Modern Trends in Paediatric Preparation and Premedication discusses: 1. Various risk factors for pre-op anxiety in children and interventions like behavioral and pharmacological approaches. 2. Psychological effects of surgery and anesthesia on children and the importance of pre-medication. 3. Guidelines for monitoring patients under sedation and different levels of sedation. 4. Common drugs used for pre-medication like midazolam, ketamine and fentanyl, their doses, routes of administration and potential complications."

1. Modern Trends in Paediatric
preparation and Premedication
Dr. P. Narasimha Reddy, MD, DA
Professor & Head
Department of Anaesthesiology
Narayana Medical College,
Nellore.
1

2. AIM
1.
2.
After this lecture the Anesthesiologist must be
able to recognise
Various risk factors for pre-op anxiety
Interventions
a.
b.
3.
4.
Behavioral
Pharmacological
Various psychological effects of surgery &
Anaesthesia
Standards of pre-medication
2

3. AIM contd..
5.
6.
7.
8.
9.
Monitoring the patient under sedation
Various levels of sedation,
Various drugs, doses, routes &
complications,
Fasting guidelines,
Necessary investigations
3

4. Modern Trends in Paediatric
Preparation and Premedication
Introduction
Whole family is under Stress
Anxiety increased by mis information
and Preconceived ideas
Psychological stress - Long
behavioural disturbances
Work of Leigh, Belton and SmithModified Anaethetic Practice.
4

5. Parental Anxiety
General: Guilt, (inability to protect the
child), loss of control, separation
anxiety,Can I manage? Financial.
Surgical: Failure of proceedure,
disfigurement, death.
Anaesthetic: Pain, Brain damage, death.
Staff Reactions: Miscommunication,
apparent lack of concern and paternalism.
5

6. Childhood Anxieties
Some Thing is going to happen
Fantasies, hidden fears (more
dangerous)
Truthful announcement of
details
Gentle
Avoid Medical Jargon
6

7. SEPARATION ANXIETY
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
Dependency behaviour
Loss of self identity, autonomy, control and
function
Individualisation of approach
7

8. 8

9. Pre-op Anxiety - predictors
1.
2.
3.
4.
5.
6.
Age
Parental Anxiety
Temperament
Social adaptability
Coping style
Lack of pre-medication
9

10. Fear of Unknown is common to
human being
Older Child is concerned about
What does “put to sleep” really
mean?
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
10

11. 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
for children.
Anything is better than needle.
11

12. Frank and truthful disclosure of anticipated events.
Family Preparation
Paediatric Play therapy
Encouraging physical expression
Use of toy tools and art material.
Parental presence
Pre-operative interview
Pre-operative preparation programs
12

13. Psychological consequences
of Anaesthesia and Surgery.
Acute: at the time of emergence from anaesthesia.
Calm arousal
Arousable
Abrupt arousal
Excited emergence
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
13

14. Chronic: Some changes continue to
adulthood.
Factors- Age, Stability of family, cultural
patterns, socio economic situations.
Psychological consequences of Anaesthesia
and Surgery.
14

15. Behavioural Problems following
anaesthesia and surgery:
Meyers
Eckenhoff Hannallah
General anxiety
General regression
Enuresis
Sleep anxiety
45%
33%
28%
34%
23%
19%
26%
32%
66%
5%
37%
65%
Eating Disturbances
33%
--
--
The role of anaesthetist is very crucial.
15

16. “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”.
16

17. Preoperative visit by
Anaesthesiologist
Positively affects quality of induction
Allowing child choices
Smooth induction decreases 50-70% of
postoperative emotional changes.
17

18. Parental Presence
Makes sense.
Induction less frightening to child
but more frightening to the anaesthetist.
Less amount of drugs.
Less postoperative behavioral problems.
18

19. Premedication
Aims
Numerous combinations of drugs
Now premedication is primarily to
produce anxiolysis.
Calm, sedated, with spontaneous
respiration with obtunded autonomic
reflexes.
Modern preoperative regimens- often
painless, rapid anxiolysis with rapid
19
emergence.

20. Universal needle phobia must be weighed
against global threat of suffocation by
mask.
EMLA made insertion of iv cannulae, LP
pain free.
Induction in the lap of the mother is
comfortable
Parent sent out after induction.
20

21. Pre-op preparation programs
1.
2.
3.
4.
5.
6.
Narrative information
Orientation tour to O.T’s
Role rehearsal using dolls
Puppet shows
Coping education &
Relaxation skills
21

22. Protective net
Safe sedation of children requires a
protective net
Skilled personnel
Vigilance
Monitoring
Appropriate drugs depending on age,
weight
life saving equipment.
22

23. SEDATION GUIDELINES
Written in 1985
Rewritten in 1992
Monitoring guidelines by Anaesthetist.
Proper drug in proper dosage.
Conscious Sedation
Medically controlled state of depressed
consciousness that
‘allows protective reflexes to be maintained, ability
to maintain spont. Resp. independently and
continuously and permits appropriate response to
physical or verbal stimuli’.
23

24. Monitoring
1.
Pulse oximetry
2.
Blood pressure
3.
Electro Cardiography &
4.
If intubated capnography
24

25. 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.
25

26. SCORING SYSTEMS OF EFFICIENCY
OF PREMEDICATION
Scoring Scale
Description
Sedation
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.
26

27. Apprehension
1.
2.
3.
4.
None, no displayed fear or apprehension
Little or minimal expression of fear or
apprehension
Moderate expression of fear/apprehension
Excessive expression of fear/apprehension
27

28. Cooperative State
1 Cooperative
2 Mildly resistant, requires minimal or no restraint
3 resistant, requires active restraint
Parental Separation
1
Excellent cooperative or asleep
2
Good
slight fear or crying, quiet
with reassurance
3
Fair
- moderate fear/crying, not
quiet with reassurance
4
Poor
- Crying with need for
restraint
28

29. Recovery Behavior
1
2
3
4
Cooperative
Agitated or Excited
Crying
Thrashing
29

30. Steps of preparation
Psychological
Premedication
Fasting guidelines
Laboratory Investigations
30

31. Preparation of Whole Family
Advantages
Ease of Induction
Increased tolerance to stress
Decreased long lasting behavioural
effects.
31

32. Drugs and routes of
Administration
Narcotics
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
32

33. Fentanyl
100 times more potent than morphine
High degree of solubility
Penetrates Blood Brain Barrier
Intermittently used – termination of action is due
to redistribution
Effects lasts for 30-45 minutes
Cause chest wall and glottic contracture and
respiratory depression
Dose 0.5 to 1.0mcgm/kg slowly – titrate.
33

34. Transmucosal Fentanyl (Lozenges or Lollipops),
Oralet.
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.
34

35. Benzodiazepines: Very useful family of drugs in
children
Diazepam:
0.1 to 0.3 mgm/kg iv or oral.
im erratic absorption, very painful
Iv Thrombophlebitis
Respiratory Depression- Combined with other
drugs.
Disadvantages – long action, painful iv injection
CNS depression common than midazolam
35

36. 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
other drugs.
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
0.3

37. Nasal-0.2 to 0.3 mgm /kg.
Effective, uncomfortable
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
37

38. Midazolam
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.
38

39. KETAMINE
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
Emergence delerium
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 .
39

40. KETAMINE
It is not known if dreaming occurs with oral
Ketamine
Some tried oral ketamine 3-6 mgm/kg with
midazolam 0.25-0.5 mgm/kg with profound
sedation.
Increase in oral dose can result in more success
rate but adverse reactions like vomiting and
profound sedation can happen.
Involuntary movements can occur..
40

41. BARBITURATES
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%
solution.
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.
41

42. Ketorolac
NSAID, no resp. depression
Dose - 0.5to1mgm/kg.
Route-oral, im and iv too
Careful in Renal problems, Asthmatics,
bleeding diathesis.
42

43. EMLA
Lidocaine+ Prilocaine
Occlusive dressing for 30-60minutes.
For venepuncture, Lumbar Puncture or before skin
infiltration.
If large dose is used - Methhaemogobinaemia
Mucosal surfaces avoided
Accidental ingestion or contact with eyes should be
avoided.
Children may chew the dressing with absorption of the
drug.
One Study of children aged 6-12 years found that N2O is
superior to EMLA
43

44. Doses of drugs commonly
used:
Drug
Dose mgm/kg.
Route
Barbiturates
Methohexital
20-30
Thiopentone
10%
rectal,
20-30
rectal
44

45. Benzodiazepines
Diazepam
Midazolam
oral
0.1-0.3
Iv
0.1-0.3
Im
not recommended
Rectal
0.2-0.3
oral
Iv
Im
Rectal
Nasal
Sublingual
0.5-0.75
0.05-0.15
0.05-0.15
0.5-0.75
0.2-0.5
0.2-0.5
45

46. Ketamine
Oral
6-10 mgs
Iv
1-3
Im
2-8
Rectal
10-15
Nasal
3-5
Sublingual 3-5
46

47. Route of admn.
Advantages
Disadvantages
Oral
painless
slow onset
IM
reliable
Rapid onset
painful, threatening,
sterile abscess
Rectal
rapid, reliable
painful defaecation
Irregular/delayed Absorption
Nasal
reliable
uncomfortable
Desaturation
Child Parent Objection
Transoral,
Muco oral
reliable
IV
most reliable
slow onset, nauseaVomiting,
desaturation
Painful, threatening
47

48. Rectal Admn:
Irregular absorption - In some patients, fast absroption and
in some slow absorption
Factors:
- 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.
48

49. Fasting Guidelines
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
increased safety.
Period of fasting were instituted.
49

50. Research directed to methods to decrease risk by
use of antacids(now clear)
H2 antagonists
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.
50

51. Factors that increase aspiration
1.Obesity
2.GI Pathology
3.Bowel Obst. 4.Opiods
5.Trauma
6.Neuro. Dysfunc.
7.Prior oesophageal surgery
8.Difficult airway 9.Lack of Experience in
Paed. Anaesthesia.
51

52. Fasting
Metclopramide increase lower oesophageal
Sphincter tone and promote gastric emptying.
H2 antagonists.
Delaying the operation (if possible) can decrease
the problem .
Gastric fluid 1ml/kg on admission after 4hrs.
0.54ml/kg
52

53. What is the true risk of aspiration in paediatric
patients?
Olsson et al. retrospectively reported threefold
increase in child less than 10years.
7/10 aspiration are preceded by laryngospasm.
Difficult airways – more associated with
aspiration.
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
53
all recovered.

54. 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
emptying.
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
Volume.
54

55. 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.
55

56. Gastric residual volume in paediatric patient.
Author
Residual
Population
N0.
Fasting
Type of Fluid
pH
Hours.
Schreiner
Children
68
53
Standard
2
NPO
apple juice
Volume ml/kg.
1.77
0.57
0.44
1.7
0.43
1.81
Water, jell-o
Splinter
Children
40
Standard
40
Splinter
Children
64
57
Meakin
Children
55
34
2-3
Standard
Applejuice
4-6
2.2
NPO
2-3
Adolescent 76
Clear fluids
std
76
0.24
1.7
NPO
2-4 orange squash1.7
0.39
2-4
drinks,biscuits
32
Splinter
NPO
NPO
2-3
0.39
1.8
0.34
1.9
0.25
1.8
0.46
1.6
1.8
0.46
Applejuice
water
0.48
56

57. Fasting guide lines for paediatric
patients - values in hours.
Milk/solids
Old
New born-6months
6months-36months
More than 36 months
4
6
8
Clear fluids
New Old
New
4
6
8
2
6
8
2
3
3
57

58. Lab Investigations
Michael. F.Raizen simplified lab investigations. He suggests
In children operation
with out blood loss
In Children operation
with blood loss
CVS diseases
Respiratory diseases
Bleeding Conditions
Renal-
-
No investigations
Hb,
grouping&crossmatching
BUN, Glucose, Xray, ECG.
BUN,Glucose, Xray, ECG
PTT, BT
Hb, Electrolytes, BUN
58

59. Conclusions
1.
2.
3.
4.
5.
6.
7.
8.
Better Psychological preparation of the child
Preparation of the parents
Creating congenial atmosphere
Protective net
Correct drug , dosage & route
Prevention of complications
Sedation guidelines
Lab investigations
59

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85. 85

86. PleaseWake Up
&
Thank You
86