ELIZEUS HANINDITO

DEPT. ANESTHESIOLOGY & INTENSIVE THERAPY

MEDICAL FACULTY – AIRLANGGA UNIVERSITY
DR.SOETOMO GENERAL HOSPITAL
 Pediatric Anesthesia

Anesthetics (premedication)
consideration for pediatric
surgery

Age-specific Case-specific
consideration consideration
 PEDIATRIC PATIENTS
Neonates : 0 – 1 months
Infants : 1 – 12 months
Toddlers : 1 – 3 years
Small children : 4 – 12 years

Adolescent : > 12 years

 PREMEDICATION

Pharmacologic premedication
&
Non-pharmacologic premedication
 Approach depends on age
 Early infancy : neonate – 7 months
Parents are the primary focus.
Gentle, comfortable separation is usual.
 Later infancy to about 3 years
Separation anxiety major , outpatient if possible.
 3 – 6 years (child become primary focus)
Explain exactly waht will happen , what you will do. Then do it that way
(Be trustworthy !)
 6 years to adolescent
Increasing involvement of patient.
Key points that argue of the use of sedative
 Preoperative anxiety in children is associated with
adverse outcome, treat it with sedative premedication.
 Midazolam premedication is associated in reduced
anxiety in both the children and their parents.
 Preoperative midazolam results in reduced postoperative
behavioural changes.
 Parents are more satisfied with the surgical experience, if
their kids are sedated and calm.
 The use of midazolam results in antegrade amnesia that
is beneficial for the recovery of the child.

Rosenbaum , 2009
Pharmacologic Premedication
Midazolam

Diazepam

Sulfas Atropine

Ketamin

Clonidine

Dexmedetomidine

Fentanyl
 Premedications in Children

Dose Onset
Type Route (mg/kg) (min) Comments
Midazolam PO 0.5-0.75 30 sedated
(Versed) IN 0.2 1 “stunned”, painful
Thiopentone PR 20-30 8-12 asleep, seizures
Ketamine IV , PO 2, 4-10 2-4 anesthesia, psych
S. Atropine IV 0.02 scolin , intubation
Clonidine PO , IV caudal epidural
Fentanyl 5-10 mcg
Oralet 10-15 must monitor
 Route of Premedication
 Oral : slow onset

 Rectal : uncomfort, erratic absorption

 Intranasal : rapid absorption, irritating

 Sublingual : rapid absorption

 Intravenous : hurt  EMLA

 Intramuscular : hurt , abscess
 Intranasal  75% mask acceptance was

 Oral good.
 Intranasal : faster , irritant.
 Rectal  Most parents were satisfied.
 Sublingual  Maximum sedation time :
 20 minutes – intranasal
 30 minutes – oral, rectal ,
sublingual.
 Perioperative anxiety & stress
 Emergence delirium.
 Maladaptive behaviour.
 Postoperative pain
 Night time crying.
 Enuresis.
 Apathy.
 Withdrawl & temper tantrums.
EMLA Cream
Steal 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
• To allay pre-operative fear & anxiety.
• To produce amnesia & analgesia.
• To reduce secretion from salivary gland.
• To depress unwanted vagal reflex.
• To potentiate anesthetics.
• To reduce incidence of PONV.
 90% wanted to be present at the induction.
 75% of parents thought that their child should receive a
premedicant.
 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 Vs Dexmedetomidine

Clonidine Dexmedetomidine
 Selectivity: 2:1 200:1  2:1 1620:1
 t1/2  : 8 hrs
 t1/2  : 2 hrs
 PO,IV,patch,epidural
 Intravenous
 Antihypertensive
 Sedative-analgesic
 Analgesic adjunct
 Primary sedative

22
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 )
 COMPARATIVE EFFECTS OF
ANTICHOLINERGICS

Sedation &
Drug Vagolytic Antisialagogue
Amnesia

Atropine 3+ 1+ 0

Scopolamine 1+ 2+ 3+

Glycopyrolate 2+ 3+ 0
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  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 nausea
vomiting
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 with
ketamine
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.
(Separation from their parents)
 Most children and parents arrive ill-informed and ill-
prepared for the stress of the situation

 The level of preoperative anxiety in children depends, in

part, on the child`s age.
1. Infants younger than 6 months of age usually separate
easily from their parents.
2. Children 6 months to 4 years of age separate poorly from
their parents and are the audience for premedication.
3. Children 5 to 12 years of age are less concerned about
separation.