pro pre medication in neonates
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ELIZEUS HANINDITO
DEPT. ANESTHESIOLOGY & INTENSIVE THERAPY
MEDICAL FACULTY ² AIRLANGGA UNIVERSITY DR.SOETOMO
GENERAL HOSPITAL
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Pediatric AnesthesiaPediatric Anesthesia
Anesthetics (premedication)consideration for pediatric
surgery
Age-specific
consideration
Case-specific
consideration
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PEDIATRIC PATIENTSPEDIATRIC PATIENTS
NeonatesNeonates : 0: 0 ² ² 1 months1 months
InfantsInfants : 1: 1 ² ² 12 months12 months Toddlers Toddlers : 1: 1 ² ² 3 years3 years
SSmall childrenmall children : 4: 4 ² ² 12 years12 years
Adolescent : > 12 years Adolescent : > 12 years
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Approach depends on age Approach depends on age
Early infancy : neonateEarly infancy : neonate ² ² 7 months7 monthsParents are the primary focus..
GGentleentle, comfortable separation is usual, comfortable separation is usual..
Later infancy to about 3 yearsLater infancy to about 3 years
Separation anxiety major , outpatient if possible.
33 ² ² 6 years6 years (child become primary focus)(child become primary focus)
Explain exactly waht will happen , what you will do. Then do itExplain exactly waht will happen , what you will do. Then do itthat way (Be trustworthy !)that way (Be trustworthy !)
6 years to adolescent6 years to adolescent
Increasing involvement of patient.
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K ey points that argue of the use of sedativeK ey points that argue of the use of sedative
Preoperative anxiety in children is associated withPreoperative anxiety in children is associated withadverse outcome, treat it with sedative premedication.adverse outcome, treat it with sedative premedication.
Midazolam premedication is associated in reducedMidazolam premedication is associated in reduced
anxiety in both the children and their parents.anxiety in both the children and their parents.
Preoperative midazolam results in reducedPreoperative midazolam results in reducedpostoperative behavioural changes.postoperative behavioural changes.
Parents are more satisfied with the surgical experience,Parents are more satisfied with the surgical experience,if their kids are sedated and calm.if their kids are sedated and calm.
The use of midazolam results in antegrade amnesia that The use of midazolam results in antegrade amnesia thatis beneficial for the recovery of the child.is beneficial for the recovery of the child.
Rosenbaum , 2009
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Pharmacologic PremedicationPharmacologic Premedication
MidazolamMidazolam
DiazepamDiazepam
Sulfas AtropineSulfas Atropine
K etaminK etamin
ClonidineClonidineDexmedetomidineDexmedetomidine
FentanylFentanyl
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PremedicationsPremedications in Childrenin Children
(Versed)(Versed)
TypeType
MidazolamMidazolam
ThiopentoneThiopentone
KetamineKetamine
S. AtropineS. Atropine
ClonidineClonidine
FentanylFentanyl
RouteRoute
POPO
ININ
PRPR
IIV , POV , PO
IVIV
PO , IVPO , IV
OraletOralet
DoseDose(mg/kg)(mg/kg)
0.50.5--0.750.75
0.20.2
2020--3030
2, 42, 4--1010
0.020.02
55--10 mcg10 mcg
CommentsComments
sedatedsedated
³stunned´, painful³stunned´, painful
asleep, seizuresasleep, seizures
anesthesia, psychanesthesia, psych
scolin , intubationscolin , intubation
caudal epiduralcaudal epidural
must monitor must monitor
OnsetOnset(min)(min)
3030
11
88--1212
22--44
1010--1515
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Route of Premedication
Oral : slow onsetOral : slow onset
Rectal : uncomfort, erratic absorptionRectal : uncomfort, erratic absorption
Intranasal : rapid absorption, irritating Intranasal : rapid absorption, irritating
Sublingual : rapid absorptionSublingual : rapid absorption
Intravenous : hurtIntravenous : hurt EMLAEMLA
Intramuscular : hurt , abscessIntramuscular : hurt , abscess
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Intranasal
Oral Rectal
Sublingual
75% mask acceptance was
good. Intranasal : faster , irritant.Most parents were satisfied.Maximum sedation time :
20 minutes ² intranasal 30 minutes ² oral, rectal ,
sublingual.
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Perioperative anxiety & stressPerioperative anxiety & stress
Emergence delirium.Emergence delirium.
Maladaptive behaviour.Maladaptive behaviour.
Postoperative painPostoperative pain Night time crying.Night time crying.
Enuresis.Enuresis.
Apathy. Apathy. Withdrawl & temper tantrums. Withdrawl & temper tantrums.
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EMLA CreamEMLA Cream
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Steal premedication/inductionSteal premedication/induction
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Preoperative anxiety frequently causes resistance to mask
application. Anesthesia mask given on preoperative visit to play with
at home, may aid to establish a familiarity with the mask and alleviate mask fear.
Anxiety level in the informed group were statistically higher than in the mask group during induction.
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Neonatal
Premedication & Anesthesia
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Aims of premedication Aims of premedication
�� To allay pre To allay pre--operative fear & anxiety.operative fear & anxiety.
�� To produce amnesia & analgesia. To produce amnesia & analgesia.
�� To reduce secretion from salivary gland. To reduce secretion from salivary gland.�� To depress unwanted vagal reflex. To depress unwanted vagal reflex.
�� To potentiate anesthetics. To potentiate anesthetics.
�� To reduce incidence of PONV. To reduce incidence of PONV.
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90% wanted to be present at the induction.
75% of parents thought that their child should receive apremedicant.
70% wanted information about premedication , induction ,side-effects of anesthesia & postoperative pain therapy.
55% wanted more extensive preoperative information. 41% wanted a videotape as part of this preparation.
Non-pharmacologic premedication
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Clonidine in pediatric anesthesiaClonidine in pediatric anesthesia
Can be a useful premedicant, provided the slow Can be a useful premedicant, provided the slow
onset of sedation is acceptable.onset of sedation is acceptable.
The duration of nerve blocks can be prolonged. The duration of nerve blocks can be prolonged. For the prevention of emergence agitation, canFor the prevention of emergence agitation, can
be administered orally, rectally, as well as during be administered orally, rectally, as well as during
anesthesia by the intravenous or caudal route.anesthesia by the intravenous or caudal route.
Johr M , 2011
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DexmedetomidineDexmedetomidine
Highly specific & selectiveHighly specific & selective --2 adrenergic agonist.2 adrenergic agonist.
Anxiolysis, analgesia, antisialogogue, gastric Anxiolysis, analgesia, antisialogogue, gastric
secretion , sympatholytic effect,PO
NV secretion , sympatholytic effect,PO
NV Minimal respiratory depressant effect.Minimal respiratory depressant effect.
Dose intranasal 2 µg/kg Dose intranasal 2 µg/kg ² ² tasteless , odorless ,tasteless , odorless ,
painless.O
nset time 30 minutes.painless.O
nset time 30 minutes. The uses in children are still ¶off The uses in children are still ¶off--label·label·
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22
ClonidineClonidine Vs Vs DexmedetomidineDexmedetomidine
ClonidineClonidine
Selectivity:Selectivity: EE2:2:EE1 200:11 200:1
t1/2t1/2 F F :: 8 hrs8 hrs
PO,IV,patch,epiduralPO,IV,patch,epidural
Antihypertensive Antihypertensive
Analgesic adjunct Analgesic adjunct
Dexmedetomidine
E2:E1 1620:1
t1/2 F : 2 hrs
Intravenous
Sedative-analgesic
Primary sedative
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Endotracheal intubation are frequently performed procedures in NICU.
� 67% - morphine ( 50 - 200 µg/kg )
� 27% - fentanyl ( 1 - 10 µg/kg )
� 6% - midazolam ( 100 µg/kg )� 51% - atropine ( 10 - 20 µg/kg )
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DrugDrug Vagolytic Vagolytic Antisialagogue AntisialagogueSedation &Sedation &
Amnesia Amnesia
Atropine Atropine 3 +3 + 1 +1 + 00
ScopolamineScopolamine 1 +1 + 2 +2 + 3 +3 +
GlycopyrolateGlycopyrolate 2 +2 + 3 +3 + 00
COMPARATIVE EFFECTS OF
ANTICHOLINERGICS
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SIDE EFFECT :
� Dry mouth, difficulty in swallowing
� Fever
� Difficulty in micturation.
� Photophobia, blurring of vision.
� Excitement
� Psychotic behavior.
COMMONLY USED DRUGS :
� Atropine ± 0.02 mg/kg IV/IM
Disadvantage ± CNS excitation
Tachycardia
Fever.
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� Hyosine : 0.015 mg/kg oral or IM in children
0.3 ± 0.6 mg IM in adult.
Disadvantages : -
More mydriatic
Prolonged sedation.
� Glycopyrrolate ± 4 ± 8 Q gm/kg
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� Considering fear for needles , routes other than im / iv
prefered
1.Sedatives and hypnotics-
Midazolam- most commonly used
0.5-0.75mg/kg orally 20 mins prior
0.2-0.3mg/kg intrnasal
0.4-0.5mg/kg per rectally
Temazepam- 0.5 mg/kg orally
Chloral elixir- 35mg/kg orally
Trichlophos- 75-100mg/kg orally
Methohexital-20-30mg/kg rectally
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2. Analgesics-
Paracetamol syrup-5-10mg/kg
10-15mg/kg rectally
Diclofenac- 1.5mg/kg rectally
3. Opioids-
OTFC-in the form of lollypop
controlled dosing
onset 20-30mins
high incidence of pruritus and nauseavomiting
Pethidine-1-2mg/kg im
Morphine-o.1-o.2mg/kg im
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4. Ketamine-
6mg/kg orally
3mg/kg intranasally
3-5mg/kg im
5. Anticholinergics-
Preffered in oral surgeries , ocular surgeries , along withketamine
Atropine- 0.02mg/kg im/iv
glycopyrrolate-50ug/kg orally
4-8ug/kg im/iv
Don¶t significantly reduce laryngeal reflexes during
intubation. However they reduce incidence of hypotension during
induction.
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6. Antiemetics-
Droperidol- 0.05-0.1mg/kg
Ondansetron- 0.1mg/kg
Promethazine- 0.5mg/kg
Every route of drug administration has its own drawback
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Getting the child to the OR.Getting the child to the OR.
(Separation from their parents)(Separation from their parents)
Most children and parents arrive illMost children and parents arrive ill--informed and illinformed and ill--prepared for the stress of the situationprepared for the stress of the situation
The level of preoperative anxiety in childrenThe level of preoperative anxiety in childrendepends, in part, on the child`s age.depends, in part, on the child`s age.
1. Infants younger than 6 months of age usually1. Infants younger than 6 months of age usuallyseparate easily from their parents.separate easily from their parents.
2.2. Children 6 months to 4 years of age separate poorlyChildren 6 months to 4 years of age separate poorlyfrom their parents and are the audience for from their parents and are the audience for premedication.premedication.
3. Children 5 to 12 years of age are less concerned3. Children 5 to 12 years of age are less concernedabout separation.about separation.