What is the true risk of aspiration in paediatric
Olsson et al. retrospectively reported threefold
increase in child less than 10years.
7/10 aspiration are preceded by laryngospasm.
Difficult airways – more associated with
Gastric distension of stomach during induction.
Tiret etal. Reported 2 children aspirationg during
Induction and maintenance and 2 more aspiration
druing recovery period out of 40,240 cases.
1/10,000 incidence. No deaths.
Bortland et al reported an incidence of 10/10,000
case with five patients having recognised risk
factors. In ASA I & II incidence is 5/10,000 and
Optimal period of Fasting
A review of gastric physiology demonstrates that
half of the ingested Normal saline is emptied from
stomach with in 11 mins.
Fat Content, Osmolality and glucose content delay
Clear fluids administered (Adlib) to infants,
children, teenagers and even adults with in 2-3
hrs. of induction do not alter gastric residual
volume compared to patient standard fasting
Some paper found higher PH and lower residual
What are Clear Fluids?
Water, apple Juice, Jell-o-without fruit, tea
Even coffee with out milk
These given 2-3 hrs . before induction
reduces hypoglycemia and hypovolemia.
This results in happier child and parents.
Gastric residual volume in paediatric patient.
Type of Fluid
2-4 orange squash1.7
Fasting guide lines for paediatric
patients - values in hours.
More than 36 months
Michael. F.Raizen simplified lab investigations. He suggests
In children operation
with out blood loss
In Children operation
with blood loss
BUN, Glucose, Xray, ECG.
BUN,Glucose, Xray, ECG
Hb, Electrolytes, BUN
Better Psychological preparation of the child
Preparation of the parents
Creating congenial atmosphere
Correct drug , dosage & route
Prevention of complications