Midazolam as premedication: is the emperor naked or just half-dressed?

Comparison of intranasal dexmedetomidine versus oral midazolam for premedication in pediatric patients: an updated meta-analysis with trial-sequential analysis

BACKGROUND

Midazolam is routinely used as preanesthetic medication in pediatric patients. Recently, dexmedetomidine has emerged as an alternative as a premedicant. We aimed to add more evidence about the efficacy and safety of two common routes of administration for pediatric premedication: oral midazolam versus intranasal dexmedetomidine.

METHODS

We systematically searched Randomized Controlled Trials (RCTs) involving patients ≤ 18 years old undergoing preanesthetic medication and comparing intranasal dexmedetomidine with oral midazolam. Risk Ratio (RR) and Mean Difference (MD) with 95% Confidence Intervals (95% CI) were computed using a random effects model. Trial-sequential analyses were performed to assess inconsistency.

RESULTS

Sixteen RCTs (1,239 patients) were included. Mean age was 5.5 years old, and most procedures were elective. There was no difference in satisfactory induction or mask acceptance (RR = 1.15, 95% CI 0.97-1.37; p = 0.11). There was a higher incidence of satisfactory separation from parents in the dexmedetomidine group (RR = 1.40; 95% CI 1.13-1.74; p = 0.002). Dexmedetomidine was also associated with a reduction in the incidence of emergence agitation (RR = 0.35; 95% CI 0.14-0.88; p = 0.02). Heart rate and mean arterial pressure were marginally lower in the dexmedetomidine group but without clinical repercussions.

CONCLUSION

Compared with oral midazolam, intranasal dexmedetomidine demonstrated better separation from parents and lower incidence of emergence agitation in pediatric premedication, without a difference in satisfactory induction. Intranasal dexmedetomidine may be a safe and effective alternative to oral midazolam for premedication in pediatric patients.

A new view on old problems in paediatric anaesthesia: premedication, postoperative agitation and dosing

PURPOSE OF REVIEW

The aim of this review is to discuss recent developments in paediatric anaesthesia, which have evolved in an undulating fashion.

RECENT FINDINGS

The role and efficacy of pharmacological premedication is reevaluated. The anxiolytic and sedative properties of midazolam and α 2 -agonists have now been defined more precisely. Both classes of drugs have their unique profile, and there is no reason to condemn one or the other. Midazolam is an excellent anxiolytic, whereas dexmedetomidine is superior in the postoperative period and for sedation during diagnostic imaging.A total intravenous technique with propofol is often considered to be the standard for the prevention of emergence agitation; but alternatives do exist, such as a co-medication with dexmedetomidine or opioids. In clinical reality, a multimodal approach may often be advisable.The theoretical basis for propofol dosing has recently been adapted. In contrast to previous beliefs, the context-sensitive half-life of propofol seems to be quite short beyond the first year of life.

SUMMARY

Midazolam and dexmedetomidine are not interchangeable; each compound has its pros and cons. As an anxiolytic drug, midazolam indisputably deserves its place, whereas dexmedetomidine is a better sedative and particularly beneficial in the postoperative period. New data will allow more precise age-adapted dosing of propofol.

Residual unabsorbed midazolam: a case report

BACKGROUND

Oral midazolam is commonly administered to reduce anxiety in children presenting for medical procedures or surgery. It is unclear what volume of medication remains unabsorbed in the stomach when the child presents for anesthetic induction prior to these procedures. The presence of any significant residual medication in the stomach has significant clinical implications in the postoperative period.

CASE PRESENTATION

A 5-year-old white Caucasian boy presented for upper gastrointestinal endoscopy after receiving oral midazolam liquid. Insertion of the endoscope into the stomach revealed a significant amount of unabsorbed medication remaining within the gastric cavity.

CONCLUSION

Clinicians should be aware that the sedative effects of midazolam may be present before the medication is fully absorbed. A significant amount of unabsorbed medication may be present in the stomach during medical procedures/surgery. This may continue to be absorbed in the intraoperative and postoperative period, with unwanted clinical effect.

A comparative evaluation of dexmedetomidine and midazolam in pediatric sedation: A meta-analysis of randomized controlled trials with trial sequential analysis

Background

The present study with trial sequential analysis (TSA) was conducted to evaluate comprehensively the efficacy and safety of dexmedetomidine and midazolam in pediatric sedation, and to investigate whether the outcomes achieved the required information size to draw the conclusions.

Methods

PubMed, Embase, and Cochrane Library were searched from inception to October 2019. All randomized controlled trials used dexmedetomidine and midazolam in pediatric sedation were enrolled. Sedative efficacy, postoperative analgesic effect, and incidence of emergence agitation were considered as the co‐primary outcomes. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was applied to rate the quality of evidences.

Results

We acquired data from 34 studies involving 2281 pediatric patients. The results indicated that administration of dexmedetomidine was associated with less incidence of emergence agitation (RR = 0.78, with 95% CI [0.65, 0.92]) and more satisfactory sedation at parental separation (RR = 0.31, with 95% CI [0.24, 0.41]) compared to midazolam, and the current sample sizes were sufficient with unnecessary further trials. Two groups did not differ significantly in sedation level at mask induction (RR = 0.86, with 95% CI [0.74, 1.00]). And using of dexmedetomidine was associated with less incidence of postoperative analgesic rescue (RR = 0.57, with 95% CI [0.35, 0.93]), but the number of patients was too few to achieve the required information size and to draw reliable conclusions. Premedication of dexmedetomidine was associated with significant less value of SBP, heart rate, increased incidence of bradycardia, and a lower rate of shivering. And there were no differences about onset of sedation and recovery time between two groups.

Conclusions

Given that more satisfactory sedation at separation from parents and less incidence of emergence agitation, dexmedetomidine is preferred for pediatric sedation. However, compared with midazolam, the superiority of dexmedetomidine in providing adequate sedation at mask induction and postoperative analgesic effects has not yet been defined.

Comparison of Intranasal Dexmedetomidine and Oral Ketamine Versus Intranasal Midazolam Premedication for Children Undergoing Dental Rehabilitation

Background

Dental rehabilitation surgery is associated with significant fear and anxiety with subsequent psychological disturbances. Midazolam has been used frequently as a premedication. However, it may be associated with side effects. Dexmedetomidine and ketamine combination has been suggested as an effective premedication in improving preoperative sedation and analgesia.

Objectives

This study compared the effects of combined intranasal dexmedetomidine and oral ketamine versus intranasal midazolam on anxiolysis and postoperative analgesia.

Methods

Seventy-six children (aged two to six years) undergoing dental rehabilitation under general anesthesia were assigned randomly to one of the two groups (n = 38 each) receiving either intranasal dexmedetomidine at 2 µg/kg and oral ketamine at 3 mg/kg (Group DK) or intranasal midazolam at 0.2 mg/kg (group M) 30 minutes prior to the anesthesia induction. The sedation levels and parental separation state were evaluated. Time to recovery, postoperative rescue analgesia, and postoperative adverse effects were assessed.

Results

Seventy-six children completed the study. Patients in group DK had significantly lower sedation scores than those in group M after 20 and 30 min (P < 0.05). The rate of satisfactory separation showed no statistically significant difference between the two groups 30 minutes after the administration of premedication (P = 0.926). A significantly higher number of patients in group M required rescue analgesic (42%) compared to those in group DK (16%) (P = 0.012).

Conclusions

Premedication with intranasal dexmedetomidine 2 µg/kg and oral ketamine 3 mg/kg is a rapid and effective alternative in children undergoing dental rehabilitation when compared to intranasal midazolam 0.2 mg/kg.

Intranasal Fentanyl, Midazolam and Dexmedetomidine as Premedication in Pediatric Patients

Background:

Surgery is a very stressful experience for patients. Children are the most susceptible to fear, anxiety, and stress due to their limited cognitive capabilities and dependency. In children, pharmacologic agents are frequently used as premedication to relieve the fear of surgery, to make child–parental separation easy, and to carry out a smooth induction of anesthesia. We conducted this study to compare the efficacy of intranasal fentanyl, midazolam, and dexmedetomidine as premedication in pediatric patients.

Materials and Methods:

The present study was conducted prospectively on 75 patients in the age group of 2–6 years of either sex of the American Society of Anesthesiologists physical Class I or II admitted in Guru Nanak Dev Hospital, attached to Government Medical College Amritsar, scheduled to undergo surgery under general anesthesia. The patients were divided into three groups of 25 each. Group F received intranasal fentanyl 1.5 μg/kg body weight, Group M received intranasal midazolam 0.3 mg/kg body weight, and Group D received intranasal dexmedetomidine 1 μg/kg body weight as nasal drops 50 min before surgery.

Results:

Children who received intranasal fentanyl and intranasal midazolam had early onset of anxiolysis and sedation as compared to dexmedetomidine. In child-parent separation, quality of induction was better with fentanyl and dexmedetomidine as compared to midazolam. Intravenous cannulation score was best achieved with fentanyl as premedicant. Postoperative sedation was better with dexmedetomidine as compared to fentanyl and midazolam.

Conclusion:

Onset of action of fentanyl and midazolam is early as compared to that of dexmedetomidine. However, fentanyl provided better conditions for induction and emergence than midazolam. With dexmedetomidine onset of action was delayed and duration of action was prolonged which helped child to remain calm and sedated even after the surgery.

Premedication with melatonin vs midazolam: efficacy on anxiety and compliance in paediatric surgical patients

Preoperative anxiety is a major problem in paediatric surgical patients. Melatonin has been used as a premedicant agent and data regarding effectiveness are controversial. The primary outcome of this randomized clinical trial was to evaluate the effectiveness of oral melatonin premedication, in comparison to midazolam, in reducing preoperative anxiety in children undergoing elective surgery. As secondary outcome, compliance to intravenous induction anaesthesia was assessed. There were 80 children undergoing surgery randomly assigned, 40 per group, to receive oral midazolam (0.5 mg/kg, max 20 mg) or oral melatonin (0.5 mg/kg, max 20 mg). Trait anxiety of children and their mothers (State-Trait Anxiety Inventory) at admission, preoperative anxiety and during anaesthesia induction (Modified Yale Pre-operative Anxiety Scale), and children's compliance with anaesthesia induction (Induction Compliance Checklist) were all assessed. Children premedicated with melatonin and midazolam did not show significant differences in preoperative anxiety levels, either in the preoperative room or during anaesthesia induction. Moreover, compliance during anaesthesia induction was similar in both groups.

CONCLUSIONS

This study adds new encouraging data, further supporting the potential use of melatonin premedication in reducing anxiety and improving compliance to induction of anaesthesia in children undergoing surgery. Nevertheless, further larger controlled clinical trials are needed to confirm the real effectiveness of melatonin as a premedicant agent in paediatric population. What is Known: • Although midazolam represents the preferred treatment as a premedication for children before induction of anaesthesia, it has several side effects. • Melatonin has been successfully used as a premedicant agent in adults, while data regarding effectiveness in children are controversial. What is New: • In this study, melatonin was as effective as midazolam in reducing children's anxiety in both preoperative room and at induction of anaesthesia.

Comparison between dexmedetomidine and midazolam premedication in pediatric patients undergoing ophthalmic day-care surgeries

Midazolam is the most commonly used premedication in children. It has been shown to be more effective than parental presence or placebo in reducing anxiety and improving compliance at induction of anesthesia. Clonidine, an a2 agonist, has been suggested as an alternative. Dexmedetomidine is a more a2 selective drug with more favorable pharmacokinetic properties than clonidine.

Premedication with dexmedetomidine in pediatric patients: a systematic review and meta-analysis

Premedication is important in pediatric anesthesia. This meta-analysis aimed to investigate the role of dexmedetomidine as a premedicant for pediatric patients. A systematic literature search was conducted to identify randomized controlled trials comparing dexmedetomidine premedication with midazolam or ketamine premedication or placebo in children. Two reviewers independently performed the study selection, quality assessment and data extraction. The original data were pooled for the meta-analysis with Review Manager 5. The main parameters investigated included satisfactory separation from parents, satisfactory mask induction, postoperative rescue analgesia, emergence agitation and postoperative nausea and vomiting. Thirteen randomized controlled trials involving 1190 patients were included. When compared with midazolam, premedication with dexmedetomidine resulted in an increase in satisfactory separation from parents (RD = 0.18, 95% CI: 0.06 to 0.30, p = 0.003) and a decrease in the use of postoperative rescue analgesia (RD = -0.19, 95% CI: -0.29 to -0.09, p = 0.0003). Children treated with dexmedetomidine had a lower heart rate before induction. The incidence of satisfactory mask induction, emergence agitation and PONV did not differ between the groups. Dexmedetomidine was superior in providing satisfactory intravenous cannulation compared to placebo. This meta-analysis suggests that dexmedetomidine is superior to midazolam premedication because it resulted in enhanced preoperative sedation and decreased postoperative pain. Additional studies are needed to evaluate the dosing schemes and long-term outcomes of dexmedetomidine premedication in pediatric anesthesia.

Intranasal clonidine vs. midazolam as premedication in children: a randomized controlled trial

OBJECTIVE

To compare anxiolysis produced by intranasal clonidine with intranasal midazolam as premedication in children undergoing surgery.

DESIGN

Double-blind randomized controlled study.

SETTING

Tertiary-care hospital, July 2009 to June 2010.

PATIENTS

60 American Society of Anesthesiologists physical status I-II surgical patients aged 1-10 yr.

INTERVENTION

Participants randomly allocated to receive either intranasal clonidine 4 mcg/kg (Group I) with atropine or intranasal midazolam 0.3 mg/kg (Group II).

OUTCOME MEASURES

Primary: satisfactory anxiolysis at 30 min after drug administration. Secondary: satisfactory mask acceptance, times of onset of sedation and anxiolysis, drug acceptance, level of sedation, wake-up score and side effects.

RESULTS

All children achieved satisfactory anxiolysis at 30 min. Group I fared significantly better than GroupII on mask acceptance (100% in Group I vs. 80% in Group II; P=0.024), drug acceptance (93% vs. 13%; P<0.001) and proportion of patients with satisfactory wake up scores (100% vs. 53%; P<0.001). Group II patients had significantly faster onset of sedation (median 10 min vs. 15 min; P<0.05) but not that of anxiolysis compared to Group-I (median 10 min for both groups; P>0.05). Side effects were significantly more frequent in Group II.

CONCLUSIONS

Though intranasal midazolam produced faster sedation, both the drugs produced satisfactory anxiolysis at 30 min.

Comparative evaluation of midazolam and clonidine as pediatric oral premedication

BACKGROUND

Clonidine provides many desirable effects like sedation, analgesia, anxiolysis, and hemodynamic stability and these properties make it a potentially useful anesthetic premedication in the pediatric settings. The aim of this study was to compare oral midazolam (0.5 mg/kg), which is considered gold standard with oral clonidine (5 mcg/kg) as a premedication in pediatric patients.

MATERIALS AND METHODS

Sixty children classified as American Society of Anesthesiologists physical status I, aged between 2 and 12, who were scheduled to undergo an elective surgery, were enrolled for a prospective, randomized, and double blind controlled trial. They received either oral midazolam (Group M) or oral clonidine (Group C) 60 minutes before induction of anesthesia and were submitted to an evaluation of anxiety and sedation scores. We also evaluated secondary outcomes such as palatability, parental separation, effect on hemodynamic status, co-operation during venipuncture and facemask application, postoperative analgesic requirement, and recovery profile.

RESULTS

Oral midazolam had better efficacy in the preoperative period as sedative and anxiolytic (P < 0.001), allowed better cooperation during venipuncture and facemask application (P < 0.001), whereas, oral clonidine provided better palatability (P < 0.001), parental satisfaction (P < 0.001), stable perioperative hemodynamics (P < 0.001), better postoperative analgesia (P < 0.001), and night sleep pattern (P < 0.05) without any noticeable side effects (P > 0.05).

CONCLUSION

We conclude that under the conditions of this study, oral midazolam is a better medication than clonidine in children in preoperative period while clonidine is a better medication postoperatively with added advantage of palatability, hemodynamic stability, and no significant side effects.

Biomarkers and clinical tools in critically ill children: are we heading toward tailored drug therapy?

In pediatric critical care, validated biomarkers are essential for guiding drug therapy. The aim of this article is to present examples of current biomarker developments in its full breadth, including biochemical substances, physiological measurements and clinical scoring tools, with a focus on the field of circulatory, renal and neurophysiologic failure. Within each field we consecutively discuss the rationale for the selected biomarkers, studies in critically ill children, biomarker validation stage and biomarker use or potential use in drug studies and clinical drug dosing. This article demonstrates that there is paucity of properly validated biomarkers. Nevertheless, recent developments in, for instance, the field of sepsis, point us toward a future wherein, for critically ill children, drug therapy may be personalized using proteomic profiling instead of a small number of biomarkers, in order to establish a personal and dynamic disease profile.

Comparative evaluation of midazolam and butorphanol as oral premedication in pediatric patients

Background:

To compare oral midazolam (0.5 mg/kg) with oral butorphanol (0.2 mg/kg) as a premedication in 60 pediatric patients with regards to sedation, anxiolysis, rescue analgesic requirement, and recovery profile.

Materials and Methods:

In a double blinded study design, 60 pediatric patients belonging to ASA class I and II between the age group of 2–12 years scheduled for elective surgery were randomized to receive either oral midazolam (group I) or oral butorphanol (group II) 30 min before induction of anesthesia. The children were evaluated for levels of sedation and anxiety at the time of separation from the parents, venepuncture, and at the time of facemask application for induction of anesthesia. Rescue analgesic requirement, postoperative recovery, and complications were also recorded.

Results:

Butorphanol had better sedation potential than oral midazolam with comparable anxiolysis at the time of separation of children from their parents. Midazolam proved to be a better anxiolytic during venepuncture and facemask application. Butorphanol reduced need for supplemental analgesics perioperatively without an increase in side effects such as nausea, vomiting, or unpleasant postoperative recovery.

Conclusion:

Oral butorphanol is a better premedication than midazolam in children in view of its excellent sedative and analgesic properties. It does not increase side effects significantly.

Onset time for pharmacologic premedication with clonidine as a nasal aerosol: a double-blind, placebo-controlled, randomized trial

OBJECTIVES/AIM

To investigate whether nasal aerosol clonidine can reduce the onset time of preoperative sedation.

BACKGROUND

Premedication is common in the pediatric population, but the optimal agent and administration route is still a matter of debate. Clonidine has many beneficial effects in the perioperative period. Clonidine nasal drops produce a similar sedative effect as after oral administration but do not reduce the onset time. Nasal aerosol administration of drugs is generally more effective than drops and an option to decrease the onset time of clonidine.

METHODS

Pediatric ASA status 1 and 2 patients were randomized to receive placebo (P), clonidine 3-4 μg kg(-1) (C4), or clonidine 7-8 μg kg(-1) (C7) as a nasal aerosol. Acceptance of administration, pre- and postoperative sedation, and adverse events were assessed.

RESULTS

A total of 60 patients were enrolled with a median age of 3.5 years (range 0.7-6.9) and median weight of 14.8 kg (range 10-25). In the C7 group, 55% of the children were found adequately sedated at 30 min as compared to 32% in the C4 group (P = 0.1202). At 45 min, adequate sedation was seen in 65% of the patients in both C4 and C7 groups, which were both found to be significantly higher compared with the placebo control group (14%) (P-values = 0.0027 and 0.0013, respectively). The postoperative sedation profile did not differ between the three study groups.

CONCLUSIONS

Clonidine administered as nasal aerosol (3-8 μg kg(-1)) was not found to achieve adequate preoperative sedation within 30 min of administration. Despite its sedative properties, no prolongation of postoperative sedation was noted compared with placebo.

[General anaesthesia in children: a French survey of practices]

INTRODUCTION

The practice of pediatric anesthesia requires a regular update of scientific knowledge and technical skills. To provide the most adequate Continuing Medical Education programs, it is necessary to assess the practices of pediatric anesthesiologists. Thus, the objective of this survey was to draw a picture of the current clinical practices of general anesthesia in children, in France.

MATERIAL AND METHODS

One thousand one hundred and fifty questionnaires were given to anesthesiologists involved in pediatric cases. These questionnaires collected information on various aspects of clinical practice relative to induction, maintenance, recovery from general anaesthesia and also classical debated points such as children with Upper Respiratory Infection (URI), emergence agitation, epileptoid signs or anaesthetic management of adenoidectomy. Differences in practices between CHG (general hospital), CHU (teaching hospital), LIBERAL (private) and PSPH (semi-private) hospitals were investigated.

RESULTS

There were 1025 questionnaires completed. Fifty-five percent of responders worked in public hospitals (CHG and CHU); 77% had a practice that was 25% or less of pediatric cases. In children from 3 to 10 years: 72% of respondents used always premedication and two thirds performed inhalation induction in more than 50% of cases. For induction, 53% used sevoflurane (SEVO) at 7 or 8%. Respondents from LIBERAL used higher SEVO concentrations. Tracheal intubation was performed with SEVO alone (37%), SEVO and propofol (55%) and SEVO with myorelaxant (8%), 93% of respondents used a bolus of opioid. For maintenance, the majority of respondents used SEVO associated with sufentanil; desflurane and remifentanil were more frequently used in CHU. Two thirds of respondents used N(2)O. Depth of anesthesia was commonly assessed by hemodynamic changes (52%), end tidal concentration of halogenated (38%) or automated devices based on EEG (7%). In children with URI, 98% of respondents used SEVO for anesthesia. To control the airway 42% used a tracheal tube, 30% a laryngeal mask and 20% a facial mask. Emergence agitation was an important concern for two thirds of respondents, while epileptoid signs were considered as important by only 20%. Eighty-nine percent of respondents practiced anesthesia for adenoidectomy. Anesthesia was induced by inhalation of SEVO 7-8% (41%), 6% (39%) or 4% (12%), 66% put an intravenous line (less frequently in LIBERAL). 67% of the responders managed adenoidectomy without any device to control the airway (more frequently in LIBERAL), 32% administrated a bolus of opioid (less frequently in LIBERAL).

DISCUSSION

This survey demonstrated that the practices regarding general anesthesia in children are relatively homogenous. Most of the differences appeared between LIBERAL and the others structures; the anaesthetic management for adenoidectomy illustrates these findings.

[Uncooperative children during induction of anesthesia : theory and practice]

Perioperative anxiety and the resulting lack of cooperation during induction of anesthesia is a common problem in pediatric anesthesia. The extent of anxiety depends on a variety of factors concerning the child, the parents, the anesthesia team and the hospital's friendly atmosphere and infrastructure. Apart from premedication there are a number of non-pharmacological means to improve the child's cooperation and thereby facilitate the induction of anesthesia. If the child is still uncooperative despite an optimal preparation, the anesthetist has to decide whether to postpone the operation or to perform induction of anesthesia under physical restraint in consideration of various criteria.

Comparison between ketamine and fentanyl-droperidol for rectal premedication in children: a randomized placebo controlled trial

PURPOSE

A common concern of anesthesiologists is the management of children involved in stressful scenarios, and premedication is considered, in most situations, as useful to reduce the stress responses. This randomized placebo-controlled study was designed to evaluate two premedicants, ketamine versus a combination of fentanyl-droperidol, rectally administered, in pediatric surgical outpatients.

METHODS

We randomly assigned 120 children to three equal groups to be rectally premedicated with ketamine 10 mg kg(-1) (group K), fentanyl 5 microg kg(-1) + droperidol 100 microg kg(-1) (group F), or saline 0.2 ml kg(-1) (group P). A blinded observer scored the children's behavior, according to a four-category behavioral scale, before premedication (time A), 45 min after premedication (time B), immediately before venipuncture (time C), and during the venipuncture (time D). Features of the premedication technique, complications, parents' opinions, and contraindications to hospital discharge were recorded.

RESULTS

Patient discharge was delayed because of anesthesia side effects in 7 cases (5.8%) and surgical problems in 9 (7.5%). Group F showed a higher rate of postoperative nausea and vomiting (PONV) than group K, whereas the latter had a higher rate of behavioral disturbances. The data showed a significant difference in the behavioral score between groups F and P, groups K and P, and groups F and K at time B, and between groups K and P at time C. The reaction score at venipuncture shows a significant difference between groups K and P only.

CONCLUSION

In this study, premedication with rectal ketamine showed significantly better overall results in the preoperative period than premedication with either fentanyl-droperidol or placebo.

The place of premedication in pediatric practice

Behind the multiple arguments for and against the use of premedication, sedative drugs in children is a noble principle that of minimizing psychological trauma related to anesthesia and surgery. However, several confounding factors make it very difficult to reach didactic evidence-based conclusions. One of the key confounding issues is that the nature of expectations and responses for both parent and child vary greatly in different environments around the world. Studies applicable to one culture and to one hospital system (albeit multicultural) may not apply elsewhere. Moreover, the study of hospital-related distress begins at the start of the patient's journey and ends long after hospital discharge; it cannot be focused completely on just the moment of anesthetic induction. Taking an example from actual practice experience, the trauma caused by the actual giving of a premedication to a child who absolutely does not want it and may struggle may not be recorded in a study but could form a significant component of overall effect and later psychological pathology. Clearly, attitudes by health professionals and parents to the practice of routine pediatric premedication, vary considerably, often provoking strong opinions. In this pro-con article we highlight two very different approaches to premedication. It is hoped that this helps the reader to critically re-evaluate a practice, which was universal historically and now in many centers is more selective.

The effect of transmucosal 0.2 mg/kg midazolam premedication on dental anxiety, anaesthetic induction and psychological morbidity in children undergoing general anaesthesia for tooth extraction

BACKGROUND

The project aims were to evaluate the benefit of transmucosal midazolam 0.2 mg/kg pre-medication on anxiety, induction behaviour and psychological morbidity in children undergoing general anaesthesia (GA) extractions.

METHOD

One hundred and seventy-nine children aged 5-10 years (mean 6.53 years) participated in this randomised, double blind, placebo-controlled trial. Ninety children had midazolam placed in the buccal pouch. Dental anxiety was recorded preoperatively and 48 hours later using a child reported MCDAS-FIS scale. Behaviour at anaesthetic induction was recorded and psychological morbidity was scored by the parent using the Rutter Scale preoperatively and again one week later. Subsequent dental attendance was recorded at one, three and six months after GA.

RESULTS

While levels of dental anxiety did not reduce overall, the most anxious patients demonstrated a reduction in anxiety after receiving midazolam premedication (p = 0.01). Neither induction behaviour nor psychological morbidity improved. Irrespective of group, parents reported less hyperactive (p = 0.002) and more pro-social behaviour (p = 0.002) after the procedure; older children improved most (p = 0.048). Post-GA dental attendance was poor and unaffected by premedication.

CONCLUSION

0.2 mg/kg buccal midazolam provided some evidence for reducing anxiety in the most dentally anxious patients. However, induction behaviour, psychological morbidity and subsequent dental attendance were not found to alter.

Withdrawal symptoms in critically ill children after long-term administration of sedatives and/or analgesics: a first evaluation

OBJECTIVE

To establish frequencies of benzodiazepine and opioid withdrawal symptoms, and correlations with total doses and duration of administration.

DESIGN

A prospective, repeated-measures design.

SETTING

Two pediatric intensive care units in a university children's hospital.

PATIENTS

Seventy-nine children, aged 0 days to 16 yrs, who received intravenous midazolam and/or opioids for >5 days.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Pediatric intensive care unit nurses assessed withdrawal symptoms using the Sophia Benzodiazepine and Opioid Withdrawal Checklist, which includes all withdrawal symptoms (n = 24) described in the pediatric literature. Over 6 months, 2188 observations in 79 children were recorded. Forty-two percent of observations were performed within 24 hrs after tapering off or discontinuation of medication. Symptoms representing overstimulation of the central nervous system, such as anxiety, agitation, grimacing, sleep disturbance, increased muscle tension, and movement disorder, were observed in >10% of observations. Of symptoms reflecting gastrointestinal dysfunction, diarrhea and gastric retention were most frequently observed. Tachypnea, fever, sweating, and hypertension as manifestations of autonomic dysfunction were observed in >13% of observations. The Spearman's rank-correlation coefficient between total doses of midazolam and maximum sum score (of the Sophia Benzodiazepine and Opioid Withdrawal Checklist) was .51 (p < 0.001). The correlation between total doses of opioids and the maximum sum score was .39 (p < 0.01). A significant correlation (.52; p < 0.001) was also found between duration of use and maximum sum score.

CONCLUSIONS

This is the first study to report frequencies of all 24 withdrawal symptoms observed in children after decrease or discontinuation of benzodiazepines and/or opioids. Agitation, anxiety, muscle tension, sleeping <1 hr, diarrhea, fever, sweating, and tachypnea were observed most frequently. Longer duration of use and high dosing are risk factors for development of withdrawal symptoms in children.

Premedication in children: a comparison of oral midazolam and oral clonidine

BACKGROUND

Oral premedication is widely used in pediatric anesthesia to reduce preoperative anxiety and ensure smooth induction. Midazolam is currently the most commonly used premedicant, but good results have also been reported with clonidine. The aim of the present study was to compare clinical effects of oral midazolam and oral clonidine.

METHODS

We performed a prospective open study in 64 children who were randomly assigned to receive either oral midazolam 0.5 mg.kg (-1) (group M) or oral clonidine 4 microg.kg (-1) (group C) prior to mask induction. Drug acceptance, preoperative sedation and anxiolysis, quality of mask acceptance, recovery profile and parental satisfaction were evaluated.

RESULTS

The taste of oral clonidine was judged as significantly better; 14% of children rejected oral midazolam. Onset of sedation was significantly faster after premedication with midazolam (30+/-13.1 min) than with clonidine (38.5+/-14.6 min), but level of sedation was significantly better after premedication with clonidine. Quality of mask induction was equally successful in both groups. A steal-induction was performed in 66% of patients of group C, but none in group M. We observed a trend towards an increased incidence of emergence agitation after premedication with midazolam. Parental satisfaction was significantly higher in group C.

CONCLUSIONS

In this study, premedication with oral clonidine appeared to be superior to oral midazolam. Quality of mask acceptance was comparable between groups, but oral clonidine was better accepted by the child, produced more effective preoperative sedation, showed a trend towards better recovery from anesthesia and had a higher degree of parental satisfaction.

Withdrawal symptoms in children after long-term administration of sedatives and/or analgesics: a literature review. "Assessment remains troublesome"

BACKGROUND

Prolonged administration of benzodiazepines and/or opioids to children in a pediatric intensive care unit (PICU) may induce physiological dependence and withdrawal symptoms.

OBJECTIVE

We reviewed the literature for relevant contributions on the nature of these withdrawal symptoms and on availability of valid scoring systems to assess the extent of symptoms.

METHODS

The databases PubMed, CINAHL, and Psychinfo (1980-June 2006) were searched using relevant key terms.

RESULTS

Symptoms of benzodiazepine and opioid withdrawal can be classified in two groups: central nervous system effects and autonomic dysfunction. However, symptoms of the two types show a large overlap for benzodiazepine and opioid withdrawal. Symptoms of gastrointestinal dysfunction in the PICU population have been described for opioid withdrawal only. Six assessment tools for withdrawal symptoms are used in children. Four of these have been validated for neonates only. Two instruments are available to specifically determine withdrawal symptoms in the PICU: the Sedation Withdrawal Score (SWS) and the Opioid Benzodiazepine Withdrawal Scale (OBWS). The OBWS is the only available assessment tool with prospective validation; however, the sensitivity is low.

CONCLUSIONS

Withdrawal symptoms for benzodiazepines and opioids largely overlap. A sufficiently sensitive instrument for assessing withdrawal symptoms in PICU patients needs to be developed.

Premedication of the pediatric patient – anesthesia for the uncooperative child

PURPOSE OF REVIEW

Inadequate handling of an uncooperative child preoperatively results in postoperative behavior problems. Premedication enables a calm induction and helps to decrease postoperative problems. Several premedicants will be covered in this review.

RECENT FINDINGS

Questions raised about the effects of oral midazolam use in children for premedication are now finding answers. New agents (dexmedetomidine and atypical antipsychotic agents) can be alternatives in premedication, especially in severely uncooperative children. The current literature highlights the missing information about the rather older premedicants.

SUMMARY

The benefits and disadvantages of new and older drugs should be weighed against each other, and decisions should be made according to the requirements of surgery, ward conditions and the severity of psychologic, developmental or mental disease. Further studies for the evaluation of the anxiolytic, sedative and antipsychotic drugs are still required.

Oral clonidine vs midazolam in the prevention of sevoflurane-induced agitation in children. A prospective, randomized, controlled trial †

BACKGROUND

This randomized, double-blind study tested the hypothesis that, in comparison with midazolam, premedication with oral clonidine reduces the incidence of emergence agitation in preschool children anaesthetized with sevoflurane.

METHODS

Sixty-eight ASA I-II children undergoing circumcision were randomized into three groups to receive different oral premedication given 30 min before anaesthesia: midazolam 0.5 mg kg-1, clonidine 2 microg kg-1, and clonidine 4 microg kg-1. Sevoflurane anaesthesia was administered via a facemask (O2/N2O: 40/60). Analgesia was with penile block (bupivacaine 0.5% 0.3 ml kg-1) and rectal paracetamol (30 mg kg-1). During the first postoperative hour, children were evaluated using a modified 'objective pain scale'.

RESULTS

Only the 4 microg kg-1 dose of clonidine was associated with a significant reduction in emergence agitation. Fewer children in the clonidine 4 microg kg-1 group displayed agitation (25%) than in the midazolam group (60%) (P=0.025). Incidence of hypotension and bradycardia, time to first micturition and first drink did not differ among groups.

CONCLUSIONS

In comparison with midazolam, clonidine 4 microg kg-1 reduced sevoflurane-induced emergence agitation without increasing postoperative side-effects.

[Propofol for paediatric patients in ear, nose and throat surgery. Practicability, quality and cost-effectiveness of different anaesthesia procedures for adenoidectomy in infants]

BACKGROUND

The aim of this study was an improvement in patient comfort, reduction of anaesthesia costs and room contamination by the use of propofol for adenoidectomy.

METHODS

A total of 103 infants (aged 1-5 years) undergoing elective adenoidectomy were randomized for anaesthesia with sevoflurane-nitrous oxide/oxygen (group 1), sevoflurane-air/alfentanil (group 2), alfentanil-propofol under induction with sevoflurane (group 3) or alfentanil-propofol (group 4).

RESULTS

Using propofol, postoperative agitation and emesis were significantly less and the anaesthesia costs as well as the need for analgesics was reduced compared to inhalative anaesthesia.

CONCLUSIONS

The use of propofol for preschool children undergoing ear, nose and throat (ENT) surgery seems to be advantageous because of less postoperative agitation, emesis and costs.

Paediatric day-case anaesthesia and pain control

PURPOSE OF REVIEW

More surgery on children is being carried out on a day-case basis and we review the anaesthetic management. Selection of appropriate patients and procedures is vital and careful preparation of children and families minimizes fear and anxiety and streamlines the organizational aspects of care. Simple, noninvasive general-anaesthetic techniques with modern agents are recommended. Good analgesia is important and is based upon local or regional blockade, nonsteroidal antiinflammatory drugs and paracetamol, with opioids being reserved for rescue analgesia. Omission of opioids helps to minimize postoperative emesis. Discharge home is facilitated by clear instructions about activities, dressings, wound care and continuing pain control.

RECENT FINDINGS

Oral clonidine premedication, new, safer local anaesthetic agents, ultrasound guidance for blocks and prolongation of single-injection caudal blocks with clonidine or ketamine are recent developments. Guidelines for safe sedation and analgesia for procedures are available. Behavioural and cognitive changes can be seen in children after anaesthesia and surgery and parents should be informed of this possibility.

SUMMARY

Children benefit particularly from day care and recent advances in anaesthesia and pain management have allowed a huge expansion of this modality of care with a consequent reduction in the need for children to be in hospital.

Distraction with a hand-held video game reduces pediatric preoperative anxiety

BACKGROUND

Video games have received widespread application in health care for distraction and behavior modification therapy. Studies on the effect of cognitive distraction during the preoperative period are lacking. We evaluated the efficacy of an interactive distraction, a hand-held video game (VG) in reducing preoperative anxiety in children.

METHODS

In a randomized, prospective study of 112 children aged 4-12 years undergoing outpatient surgery, anxiety was assessed after admission and again at mask induction of anesthesia, using the modified Yale Preoperative Anxiety Scale (mYPAS). Postoperative behavior changes were assessed with the Posthospital Behavior Questionnaire (PHBQ). Patients were randomly assigned to three groups: parent presence (PP), PP+a hand-held VG, and PP+0.5 mg.kg-1 oral midazolam (M) given>20 min prior to entering the operating room.

RESULTS

There was a statistically significant increase in anxiety (P<0.01) in groups M and PP at induction of anesthesia compared with baseline, but not in VG group. VG patients demonstrated a decrease in anxiety from baseline (median change in mYPAS -3), the difference compared with PP (+11.8) was significant (P=0.04). The change in anxiety in the M group (+7.3) was not statistically different from other groups. Sixty-three percent of patients in VG group had no change or decrease in anxiety after treatment, compared with 26% in M group and 28% in PP group (P=0.01). There was no difference in anxiety changes between female and male patients.

CONCLUSIONS

A hand-held VG can be offered to most children as a low cost, easy to implement, portable, and effective method to reduce anxiety in the preoperative area and during induction of anesthesia. Distraction in a pleasurable and familiar activity provides anxiety relief, probably through cognitive and motor absorption.

Clonidine: an alternative to benzodiazepines for premedication in children

PURPOSE OF REVIEW

The aim of this review is to summarize the use of clonidine for paediatric premedication and to make a comparison with benzodiazepines. A routine clonidine premedication protocol is also presented.

RECENT FINDINGS

In the US 50% of young children undergoing surgery receive premedication and midazolam is the most frequently used drug. The number of trials that compare midazolam with active controls are few and this premedicant is not adequately validated. Clonidine is still used as premedication in a small number of centres but the literature on paediatric use of clonidine is steadily growing. A recent review article has concluded that the use of clonidine does enhance the quality of perioperative management in infants and children and more recent publications support the use of clonidine for premedication. Its effect on the circulation is mild but routine atropine administration is recommended. Contraindications to the use of clonidine are few. Apart from a general overview on the effects of clonidine this article will also summarise the published trials that have compared clonidine with benzodiazepines for premedication in children.

SUMMARY

Midazolam the most commonly used drug for paediatric premedication worldwide. Despite having a number of beneficial effects it is far from an ideal premedicant, especially concerning its effect on cognition/amnesia, confusion and long-term behavioural disturbances. Clonidine lacks the majority of the negative effects associated with midazolam and is associated with a number of beneficial perioperative effects. Our clinical experience of replacing midazolam with clonidine as premedicant in children, including also outpatients, has been favourable.