peadiatric premedication and preparation

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Modern Trends in Paediatric Modern Trends in Paediatric preparation and Premedicationpreparation and Premedication

Dr. P. Narasimha Reddy, MD, DA

Professor & Head

Department of Anaesthesiology

Narayana Medical College,

Nellore.

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AIMAIM

After this lecture the Anesthesiologist must be able to recognise

1. Various risk factors for pre-op anxiety 2. Interventions

a. Behavioralb. Pharmacological

3. Various psychological effects of surgery & Anaesthesia

4. Standards of pre-medication

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AIM contd..AIM contd..

5. Monitoring the patient under sedation

6. Various levels of sedation,

7. Various drugs, doses, routes & complications,

8. Fasting guidelines,

9. Necessary investigations

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Modern Trends in Paediatric Modern Trends in Paediatric Preparation and PremedicationPreparation 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 Smith-Modified Anaethetic Practice.

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Parental AnxietyParental 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.

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Childhood AnxietiesChildhood AnxietiesSome Thing is going to happenSome Thing is going to happenFantasies, hidden fears (more Fantasies, hidden fears (more dangerous)dangerous)Truthful announcement of Truthful announcement of detailsdetailsGentleGentleAvoid Medical JargonAvoid Medical Jargon

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SEPARATION ANXIETYSEPARATION 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

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Pre-op Anxiety - predictorsPre-op Anxiety - predictors

1. Age

2. Parental Anxiety

3. Temperament

4. Social adaptability

5. Coping style

6. Lack of pre-medication

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Fear of Unknown is common to Fear of Unknown is common to human beinghuman beingOlder Child is concerned aboutOlder Child is concerned aboutWhat does “put to sleep” really What does “put to sleep” really mean?mean? Will I be awaken during operation? Will I be awaken during operation?Will I move during Operation?Will I move during Operation?Am I going to die?Am I going to die?Will I be naked totally?Will I be naked totally?Concerns of mutilation andConcerns of mutilation and torture torture

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Needle Phobia - Rice summarised Needle Phobia - Rice summarised perception of needle phobiaperception of needle phobiaNeedle is perceived as direct threat Needle is perceived as direct threat to body integrity. to body integrity. Scratching my bones or pushing it Scratching my bones or pushing it all the way inall the way inNeedle Phobia-decades of Needle Phobia-decades of inadequate postoperative analgesia inadequate postoperative analgesia for children.for children.Anything is better than needle.Anything is better than needle.

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Frank and truthful disclosure of anticipated events.Family PreparationPaediatric Play therapyEncouraging physical expressionUse of toy tools and art material.Parental presence Pre-operative interview Pre-operative preparation programs

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Psychological consequences Psychological consequences of Anaesthesia and Surgery.of Anaesthesia and Surgery.

Acute: at the time of emergence from anaesthesia.Calm arousalArousableAbrupt arousalExcited 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

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Chronic: Some changes continue to adulthood.

Factors- Age, Stability of family, cultural patterns, socio economic situations.

Psychological consequences of Anaesthesia and Surgery.

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Behavioural Problems following Behavioural Problems following anaesthesia and surgery:anaesthesia and surgery:

  Meyers Eckenhoff Hannallah 

General anxiety 45% 23% 66% General regression 33% 19% 5% Enuresis 28% 26% 37% Sleep anxiety 34% 32% 65%

Eating Disturbances 33% -- --

The role of anaesthetist is very crucial.

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“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”.

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Preoperative visit by Preoperative visit by AnaesthesiologistAnaesthesiologist

Positively affects quality of induction Allowing child choices Smooth induction decreases 50-70% of

postoperative emotional changes.

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Parental PresenceParental Presence

Makes sense. Induction less frightening to child

but more frightening to the anaesthetist. Less amount of drugs. Less postoperative behavioral problems.

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PremedicationPremedication AimsAims Numerous combinations of drugs Numerous combinations of drugs Now premedication is primarily to Now premedication is primarily to produce anxiolysis.produce anxiolysis.Calm, sedated, with spontaneous Calm, sedated, with spontaneous respiration with obtunded autonomic respiration with obtunded autonomic reflexes.reflexes.Modern preoperative regimens- often Modern preoperative regimens- often painless, rapid anxiolysis with rapid painless, rapid anxiolysis with rapid emergence.emergence.

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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.

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Pre-op preparation programs Pre-op preparation programs

1. Narrative information

2. Orientation tour to O.T’s

3. Role rehearsal using dolls

4. Puppet shows

5. Coping education &

6. Relaxation skills

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Protective netProtective net

Safe sedation of children requires a protective net

Skilled personnel Vigilance Monitoring Appropriate drugs depending on age,

weight life saving equipment.

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SEDATION GUIDELINESSEDATION 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’.

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Monitoring Monitoring

1. Pulse oximetry

2. Blood pressure

3. Electro Cardiography &

4. If intubated capnography

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DEEP SEDATION (Procedural sedation)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 sedation- Monitor with Pulse oximeter.

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SCORING SYSTEMS OF EFFICIENCY SCORING SYSTEMS OF EFFICIENCY OF PREMEDICATIONOF PREMEDICATION

Scoring Scale Description Sedation1 Awake2 Awake, Calm and quiet3 Drowsy, readily responds to

verbal gentle stimuli4 Asleep, slowly responds to

verbal/gentle stimuli.5. Asleep, not readily arousable.

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Apprehension

1. None, no displayed fear or apprehension2. Little or minimal expression of fear or

apprehension3. Moderate expression of fear/apprehension4. Excessive expression of fear/apprehension

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Cooperative State1 Cooperative2 Mildly resistant, requires minimal or no restraint3 resistant, requires active restraintParental Separation1 Excellent - cooperative or asleep2 Good - slight fear or crying, quiet

with reassurance3 Fair - moderate fear/crying, not

quiet with reassurance4 Poor - Crying with need for

restraint

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Recovery BehaviorRecovery Behavior

1 Cooperative 2 Agitated or Excited 3 Crying 4 Thrashing

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Steps of preparationSteps of preparationPsychological

Premedication

Fasting guidelines

Laboratory Investigations

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Preparation of Whole FamilyPreparation of Whole Family

Advantages

Ease of Induction

Increased tolerance to stress

Decreased long lasting behavioural effects.

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Drugs and routes of Drugs and routes of AdministrationAdministration

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

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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.

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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.

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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

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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,oral-0.3

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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

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MidazolamMidazolam 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.

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KETAMINEKETAMINE 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 .

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KETAMINEKETAMINE

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..

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BARBITURATESBARBITURATES 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.

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KetorolacKetorolac

NSAID, no resp. depression Dose - 0.5to1mgm/kg. Route-oral, im and iv too Careful in Renal problems, Asthmatics,

bleeding diathesis.

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EMLAEMLALidocaine+ PrilocaineLidocaine+ PrilocaineOcclusive dressing for 30-60minutes.Occlusive dressing for 30-60minutes.For venepuncture, Lumbar Puncture or before skin For venepuncture, Lumbar Puncture or before skin

infiltration.infiltration.If large dose is used - MethhaemogobinaemiaIf large dose is used - MethhaemogobinaemiaMucosal surfaces avoided Mucosal surfaces avoided Accidental ingestion or contact with eyes should be avoided.Accidental ingestion or contact with eyes should be avoided.Children may chew the dressing with absorption of the drug.Children may chew the dressing with absorption of the drug.One Study of children aged 6-12 years found that N2O is One Study of children aged 6-12 years found that N2O is

superior to EMLAsuperior to EMLA

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Doses of drugs commonly Doses of drugs commonly used:used:

 Drug Dose mgm/kg. Route

Barbiturates

 Methohexital 20-30 10% rectal,

 Thiopentone 20-30 rectal

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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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Route of admn. Advantages Disadvantages Oral painless slow onset IM reliable painful, threatening,

Rapid onset sterile abscess Rectal rapid, reliable painful defaecation

Irregular/delayed Absorption Nasal reliable uncomfortable Desaturation

Child Parent Objection

 Transoral, Muco oral reliable slow onset, nauseaVomiting,

desaturation  IV most reliable Painful, threatening 

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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.

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Fasting GuidelinesFasting 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.

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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.

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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.

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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

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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 all recovered.

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Optimal period of FastingOptimal 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.

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What are Clear Fluids?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.

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Gastric residual volume in paediatric patient. Gastric residual volume in paediatric patient.   

Author Population N0. Fasting Type of Fluid pH Residual Hours. Volume ml/kg.   Schreiner Children 68 Standard NPO 1.77 0.57 53 2 apple juice 1.81 0.44 Water, jell-o   Splinter Children 40 Standard NPO 1.7 0.43

40 2-3 Applejuice 2.2 0.24     Splinter Children 64 Standard NPO 1.7 0.39

57 2-3 Clear fluids 1.8 0.34     Meakin Children 55 4-6 NPO 1.9 0.25 34 2-4 orange squash1.7 0.39 32 2-4 drinks,biscuits 1.8 0.46

      Splinter Adolescent 76 std NPO 1.6 0.48 76 2-3 Applejuice water 1.8 0.46  

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Fasting guide lines for paediatric Fasting guide lines for paediatric patients - values in hours.patients - values in hours.

Milk/solids Clear fluids

Old New Old New

  New born-6months 4 4 2 2 6months-36months 6 6 6 3 More than 36 months 8 8 8 3

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Lab InvestigationsLab Investigations

Michael. F.Raizen simplified lab investigations. He suggests

In children operation with out blood loss - No investigations In Children operation - Hb, with blood loss grouping&crossmatching CVS diseases - BUN, Glucose, Xray, ECG. Respiratory diseases - BUN,Glucose, Xray, ECG Bleeding Conditions - PTT, BT Renal- Hb, Electrolytes, BUN

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Conclusions Conclusions

1. Better Psychological preparation of the child

2. Preparation of the parents

3. Creating congenial atmosphere

4. Protective net

5. Correct drug , dosage & route

6. Prevention of complications

7. Sedation guidelines

8. Lab investigations

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PleaseWake UpPleaseWake Up&&Thank YouThank You