Sedation and premedication Why? --Aims of premedication! When? How? Drugs for premedication! Routes for administration! Side effects & complications! Parental Anxiety SEPARATION ANXIETY Kids not small adults 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 Allay Anxiety & fear. Reduce saliva and airway secretions. Enhance the hypnotic effects of general anaesthesia. Reduce postoperative nausea & vomiting.

1. PREOPERATIVE SEDATION AND
PREMEDICATION IN PEDIATRICS
DR NIDA FATIMA
JAWAHARLAL NEHRU MEDICAL
COLLEGE,AMU ALIGARH

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

3. • 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

4. 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

5. •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

6. 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
Needle phobia
Fear of Unknown-older kids

7. 1. Narrative information
2. Orientation tour to O.T’s
3. Role rehearsal using dolls
4. Puppet shows/ Videos of O.R
5. Communication
6. Consent
Pre-op preparation programs

8. • Allay Anxiety & fear.
• Reduce saliva and airway secretions.
• Enhance the hypnotic effects of general
anaesthesia.
• Reduce postoperative nausea & vomiting.
AIMS OF PREMEDICATION

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

10. • Untreated severe GERD
• Recent apnea history
• Congenital airway anomalies -macroglossia,
micronathia, etc.
• Extreme Tonsillar hypertrophy
• Mitochondrial or metabolic disease
Specific risks

11.  Greater risk for aspiration
 Low gastric pH
 High residual volumes
Type Fasting time (hrs)
Clear liquids 2
Breast milk 4
Infant formula 6
Solid (fatty or fried) foods 8
Preoperative fasting

12. • 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

13. Drugs options for sedation
• Narcotics: Morphine, fentanyl
• Benzodiazpines: Diazepam, Midazolam
• Ketamine
• Barbiturate: Thiopentone, Methohexital
• Propofol
• Clonidine, Dexmedetomidine
• Chloral hydrate

14. 14
. 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

15. Routes of administration
Route of administration Advantages Disadvantages
Oral painless slow onset
IM Rapid onset
reliable
painful, threatening, sterile
abscess
Rectal rapid, reliable painful defaecation
Irregular / delayed
absorption

16. Route of
administration
Advantages Disadvantages
Nasal reliable uncomfortable,
Desaturation
Transoral,
Muco oral reliable slow onset,
nausea,Vomiting,
desaturation
IV most reliable Painful, threatening

17. 17
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

18. 18
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

19. 19
• KETAMINE Oral 6-10 mgs
Iv 1-3
Im 2-8
Rectal 10-15
Nasal 3-5
Sublingual 3-5

20. • 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

21. • 3. Availability-
adequate
preoperative and
postoperative
nursing care
• 4. Surgical and
anaesthetic
management
available
FACTORS AFFECTING CHOICE OF
PREMEDICANT DRUG

22. 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

23. • 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/transmucosal
sedatives

24. • 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

25. • 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

26. • 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

27. • 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

28. • Lollipop: Fentanyl-Actiq, 5–15 mcg/kg
• Fentanyl levels continue to rise intraop and
contribute to postoperative analgesia.
Other routes:

29. 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

30. • 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

31. • 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

32. 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.

33. • 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.

34. • 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

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

36. •
• 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

37. ANTI-EMETICS
1.Metoclopramide–0.15-0.20 mg/kg iv
2.Ondansetron-0.10-0.12 mg/kg iv
3. Droperidol 0.05-0.075 mg/kg.
4. Dexamethasone 0.1-0.2 mg/kg
Combination of metocopramide, ondansetron,
dexamethasone etc.

38. 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.

39.  Suppress cardiovascular system
Respiratory side effects (decreased ventilation)
Hard to monitor effects
Side effects of individual drugs
DISADVANTAGES OF PREMEDICATION

40. 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

41. • 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

42. 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