Preoperative Issues in Children: Premedications

1. Preoperative Issues in Children:Premedications Amr E. Abouleish, MD, MBA Pediatric Anesthesia The University of Texas Medical Branch Galveston, Texas

2. Clarification Premedications Different than sedation in children

3. Premedications - Indications Vagolytic Agents Separation Anxiety - The Child Separation Anxiety - The Parent General Fear/Anxiety Ease Induction Improve Postoperative Pain

4. Vagolytic Agents Purpose Drying agent Reduce chance of bradycardia Indications Routine -- Depends on the anesthesiologist and institution Before succinylcholine Before awake intubation Oral vs. IM atropine Glycopyrollate

5. Separation Anxiety in the Child Begins at 6 - 9 months One may be able to distract 6-12 months of age After 12 months of age, premedication needed Sedation dose needed - child cannot handle anxiety Ends (?) at school age Recommend routine premedication Evaluate 6-12 months of age and order prn begin at 12 months end at school age

6. Postoperative Behavior Changes Types of Changes Separation Anxiety Eating Disturbances General Anxiety Apathy/Withdrawal Aggression Sleep Disturbances Occurs in 60-80% 30% by 2 weeks Most resolve by 6 months Versed reduces in first two weeks Eating Disturbances Separation Anxiety

7. Separation Anxiety in Parents Should always be present Important to have an atraumatic separation Parents must help child through behavior problems Litigation in the DSU setting Compassion for the parent

8. School Age � General Fears and Anxiety Factors Personality of child Parental anxiety Preoperative preparation Previous inductions & chronic illness Able to handle anxiety with help Parent present for induction Sedation dose in 5 - 8 yr olds (up to 3rd grade) Anxyliotic dose in older children EMLA cream for older children

9. Help Ease Induction Decrease sympathetic outflow For inhalational Acceptance of mask Decrease excitement stage

10. Improve Postoperative PainThe Issue of p.o. vs. p.r. Tylenol Rectal Tylenol Suppository Dose of 30 -40 mg/kg for therapeutic levels Onset 60 - 90 minutes Different than Tylenol solution rectally For BMT surgery, oral Tylenol (15 mg/kg) is equal or better ... vs. rectal Tylenol (15 mg/kg) vs. oral ketorolac vs. oral Tylenol with codeine Oral Tylenol less expensive than grape syrup Routine for BMT in infant < 1 year old as sole premedication

11. Premedications in Children

12. References for dosages Feld LH, Negus JB, White PF. Oral midazolam preanesthetic medication in pediatric outpatients. Anesthesiology 73:831, 1990 Davis PJ, Tome JA, McGowan FX, et al. Preanesthetic medications with intranasal midazolam for brief pediatric surgical procedures. Anesthesiology 82:2, 1995 Liu LM, Goudsouzian NG, Liu PL. Rectal methohexital premedication in children, a dose-comparison study. Anesthesiology 53:343, 1980. Rockoff MA, Goudsouzian NG. Seizures induced by methohexital. Anesthesiology 54:333, 1981. Wyant GM. Intramuscular ketalar in paediatric anaesthesia. Can J Anaesth 18:72, 1971. Hannallah RS, Patel RI. Low-dose intramuscular ketamine for anesthesia pre-induction in young children undergoing brief outpatient procedures. Anesthesiology 70:598, 1989. Gajraj NM, Pennant JH, Watcha M. Eutectic mixture of local anesthetics (EMLA) cream. Anesth Analg 78:574-583, 1994. Feld LH, Champeau MW, van Steennis CA, Scott JC. Preanesthetic medication in children: a comparison of oral transmucosal fentanyl citrate versus placebo. Anesthesiology 71:374-377, 1989.