preoperative sedation and premedication in pediatrics
TRANSCRIPT
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PREOPERATIVE SEDATION AND PREMEDICATION IN PEDIATRICS
DR NIDA FATIMAJAWAHARLAL NEHRU MEDICAL
COLLEGE,AMU ALIGARH
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objectives
• Sedation and premedication• Why? --Aims of premedication!• When?• How?• Drugs for premedication!• Routes for administration!• Side effects & complications!
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• 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
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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
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•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
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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
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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
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• Allay Anxiety & fear.• Reduce saliva and airway secretions.• Enhance the hypnotic effects of general
anaesthesia.• Reduce postoperative nausea & vomiting.
AIMS OF PREMEDICATION
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• Attenuate vagal reflexes.• Produce amnesia.• ↓ volume & ↑pH of gastric contents.• Attenuate sympathoadrenal responses. • ↓amount of drug produce-unconsciousness.• Provide analgesia before surgery.
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• Untreated severe GERD • Recent apnea history• Congenital airway anomalies -macroglossia,
micronathia, etc.• Extreme Tonsillar hypertrophy• Mitochondrial or metabolic disease
Specific risks
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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
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• 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
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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
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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
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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
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•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
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• 3. Availability- adequate preoperative and postoperative nursing care
• 4. Surgical and anaesthetic management available
FACTORS AFFECTING CHOICE OF PREMEDICANT DRUG
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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
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• 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
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• 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
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• 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
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• 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
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• 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
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• Lollipop: Fentanyl-Actiq, 5–15 mcg/kg• Fentanyl levels continue to rise intraop and
contribute to postoperative analgesia.
Other routes:
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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
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• 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
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• 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
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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.
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• 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.
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• 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
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Antihistaminics
• Central antiemetic action • Sedation • Anxiolysis • H2 receptor antagonism• ά – adrenergic anatagonism • Anticholenergic properties • Potentiation of opiod analgesia
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•
• 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
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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.
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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.
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Suppress cardiovascular system
Respiratory side effects (decreased ventilation)
Hard to monitor effects
Side effects of individual drugs
DISADVANTAGES OF PREMEDICATION
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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
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• 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
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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
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Thanks!!