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Indian J. Anaesth.

LAKSHMI : PAE &2004; 48 (5) : 347-354
PREMEDICATION 347

PREANAESTHETIC EVALUATION AND
PREMEDICATION IN PAEDIATRICS
Dr. Lakshmi Vas

Introduction parental approval of the doctor and are less likely to be
The outcome of any anaesthetic is determined by wary of him at the next meeting in OT.
how well prepared the anaesthesiologist is, to handle that In our country the workload per doctor is such that
particular patient. The pre operative visit paves the way medical aspect of anaesthesiology takes precedence over
for medical and the equally important psychological aspect the psychological impact of these treatments on the child.
of preparation. A conscious effort is made in this article to stress the
The lifespan of the paediatric patient might not importance of the attitude, approach and gentleness so
have been long enough for a clear manifestation of essential in a paediatric anaesthesiologist.
symptoms of any underlying problem. Only a careful
Psychological aspects of hospitalization, surgery and
assessment by an experienced anaesthesiologist would identify
attendant procedures
any syndrome or genetic disorder that requires the
anaesthetic management to be custom designed for that Children admitted to hospital are displaced from
child at that point of time. their comfort zone of home, family and siblings. Usually
shorter the stay more fleeting this effect is in paediatric
Anaesthesiology OPD is a screening clinic to
determine the need for a detailed work up of any underlying hospitals, designed for a playful child vis-à-vis personnel
medical condition. Optimal use of this facility avoids attitude, ambience and equipment. However in India, it
unnecessary postponements, suboptimal utilization of becomes necessary to treat children in an adult facility
operation theatre, personnel and parental time. Instructing as we have very few hospitals dedicated exclusively for
urban parents to call and inform about any intercurrent children. The prevailing atmosphere in an adult hospital,
illnesses like upper respiratory infection (URI), diarrhea businesslike, clinical, somber is totally unsuitable for a
etc., is particularly useful in “Daycare” patients who come scared child. Even a short stay can be traumatic enough to
in only on the day of surgery. This avoids inconvenience to induce a lifelong aversion to hospitals. Children who have
the hospital and economic loss for parents who would have had previous surgeries, long hospital or ICU stays may
taken time off, travelled long distances etc. suffer lasting psychological effects. They require more
effort to establish rapport, but it is definitely worth the
Children cannot comprehend the need for
hospitalization or treatment. It is imperative to establish time and energy spent.1,2
rapport with the patient and the family with a preoperative When one meets a child it is important to bend or
visit. Seen without the face mask and OT apparel, kneel down to establish eye contact at the child’s level,
anaesthesiologist ceases to be the faceless person who introduce oneself and say hello to the child first so that he
just gives “chloroform”. Discussions of the options is the center of attention. Then proceed to have a social
available for preoperative comfort, the intraopeartive conversation before unobtrusively guiding the conversation
safety, and post operative recovery with optimal pain to the child’s procedure in hospital, anaesthesia, about nice
management emphasizes the role of the anaesthesiologist smelling, laughing gas (nitrous oxide) that is ‘magic’. That
as a concerned, dynamic preoperative physician who this magic gas may make him sleepy, laugh, giggle or even
plays a vital role at a difficult time in the medical history
be silly before drifting off to sleep. When the surgery is
of their child. This goes a long way in changing the public
over, he/she will magically wake up with mummy there.
perception of our specialty. Even shy children are naturally
This effort usually takes less than 5-10 mins but this time
curious and astute observers. They get influenced by the
spent makes all the difference to the child and family and
M.D., Consultant Paediatric Anaesthesiologist and finally to ourselves.
Interventional Pain Specialist.
Correspond to : Factors governing the psychological response of a child
Dr. Lakshmi Vas Psychological preparation and premedication are much
E-mail : lakshmi1@hotmail.com
needed in neonates and infants. They are comfortable with
348 PG ISSUE : PAED ANAESTH INDIAN JOURNAL OF ANAESTHESIA, OCTOBER 2004

anybody who handles them gently since communication is Children older than 4-6 years from a cosmopolitan
more by handling than verbal. Sedatives may increase the upbringing are easier to communicate with. Our children
risk of apnoea and interfere with early resumption of feeds. from rural areas or reclusive or small families with limited
However it must be understood that analgesia for any painful interaction with people may still be shy and overawed.
procedure is mandatory as it is indisputable that neonates This age group has quite an active imagination and may
do feel pain and its adverse effects. imagine and dread the weirdest and worst things happening
to them. An intelligent child exposed to urban elite parental
Infants more than 6 months do resent separation
conversations will have an active mind which wonders about
from parents and it is advisable to either have the parent
everything including death and what happens after (After
hold the child for “stealing with inhalational induction”.
all India is the land of Markandeya, Nachiketa, Prahlad
The angle piece without the mask is held away from the
and Dhruva, all children who wondered about life, death
face to create a cloud of anaesthetic (simple nitrous oxide
and after life). They may not articulate these thoughts but
and/or halothane in oxygen) or a nipple from which the
the underlying fear may be there. They need an honest,
infant sucks (fig. 1,2). The parental touch and voice soothes
reassuring explanation of the premedication and induction
the baby while he goes to sleep. Without this individualized
etc. It is best to liken the sedation and anaesthesia to their
attention, infants and toddlers 6 m – 5 years, may develop
normal routine like sleeping at night and waking up next
post hospitalization regressive behaviour, fear of separation,
morning. And emphasize that they will wake up and not
clinging to mother in presence of strangers, screaming on
have dreams. They dread injections and should be reassured
entering a closed room, poor sleeping, feeding, nightmares,
that they will receive most medications orally till they go
bedwetting, loss of toilet training etc.
to sleep . They should be told about use of EMLA cream
if at all injections become necessary.
Adolescents have fears as well, but have too much
bravado to express them. They need as much reassurance
as a child but offered in a matter of fact manner as befitting
the adult they imagine themselves to be. They have
considerable anxiety and fear of breaking down, crying,
waking up halfway through surgery to feel pain etc. This is
addressed by explaining to them that anaesthesia is designed
to ensure that they will not feel pain. This is particularly
tricky when ‘wake up test’ is to be explained in patients of
scoliosis. They have to be told “You will feel as if someone
is calling you from a distance, just like your mom asking
you to get up in the morning! You will be asked to move
your fingers, toes, and feet. You may be sleepy and too
Fig. 1 comfortable to move but this little effort from you will help
us give you better results”. In this statement he has been
assured that he will be comfortable (no pain!) but capable
of doing something important enough to be woken up for.
To summarize, children of all ages need careful,
affectionate consideration at this difficult time in their
life. With a little effort, anaesthesiologists can start this
process in the preoperative visit.
Medical preparation : A careful history and
examination will reveal the presence of :
1. Airway problems (anatomical, physiological, allergic,
asthma, etc).
2. Convulsions, sleeping disturbances (obstructive sleep
apnoea, particularly in children coming for
Fig. 2
tonsillectomy).
LAKSHMI : PAE & PREMEDICATION 349

3. Cardiorespiratory problems. absence of a senior paediatric anaesthesiologist even if
there is a slightest suspicion of URI. A sudden onset of
4. Urinary and bowel problems
runny nose or cough or change in voice at home (before
5. Haematological problems like thalassaemia major and crying at a hospital environment starts) crankiness,
minor, clotting factor deficiencies, sickle cell disease irritability, a bout of fever (>390 C) and reduction in
etc., seen in some of the tribals and communities. activity or playfulness are definite indication of either the
They require a preoperative transfusion to raise their prodrome or actual infection. An observant intelligent mother
Haemoglobin above 10 gdl-1, or platelets etc., and would be the ideal person to give this information.
specific avoidance of hypovolemia, hypotension and
However it becomes impractical to postpone every
hypoxia.
suspected URI and reschedule them 6 weeks later. There
6. Inborn errors of metabolism or deficiencies may run is a gray area where ambiguity exists between a suspected
in families or communities, like pseudocholinesterase and significant URI. One of the confusing issues is to
deficiency in vysya community. distinguish between a runny nose and hoarse voice of
prolonged crying or allergic rhinitis and a frank URI. With
7. Medications that cause alterations in physiology
the rising vehicular and industrial pollution, chronic dry
and interact with anaesthetic drugs particularly relevant
cough or a runny nose at a specific time of the day or
are corticosteroids, cardiorespiratory medications
season is not uncommon. Such a history in a bouncy playful
(b stimulants, ophthalmic drugs), anticonvulsants, and
child, who has been investigated to be normal, is unlikely
chemotherapeutic agents which cause serious
to be URI.
compromise like bone marrow depression, pulmonary
fibrosis (bleomycin), cardiac (adriamycin) or renal Benefit of doubt and judicious anaesthesia may be
(cis platinum) side effects. given to a clear rhinitis with a dry cough or a child is
recovering from it. Obviously this concession is only for
Specific problems that require special preparation short procedures which are unlikely to lead to significant
Child with runny nose : It is one clinical situation homeostatic disturbances (eg. surface surgery on distal
where the previous experiences of the anaesthsiologist and extremities amenable to regional anaesthesia.) The choice
lack of clarity in the literature cloud the issue. A sudden of anaesthesia is such that the GA is given only to place
severe laryngospasm in a chubby child who becomes blue the regional anaesthetic block. Once the block starts acting
and bradycardic with alarming rapidity can demoralize a GA is tapered off to a minimum. Elective herniotomy done
young anaesthesiologist into lifetime of nervous indecision, to avoid an emergency surgery for obstruction is a special
postponing every child with runny nose. Conversely, consideration in this context.
previous uneventful anaesthetics in children with apparent
The anaesthesia has to be light enough for a daycare
cold may embolden one to foolhardily accept a child with
admission but deep enough to allow handling of the peritoneal
a significant URI.
sac requiring analgesia from T4 to L2 level. This aim is
There is clearly a higher incidence of respiratory possible with a brief anaestheia for a few minutes to place
complications in children with URI.3-6 Once a child has a 2 level hernia block, superficial and deep to the internal
contacted URI there is an increased incidence of adverse oblique muscle. Ilioinguinal nerve block (between the external
airway related events during the recovery period, of 6-8 oblique aponeurosis and internal oblique muscle) provides
weeks it takes for the irritability of the respiratory mucosa body wall anaesthesia. Peritoneum is anaesthetized by
to diminish (citation 1 under further reading). Cancelling depositing LA under the internal oblique muscle at the neck
and rescheduling the surgery after 2 weeks does not eliminate of the sac.
the increased frequency of problems. Thus a child who is Awake spinal anaesthesia with EMLA also achieves
postponed will be safe to anaesthetize only six weeks later. this goal. Caudal epidural may or may not, depending on
This kind of rigid protocol is essential in surgeries where the level of spread of LA in the neuraxis. A coughing fit
the airway is shared between surgeon and anaesthesiologist at the time of tying the peritoneal sac can make surgery
(cleft lip and palate corrections, thyroglossal cyst excision impossible and lead to significant desaturation. In such a
or tonsillectomies). Head neck surgeries where the access patient all care should be taken to avoid irritation of the
to airway for emergency intubation is restricted by surgical airway. In case problems develop they can be dealt with in
drapes or personnel, necessitates a planned endotracheal a planned manner. Continuous oxygen to maintain optimal
intubation eg. biopsy of lymph node from neck, torticollis, baseline oxygen in plasma and haemoglobin, b-agonist
brachial cyst etc. are relatively contraindicated in the and/or inhalation agent kept ready to relieve bronchospasm.
350 PG ISSUE : PAED ANAESTH INDIAN JOURNAL OF ANAESTHESIA, OCTOBER 2004

coughing fit is best left alone unless desaturation is The assessment of the airway will include assessment
significant.4 In that case as with laryngospasm, it is found of mandibular space; i.e assessing how many fingers can be
that a small bolus of propofol to be useful as it suppresses inserted between the mandible and hyoid. Normally 2-3
laryngeal reflexes. Refractory laryngospasm not resolving adult fingers can be accommodated.13 Any reduction should
with CPAP ventilation alone may need succinylcholine and alert the examiner to a compromised laryngoscopic view.
IPPV. Endotracheal intubation in such a case is best avoided
Any difficulty with laryngoscopy and intubation is
as it only helps the immediate ventilation but postpones the
because of a reduction of the space available inside the
problem to the post extubation period. Mask ventilation is
mouth for introduction of the laryngoscope, or increase in
preferable and lignocaine throat spray can be used to avoid
the soft tissues of the floor of the mouth that have to be
further irritation. The child should be allowed to breathe
compressed to form the line of vision to the larynx. The
without undue assistance as he is coming out of the effects
space into which the soft tissues of the tongue are compressed
of scoline. All these complications are disturbing but not
by the laryngoscope is called the mandibular space, the
life threatening provided one is prepared with drugs and
incomplete bony ring formed by the rami of mandible in
equipment ready and has the requisite experience to handle
front and hyoid bone behind. Any reduction of this space by
the situation confidently.
micrognathia and retrognathia will make laryngoscopy
It is essential to balance the risk of complications difficult. Conversely any increase in the bulk of soft tissues
against pressure from surgeons, about the need to proceed in the mouth as in lymphangioma, haemangioma or
with elective surgeries. Discretion in planning the type of mucopolysaccharide diseases can also make intubations
airway manipulation like ETT or LMA, and the ability to extremely difficult. Mucopolysaccharide diseases deserve a
manage any ensuing complications calmly and competently special mention because they have a high failure rate of
can only come from objective learning and experience. intubation even in the hands of experienced consultants.
They usually present for minor problems like hernia but
Reactive airway disease (Asthma): It is quite simple
have to be approached with extreme caution and preparation.
to manage with non irritant inhalational agents by a careful
Regional techniques may fail because of abnormal chemical
anaesthesiologist. An asthmatic child can be safely
depositions in the nervous system.12
anaesthetised after ensuring that there is no active or brewing
URI and that he receives his regular bronchodilators on the Another very simple investigation is a lateral X-ray
day of surgery. Consultation with the respiratory physician of head and neck to outline the air shadow of the upper
can help prior optimization with steroids orally, by spray airway from the mouth, oropharynx down to the tracheal..
or nebulization. It is advisable to give him a puff prior to A well taken X-ray will delineate the air shadow, the
induction. Use of LMA reduces lower airway manipulation. epiglottis and any obstructions well (fig 3). Different types
When necessary, intubation as well as extubation has to be of laryngoscopes, LMAs, fibreoptic laryngoscope, airway
done in a deeper plane of anaesthesia. devices for retrograde intubation, tube changers, airway
catheters (Cookâ), cricothyrotomy and tracheostomy should
Difficult airway : Patients with major airway
be planned and to be kept ready in such cases.
problems like Treacher Collins , Pierre Robins, Midface
hypoplasias and TM joint ankylosis may present for
corrective surgery. Other complex syndromes like Freeman
Sheldon, Aperts, Beckwith Wideman syndrome etc., may
present for other surgeries but their airway problems need
to be addressed.7-12 Muscular dystrophies may present for
orthopaedic procedures or muscle biopsy. Since it is
impossible to know all the congenital problems, references
and patient’s papers should be scrutinized for the anatomical
and physiological ramifications of the syndrome and its
implications. Presently, with easy access to internet this
kind of information is easy to come by even if libraries do
not have the relevant books on these esoteric topics. Details
of previous anaesthetic experiences should be sought for
information but not for complacence. A child with previous
uneventful anaesthetic may prove to be presently impossible
to intubate,11 because the skeletal and soft tissue
Fig. 3
abnormalities grow with the patient.
LAKSHMI : PAE & PREMEDICATION 351

Patients with major cardiovascular problems : Unlike anaemia.18 They concluded that all preterm infants less
adults cardiovascular problems are uncommon other than than 56 weeks postconceptual age were at risk, especially
congenital heart disease. The rare exceptions are those with obvious apnoea in the recovery room, and all
pheochromocytoma and adrenal hyper or hypoplasias, those ex-preterm infants with anaemia should be admitted
deposition of mucopolysaccharides in coronary arteries and monitored with oximeter as well as apnoea monitors.
causing ischaemic heart disease. The incidence of apnoea may be reduced by use of
theophylline or caffeine19 or use of regional anaesthesia17,20,21
These require a meticulous planning of anaesthesia,
unsupplemented by sedatives or other agents. Ketamine in
of cardiovascular drugs and electrolytes for medical
particular, seems to markedly increase the propensity
optimization of the patient before the surgical handling of
towards apnoea.21 However regional anaesthesia can itself
these physiologically labile patients.14
be associated with life threatening complications.22 So a
In general soft systolic variable murmurs are usually balanced view should be presented to the parents at the
innocent unless associated with symptoms. Loud, constant preanaesthetic visit and anesthesia preparation and
transmitted murmurs and diastolic murmurs are likely to management has to exemplary in this difficult subgroup of
have structural defects. History of breathlessness on exertion, infants.
inability to run and play in older children, and inability to
Post operative nausea and vomiting: Parents should
feed without breathlessness in infants and reduction of
be told that strabismus repair, tonsillectomy and middle
general activity point to a compromise. After corrective
ear reconstruction are associated with an increased risk of
surgeries in infancy residual problems like pulmonary
post operative nausea and vomiting. Use of opioids,
hypertension may persist. Cardiology consultation and a 2D
pentazocine and tramadol increases this tendency.
echocordiograft will solve the dilemma about the significance
Prophylactic preoperative use of serotonin inhibitors like
of any murmur, need for prophylactic antibiotics facilitates
ondansetron or granisetoan23 reduces this incidence. A single
the best plan of management for children with complex
preoperative dose of dexamethasone has been used in
haemodynamics.
tonsillectomy.24 Treatment of established nausea and vomiting
An impeccable perioperative analgesic management is more difficult but metoclopramide25 either preoperatively
is mandatory as is avoidance of stress and emotional or later does help in emptying the stomach and reducing the
disturbances which can provoke or worsen the dreaded vomiting.
complication of pulmonary hypertension. It is important to
Pre anaesthetic laboratory testing : Even though
reiterate that good rapport and gentle handling is vital in
institutions abroad have eschewed routine haemoglobin
children with a psychological baggage from previous surgery.
estimation and urinalysis, it is still necessary in our country
Ex-premature baby- With improved perinatal care, with parasitic infestations, malnutrition etc, if a clinical
the number of NICU graduates coming for herniotomy or examination warrants it. It is particularly indicated in infants
cataract is rising. They require special care for certain below 6 months with physiological anaemia and exprematures
vulnerabilities like apnoea, retinopathy of prematurity, are prone to iatrogenic anaemia from repeated investigations
bronchopulmonary dysplasia etc., Recommendations for and resultant apnoea risk. Special investigations may be
overnight close monitoring are controversial, whether up to warranted by the preoperative medical problems eg.,
the age of 60 weeks15 or 45 –50 weeks16 of postconceptional electrolytes in chronic diarrhea vomiting, full coagulation
age. A micro and macro (meta)analysis of 8 studies on profile for family history of bleeding diatheses or if massive
apnoea of prematurity (255 patients) from 4 institutions blood loss is expected, hormone assays in endocrine problems
over 6 years17 focused on babies having a single procedure etc.
like herniotomy under GA without special treatments like
Special pre anaesthetic preparation : Advances in
caffeine or use of regional anaesthesia. Apnoea was defined
paediatric anaesthesia have made surgeries like scoliosis
as that lasting > 15 secs or that < 15 secs but associated
correction, transplants, excision of hepatomas etc.,
with a bradycardia of <80 beatsmin-1. The risk of apnoea
possible. These may require special techniques like
was found to be inversely related to both gestational age as
induced hypotension, hypothermia, acute normovolemic
well as postconceptual age. eg. Body born at 30 weeks had
haemodilution and preoperative autologous blood collection
a higher risk of apnoea than the body born at 35 wks though
with intermittent erythropoietin injections. These procedures
both were of same postconcetual age of 50 weeks. Conversely
require a significant coordination between the family,
if both were born at 26 weeks gestational age, one who was
anaesthesiologist, haematologist and other specialities for
50 weeks of post conceptual age at surgery had a higher
immaculate preoperative planning and execution.
risk than another of 55 wks. Another major risk factor was
352 PG ISSUE : PAED ANAESTH INDIAN JOURNAL OF ANAESTHESIA, OCTOBER 2004

Preanaesthetic fasting : Instruction to the family Discretion should be used in the select group of
regarding the solid and fluid intake and the type of fluid is children at risk from premedication like those with upper
essential. Clear liquids (normal saline, apple juice, sugar airway obstruction, those with poor reflex control, prone to
water) are rapidly emptied from the stomach (half life - aspiration like incoordinate swallowing and coughing. Sleep
about 15 mins). So a limit of about 2 hours for these is apnea, central or obstructive (adenoid hypertrophy, functional
reasonable. Milk, either from a formula or breast milk or macroglossia as in Beckwith Wideman, Down’s or Pierre
cow’s milk is considered to be a solid as it curdles in the Robin syndrome) is an absolute contraindication as are
stomach, and should be restricted for 4 hours before children with muscular dystrophy with border line respiratory
anaesthesia in infants below 6 months. The fat content reserve with increased susceptibility to drugs.
which determines its gastric emptying time of the breast
The premedicant drugs : The commonly used drugs
milk depends on the maternal diet and this is the reason
to avoid separation anxiety are midazolam, and ketamine.
why it is now considered in the same category as other
An attractive alternative but presently unavailable in India
types of milk. In children more than 6 months, all solids,
and milk is restricted for 6 hours before surgery. But they is transmucosal fentanyl and oral clonidine. As we no longer
can have unlimited clear fluids for 3 hours before. This use irritant anaesthetics or succinylcholine, atropine is not
liberal approach avoids irritability, excessive hunger and specifically indicated in routine anaesthesia. Its interference
acid accumulation in the stomach with resultant problems with thermoregulation in hot climate and in children with
of aspiration. Special care should be taken to adhere to fever is a major deterrent to its routine use in our country.
strict regimen to avoid prolonged starvation in catabolic It also causes relaxation of gastro-oesophageal sphincter
states like burns, septicemia , those on enteral or parenteral and can predispose to gastro-oesophageal reflux particularly
nutrition for debilitating disorders, insulinomas etc. These in children at risk. A few situations where there is a
children are highly dependant on continuous adequate relative indication for atropine are neonates who have a
nutrition. Their IV intake has to be increased to avoid rate dependant cardiac output where bradycardia can mean
significant hypoglycemia or dehydration even with routine a significant fall in cardiac output, especially when cardiac
starvation, which would be uneventful in a normal child. depressant agents like halothane are used. Others conditions
where antisialogogue effect is necessary are oral surgery
Child with full stomach : There are very few (tonsillectomy, cleft palate), difficult intubation or when
conditions which warrant immediate surgery irrespective of secretogogues like ketamine are used. It may also be
starvation status. Usually even after prokinetic agents like preferred in strabismus surgery to forestall the oculocardiac
metoclopramide25,26, it is preferable to wait for 6 hours. reflex . Glycopyrrolate has a longer duration of action and
Exceptions may be unstable foreign body in the airway, does not cross the blood brain barrier. It can be used orally
torsion testis, volvulus, trauma with haemorrhage, or in a dose of 50 mgkg-1 in lieu of atropine
intestinal obstruction where integrity of gut is threatened
from delayed diagnosis, etc. Metoclopramide,25,26 H2 blockers The route of administration
like ranitidine are given to act while stabilizing the patient. Oral route : the physiological route is the one most
A nasogastic tube is useful to empty the stomach in various preferred by the child. Previously vallergan, triclofos, and
angles while turning the table head up, down, lateral etc. presently midazolam, ketamine singly or in combination
It is removed just prior to the rapid sequence induction to have become very popular with children and the
maintain the integrity of both cricopharyngeal and anaesthesiologists alike. The intravenous formulation of both
oesophagogastric sphincters. midazolam and ketamine have a bitter and astringent taste.
Pre medication : Best premedication is the presence So to make it palatable they have been mixed with cola,
of the parent till the child goes to sleep. However the honey, apple juice etc. Concentrated orange crushes which
parents may be equally anxious, can faint in theatre and are much sweeter than cola and can effectively mask the
they need to be escorted out by a responsible person ( taste of these drugs is prefered. Alternatively these may be
enough staff!) etc. One study compared the anxiety levels mixed with paracetamol syrup. The speed of onset can be
at critical points with 3 groups of children; One with parents, augmented by 4 minutes by the addition of sodium citrate.28
one with oral midazolam (0.5 mgkg-1) and a control group Midazolam 0.5 - 0.75 mgkg-1 with the maximum dose of
with neither. The parents with the children in the 15 mg results in a sedated child in about 10-30 minutes. By
premedication, group showed the minimum anxiety.27 45 minutes the scores for satisfactory separation start to
Occasionally a combination of parental presence as well as decline but light sedation may persist for up to 2 hours. As
premedicants becomes necessary as in autistic and mentally such, the time to hospital discharge is unchanged. Increasing
retarded children, highly intelligent children who are very the dose increases the side effects (loss of balance, blurring
anxious (eg., siblings of a doctor). of vision, dysphoria) more than enhancing the sedation. In
LAKSHMI : PAE & PREMEDICATION 353

case of an overdose it can be immediately reversed by IV route is used to give the first sedative it is necessary to
flumazenil in increments of 10 mgkg-1 upto 1 mg. remember that midazolam takes some time to induce EEG
changes of sedation (3 times more time than diazepam. So
Ketamine in a dose range of 3-10 mgkg-1 provides a
IV route does not mean instantaneous sedation unless
dissociation in that the child is distant or totally unaware,
induction agents like pentothal or propofol are used.
unlike with midazolam where the child is aware but calm.
It also has the added advantage of providing analgesia (in Intramuscular route : Was mainly used to administer
the higher range) for the prick of the IV or regional block. ketamine (5-10 mgkg-1) and atropine (0.02 mgkg-1) and
Whether the children get dreams with this is not known midazolam (50 mgkg-1) for radiotherapy, and prior to
but obvious emergence phenomena have not been reported. interventional cardiac procedures in the cath lab. Never
For avoiding dreams it is preferable to mix ketamine popular with the children, it has gone out of favour with
(5-8 mgkg-1) with midazolam (0.3-0.5 mgkg-1). Oral atropine paediatric anaesthesiologists in the last 2 decades. It has no
(0.02-0.04 mgkg-1) can oppose the sialogogue action of present relevance because it takes as much time as the oral
ketamine and possibility of laryngospasm.1,29-31 route or longer than the nasal or rectal route to act. and
is extremely unpleasant for the child.
Nasal route : The nasal route accesses the
blood stream directly from the capillaries in the nose so Conclusion
there is no first pass effect and the sedation sets in rapidly
To provide an empathetic care to a child,
within 5-10 minutes so resuscitation facility should always
anaesthesiologist has to be concerned enough to study and
be available. However it is not used commonly because the
understand the emotional needs and responses of the child,
nasal route is irritating and most children don’t like it. A
develop an easy playful upbeat manner with them, and
theoretical cause of concern is that the drugs can directly
cultivate the gentleness and consummate skill for the
access the CNS along the olfactory nerves through the
interventions needed for anasethesia. It is as important to
cribriform plate drugs with preservatives should be avoided.
acquire the art of paediatric anaesthesia as the diligence to
Midazolam and sufentanyl have been used by this route
science. This is only possible to a dedicated well informed
for the rapid onset and effectiveness. Preservative free
physician who acknowledges the importance of being
ketamine can also be used, but reserve it for those children
concerned and practices it uniformly with every child.
who are very rowdy, refuse oral premedication and need to
be quietened quickly to reduce their screaming and distress. References
Rectal route : It is usually used in the younger 1. Steward DJ. Experiences with an outpatient anesthesia service
age group still in diapers. It used to be popular for for children Anaesth Analg 1973; 52: 877.
administering methohexitone, thipentone etc., but now 2. Rita L et al. Ketamine hydrochloride for pediatric
midazolam, ketamine and atropine can be used to induce premedication; comparison to pentazocine. Anesth Analg
sedation in 9-11 mins.1 The parent can assist in the 1974; 53: 375.
administration and thus the child accepts it more readily. 3. Cohen MM, Cameron CB. Should you cancel the operation
The venous drainage of the lower rectum is into the when a child has an upper respiratory tract infection? Anesth
inferior hemorrhoidal veins which do not go into the portal Analg 1984; 72: 282.
circulation so a first pass effect is avoided. However if the 4. Rolf N, Cote CJ. Frequency and severity of desaturation
drug is placed above the pectinate line in the rectum, then events during general anesthesia in children with and without
upper respiratory infections. J Clin Anaesth 1992; 4: 200.
the superior hemmorrhoidal vein drains it into the portal
system so that the first pass metabolism in the liver and 5. Kinouchi K et al. duration of apnea in anesthetized infants
loss of effective drug does occur. Another problem is that and children required for deasaturation of Haemoglobin to
95%; The influence of upper respiratory infection.
the child may expel some of the drug.
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Mcgraw Hill : New York.

FAMILY BENEFIT SCHEME
The Indian Society of Anaesthesiologists through its family welfare programmes
support the next kin of the deceased member of ISA to the tune of Rs. 10,00,000/- ?
Contact : Dr. S.S.C. Chakra Rao, Secretary, Family Benefit Scheme, ISA.
67 B, Shanti Nagar, Kakinada – 533 003,
Tel : 09440176634, E-mail : chakrarao@yahoo.co.in