novel oral paediatric medication for anaesthesiologist

1. MOKA ICECUBES
( A Novel Combination of Oral Premedication in Paediatric Patients )
Dr. Tushar Chokshi M.D.
Private Practicing Anaesthesiologist
VADODARA

2. Background
• Pre surgery anxiety in children may result in preoperative and
postoperative complications
• Anxiety associated with operative procedures is distressful for children
and families
• Preoperative anxiety displayed several ways
* difficulty separating from parents
* difficulty accepting anaesthesia mask
* to access intravenous line

3. Aims & Objectives
• To provide comprehensive and easily available preparation of
premedication in paediatric patients undergoing anaesthesia
• To study the effect of combining four common drugs
Midazolam,
Ondansetron given orally as ice cubes for premedication
Ketamine
Atropine

4. Materials & Methods
• Permission of my surgical colleagues and explaining in details to the
parents of paediatric patients
• 25 paediatric patients aged from 2 to 15 years and ASA-1 selected
• Surgical procedures were
* Tonsillectomy
* Circumcision
* Congenital hernia repair
* Cervical lymph node removal
Investigations e.g. Hb, TC, DC, BT, CT, FBS and chest X-ray (sos)

5. Contd….
• Patients were given MOKA ice cubes according to age by trained OT staff
one hour before anaesthesia and surgery
• MOKA ice cubes are prepared with mixing all four drugs from IV
ampoules 2 ml each, and putting that liquid in deep freeze to form ice
• Dose was given as follows :
2 year ------ 1 ice cube
2-5 Year ---- 2 ice cubes
5-10 Year --- 3 ice cubes
10-15 Year --4 ice cubes
One Icecube Contains
Midazolam 2 ml ------ 2 mg
Ondansetron 2 ml ---- 4 mg
Ketamine 2 ml -------- 100 mg
Atropine 2 ml ----------1 mg
During one hour trained OT staffs were continuously monitoring the patient
with pulse oximeter and any nausea or vomiting were noted
&
Parents were strictly instructed to allow sleeping their child after oral ice cube
premedication

6. Oral Pharmacological Dose
( as per textbook)
• Midazolam 0.2 mg /kg
• Ondensetron 0.2 – 0.4 mg/kg
• Ketamine 6 - 10 mg /kg
• Atropine 0.1 -0.2 mg /kg

7. Results
• After one hour all patients were sedated and separated from their
parents without any difficulty
• No major side effects or complications found during one hour after oral
dose except complaint of giddiness and sleepy state mind
• Not a single patient required intubation or airway insertion
• During one hour clinically patients’ vitals were stable & SpO2
maintained very well between to 95 to 100 % without oxygen

8. Discussion
• Preoperative period is a stressful event for the majority of paediatric
patients undergoing surgery and anaesthesia
• Pharmacological and behavioural interventions are used to treat
preoperative anxiety in children and their parents
• In order to alleviate physiological and psychological effects of
preoperative anxiety in children, most anaesthesiologists use either
presence of parents or sedative premedication, since separation from
parents and induction of anaesthesia are considered the most stress
inducing phases

9. Contd…
• Anaesthesiologists who allow presence of parents during
induction of anaesthesia and oral sedative premedication win the
situation
• All four drugs are given orally as an individual agent but none of
them alone if given orally gives good sedation or favourable
condition to separate paediatric patient from their parents
• After combining all four drugs and given orally the absorption is
from 16 to 25 %
• side effects of each individual drug less in orally than given by
other routes e.g. IV or IM, but sedative effect is good to control
paediatric patient

10. Conclusion
• MOKA ice cube is novel mixture of Midazolam, Ondansetron, Ketamine
and Atropine
• After oral premedication all paediatric patient are calm, cool, quiet,
sleepy and separation from their parents are without any problem
• We do not find any crying, rowdiness, injection fear or anxiety in both
patients as well as in parents