peadiatric premedication and preparation
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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."
peadiatric premedication and preparation
- 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
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- 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
- 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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