Pro Pre Medication in Neonates

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ELIZEUS HANINDITO

DEPT. ANESTHESIOLOGY & INTENSIVE THERAPY

MEDICAL FACULTY ² AIRLANGGA UNIVERSITY DR.SOETOMO

GENERAL HOSPITAL



Pediatric AnesthesiaPediatric Anesthesia

Anesthetics (premedication)consideration for pediatric

surgery

Age-specific

consideration

Case-specific

consideration



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



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.



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



Pharmacologic PremedicationPharmacologic Premedication

MidazolamMidazolam

DiazepamDiazepam

Sulfas AtropineSulfas Atropine

K etaminK etamin

ClonidineClonidineDexmedetomidineDexmedetomidine

FentanylFentanyl



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



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



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.



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.



EMLA CreamEMLA Cream



Steal premedication/inductionSteal premedication/induction



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.



Neonatal

Premedication & Anesthesia



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.



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



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



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·



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



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 )



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



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.



� 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



� 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



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



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.



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



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.

Pro Pre Medication in Neonates

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