Pediatric Anesthesiology
Preoperative Preparation of the Pediatric Patient - 6

Premedication Options

Parents and Toys

• "Parents are often the best premedication." -G. Gordon, MD
• "The presence of the parents during induction has virtually eliminated the need for sedative premedication." -Fred Berry, MD, 1990
• Parental presence is especially helpful for children older than 4 years who have calm parents.*
• Midazolam is more effective than parental presence. - Zeev Kain, 1998*
• Anxiety associated with oral midazolam administration was significantly reduced in children who had earlier received a toy to play with. - Golden et al, 2006 *

Pharmacologic premedication options

1. Pharmacologic premedication has a role when awake separation of child from parent before induction is planned. Its success may be judged by the peacefulness of the separation.
2. Large volume of literature indicates lack of clearly ideal technic
3. midazolam (Versed)
   • PO: 0.5 to 1.0 mg/kg up to 10 mg max.
     • Bioavailability = 30%
     • Peak serum levels after about 45 minutes
     • Peak sedation by about 30 minutes
     • 85% peaceful separation
     • Mix with grape concentrate or acetaminophen (Tylenol) syrup or elixir or Motrin Suspension (10 mg/kg of the 2% suspension)
     • Mother may administer to child for better acceptance
     • Beware: total volume of dose should probably not exceed 0.4-0.5 ml/kg (NPO!)
     • 0.75 mg/kg may delay PACU discharge 30 minutes
     • 0.5 mg/kg causes anterograde amnesia beginning after 10 minutes and significant anxiolysis by 15 minutes *
     • 0.5 mg/kg slightly prolonged recovery but reduced at home sleep disturbances after adenoidectomy *
   • Nasal: 0.2 to 0.6 mg/kg
     • Peak serum level in 10 minutes
     • 0.2 mg/kg same as 0.6 mg/kg except
       • 0.2 mg/kg did not delay recovery
       • 0.6 mg/kg may delay extubation
     • Possible concern: animal studies reveal neurotoxicity after topical applicaton.
   • Sublingual: 0.2-0.3 mg/kg as effective as 0.2 mg/kg intranasal
   • Rectal: 0.35 to 1.0 mg/kg
     • Some effect by 10 minutes, peak effect 20-30 minutes.
     • 1.0 mg/kg did not delay PACU discharge.
4. methohexital (Brevital) : Rectal
   • 25 to 30 mg/kg as 10% solution in warm tap water
   • 85% sleeping within 10 minutes = rectal induction of GA (very peaceful separation)
   • sleep duration: about 45 to 90 minutes
   • 25 mg/kg did not delay recovery in one study, but some delay may be expected after a short (less than 30-minute) case.
5. ketamine
   • PO: 6 to 10 mg/kg
     • may slightly prolong time to discharge after a short case
   • IM:
     • 3 to 4 mg/kg sedation;
     • 2 mg/kg did not delay recovery
     • 6 to 10 mg/kg = IM induction of general anesthesia
     • 10 mg/kg: as effective as midazolam 1 mg/kg but some delay in recovery may be expected *
6. midazolam + ketamine : PO
   • 0.4 mg/kg + 4 mg/kg respectively
   • 100% successful separation,
   • 85% easy mask induction
   • Doubling dose leads to "oral induction of general anesthesia" in most cases. Lasts 30 to 60 minutes.
7. fentanyl "lollipops" (oral transmucosal fentanyl)
   • 15 to 20 mcg/kg
   • increased volume of gastric contents
   • nausea and vomiting
   • pruritus
   • hypoventilation (SpO₂ <90)
8. metoclopramide (Reglan)
   PO or IV: 0.2 mg/kg
9. ranitidine (Zantac)
   PO 2.5 mg/kg
10. EMLA cream
    • Eutectic mixture of lidocaine and prilocaine
    • For cutaneous application by occlusive dressing one hour preop
11. glycopyrrolate
    Consider for selected patients for planned airway instrumentation; e.g.: fiberoptic endoscopy, oral or upper airway surgery, cleft palate)
    5-10 mcg/kg IV
    10 mcg/kg IM