Premedication with intranasal midazolam in pediatric anesthesia

To evaluate nasally administered midazolam 0.2 mg.kg-1 for preinduction of anaesthesia in paediatric patients the authors studied ASA 1 patients scheduled for elective surgery. Forty-five children, ages 3 to 126 months, were randomized in three groups: group D (n = 16) received diazepam 0.33 mg.kg-1 orally, group P (placebo) (n = 13) 0.04 ml.kg-1 normal saline via the nasal route; in group MDZ (n = 16) the children were given intranasal midazolam 0.3 mg.kg-1. The premedication was assessed on a 5-point sedation scale, modified to include the response to mask placement and the quality of the induction of general anaesthesia. The degree of sedation, heart rate, blood pressure, respiratory rate and oxygen saturation levels were recorded on the arrival in the operating room (0 min) and 3, 6, 9, 12 and 15 min (mask placement) after drug administration. With intranasal midazolam sedation was demonstrable at 6 min and was significant at 9 and 12 min. In this group all the children were calm or drowsy. The induction of anaesthesia was equivalent in group D and MDZ but easier than in those patients receiving normal saline. Vital signs did not change during the study period in any of the three groups. Intranasal midazolam was slightly more effective than oral diazepam. In children, it produces anxiolysis and sedation with rapid onset and is an attractive alternative to other routes for preanaesthetic medication.     

Premedication of children with oral midazolam

In a randomized, double-blind, placebo-controlled study, the safety, efficacy and feasibility of oral midazolam premedication in children were evaluated in an ambulatory surgery unit. Eighty unmedicated children (ASA PS I or II, ages 1-6 yr) were randomly assigned to one of four groups receiving midazolam 0.5, 0.75, or 1.0 mg.kg-1 or a placebo 30 min before separation from parents. Heart rate, systolic blood pressure, arterial oxygen saturation, respiratory rate, sedation and anxiolysis scores were recorded before premedication, every five minutes for 30 min and then during induction of anaesthesia and recovery. We found that heart rate, systolic blood pressure, arterial oxygen saturation and respiratory rate were unchanged during the study. Sedation and anxiolysis scores in the midazolam-treated groups were greater than those in the placebo group and that anxiolysis at the time of separation from the parents was judged excellent in 80-90% of the children who received midazolam. However, sedation and anxiolysis did not differ among the three midazolam groups. Mean times to discharge from hospital were similar for all four groups. The side effects, loss of balance and head control, blurred vision and dysphoric reactions were observed only in the 0.75 and 1.0 mg.kg-1 midazolam groups. We conclude that oral midazolam 0.5 mg.kg-1 is a safe and effective premedication and that 0.75 and 1 mg.kg-1 while offering no additional benefit, may cause more side effects.     

术前口服咪达唑仑对患儿七氟醚麻醉苏醒期躁动的影响

目的评价术前口服咪达唑仑对患儿七氟醚麻醉苏醒期躁动的影响。方法选择择期七氟醚麻醉下行扁桃体/腺样体切除术的患儿60例,男34例,女26例,年龄2~7岁,ASAⅠ或Ⅱ级,将入选患儿随机分为低剂量咪达唑仑组(M1组)、高剂量咪达唑仑组(M2组)和对照组(C组),每组20例。麻醉前30min分别给予M1组和M2组患儿分别口服咪达唑仑0.5 mg/kg和0.75 mg/kg,口服10%葡萄糖混合液5ml。吸入8%七氟醚行麻醉诱导,术中吸入七氟醚及静脉泵注瑞芬太尼维持麻醉。记录患儿分离焦虑量表(PSAS)评分、麻醉苏醒谵妄量表(PAED)评分和FLACC疼痛评分,并记录拔除气管导管时间和滞留PACU时间。结果 C组患儿的分离焦虑发生率明显高于其他两组(P0.05)。三组苏醒期躁动发生率、最高PAED评分、FLACC疼痛评分以及拔除气管导管时间差异均无统计学意义。M2组滞留PACU时间明显长于其他两组(P0.05)。结论术前口服咪达唑仑0.5mg/kg或0.75mg/kg能有效减轻患儿术前分离焦虑,但不能减少七氟醚麻醉苏醒期躁动的发生,咪达唑仑0.75mg/kg会延长PACU滞留时间。     

Premedication with melatonin vs midazolam in anxious children

Aim: Failure of dental treatment caused by anxiety is a common problem in children. Oral midazolam has been the most commonly used premedication for pediatric patient but the use of midazolam may be associated with paradoxical reactions in children. Melatonin may induce a natural sleepiness and improve sedation. We have investigated premedication with melatonin compared with midazolam in children under nitrous oxide/oxygen (N₂O/O₂) sedation for dental treatment. Methods: In a randomized study, 60 children received either 3 mg of melatonin [Melatonina (3 mg®) 60 min before the procedure (n = 15); group I], 0.5 mg·kg^?1 melatonin 60 min before the procedure (n = 15; group II), 0.75 mg·kg^?1 midazolam [Dormicum (15 mg/3 ml ®) 15 min before the procedure (n = 15); group III] or 3 ml of 0.09 NaCl 15 min (n = 7) or 60 min before the procedure (n = 8; group IV) orally. The children were sedated with 40/60% N₂O/O₂ inhalation. The heart rate and O₂ saturation were monitored during the treatment period. The level of sedation was assessed according to the Ramsay Sedation Scale. The children’s sedation success during dental treatment was classified. The sedation success and other sedation‐related events recorded. Comparisons among the four groups were made using one‐way anova or Kruskal–Wallis test, and if any significant differences were noted, the Tukey’s HSD or Mann–Whitney U‐test were used for intergroup comparisons. All differences were considered significant at P < 0.05. Results: The evaluation of sedation success was as follows: group I: satisfactory (n = 1), average satisfactory (n = 4), and unsatisfactory (n = 10); group II: satisfactory (n = 2), average satisfactory (n = 3), and unsatisfactory (n = 10); group III: satisfactory (n = 9), average satisfactory (n = 6); and group IV: satisfactory (n = 1), average satisfactory (n = 3), and unsatisfactory (n = 11). Conclusion: In these doses and clinical conditions, melatonin was similar to that of placebo and did not contribute to N₂O/O₂ sedation of anxious children.     

Premedication in children: hypnosis versus midazolam

BACKGROUND: The main objectives of premedication in children are to facilitate the separation from the parents, to reduce preoperative anxiety, to smooth the induction of anesthesia and to lower the risk of postoperative behavioral disorders. The most common technique is sedative premedication with midazolam. Hypnosis enables a state of relaxation to be achieved and has never been evaluated as a premedication technique. The aim of the present study was to evaluate the efficacy of hypnosis on anxiety and perioperative behavioral disorders versus midazolam. METHODS: Fifty children from 2 to 11 years of age were randomized into two groups: group H received hypnosis as premedication; group M were given 0.5 mg x kg(-1) midazolam orally, 30 min before surgery. Preoperative anxiety was evaluated using the Modified Yale Preoperative Anxiety Scale (mYPAS) score when arriving in the department (T1), when entering the operating room (T2), and when fitting the facemask (T3). Postoperative behavioral disorders were evaluated using the Posthospitalization Behavioral Questionnaire (PHBQ) at days 1, 7 and 14. RESULTS: The two groups showed no significant difference preoperatively with the PHBQ: (M) 21 (17-25) vs (H) 20 (8-25) and mYPAS score: (M) 28 (23-75) vs (H) 23 (23-78). The number of anxious children was less during induction of anesthesia in the hypnosis group (T3: 39% vs 68%) (P < 0.05). Postoperatively, hypnosis reduced the frequency of behavior disorders approximately by half on day 1 (30% vs 62%) and day 7 (26% vs 59%). CONCLUSIONS: Hypnosis seems effective as premedication in children scheduled for surgery. It alleviates preoperative anxiety, especially during induction of anesthesia and reduces behavioral disorders during the first postoperative week.     

Maintenance and recovery characteristics after sevoflurane or propofol during ambulatory surgery in children with epidural blockade

PURPOSE: To compare the maintenance and recovery characteristics after sevoflurane with those after propofol in children with epidural blockade. METHODS: Fifty unpremedicated, children ASA I-II, 2-8 yr of age, scheduled for elective urological surgery as outpatients, were randomly allocated to receive either: 1) sevoflurane for induction and maintenance of anaesthesia or 2) propofol for induction (2-3 mg.kg-1 i.v.) and for maintenance (5-10 mg.kg-1.hr-1 i.v.). All children received N2O 70% in oxygen before induction and throughout the anaesthetic, rocuronium for neuromuscular blockade and a lumbar or caudal epidural block before incision. Heart rate (HR), systolic blood pressure (SBP), recovery times and all side effects during maintenance and recovery were recorded by a blinded observer. Adverse events during the first 24 hr were also recorded. RESULTS: Mean HR increased 5-10% after induction in both groups reaching a maximum by five minutes. Heart rate returned to baseline by skin incision in the sevoflurane group and by 10 min after induction in the propofol group. During maintenance, HR decreased by 10-20% below baseline values by 20 min in the propofol group only, where it remained for the remainder of the anaesthetic. Similarly, SBP increased by 10% after induction of anaesthesia in both groups, but returned to baseline by 10 min. Light anaesthesia occurred in four (16%) children, all in the propofol group. Emergence and recovery indices were similar in the two groups. DISCUSSION: Sevoflurane and propofol exhibit similar maintenance and recovery profiles when combined with epidural analgesia in children undergoing ambulatory surgery.     

Premedication with nasal s-ketamine and midazolam provides good conditions for induction of anesthesia in preschool children

PURPOSE: To evaluate the efficacy and safety of intranasally administered s-ketamine and midazolam for premedication in pediatric patients. METHODS: Ninety children were randomly allocated to receive intranasally administered s-ketamine 1 mg.kg(-1) and midazolam 0.2 mg.kg(-1) (Group K1, n = 30), s-ketamine 2 mg.kg(-1) and midazolam 0.2 mg.kg(-1) (Group K2, n = 30), or midazolam 0.2 mg.kg(-1) (Group M, n = 30) as premedicants, using a double-blind study design. Sedation and anxiolysis were evaluated using a sedation and cooperation scale and recorded at several time points. RESULTS: Acceptable conditions (K1: 23; K2: 26, M: 19) for parental separation were not different between groups. Induction conditions were acceptable in 26 patients in K2 (P < 0.05 vs M) (K1: 23; M: 19). Compared to baseline values individual conditions significantly improved in groups K1 and K2 from 2.5 min after premedication until induction of anesthesia (P < 0.003), in group M conditions improved only five minutes after premedication (P < 0.05). Adverse effects observed in this series were within an acceptable range and similar for the three groups. CONCLUSION: Intranasal administration of s-ketamine and midazolam is an appropriate premedication in preschool children.     

Premedication using intrarectal midazolam. Study of effective dosage in pediatric anesthesia

The object of this study was to determine the optimal dose of midazolam given per rectum which would produce sedation adequate for inducing inhalational anaesthesia in paediatric practice. Five doses were studied: 0.15, 0.25, 0.30, 0.35 and 0.40 mg X kg-1. The criteria used to appreciate the effectiveness of the sedation at 30 min were the change in the child's behaviour, with a scale of 6 levels, and the acceptance of the mask and anaesthetic vapours. There was a significant correlation between the dose administered and the degree of sedation, as well as between the dose administered and the lack of reaction to the mask. Significantly better results were found with the higher doses of 0.35 and 0.40 mg X kg-1, when compared with the children who had received 0.15 and 0.25 mg X kg-1. Only in the groups who received 0.35 and 0.40 mg X kg-1 were the degrees of sedation and acceptance of induction considered as adequate. The dose of 0.35 mg X kg-1 seemed to be the best dose for adequately premedicating a child.     

Effect of flumazenil on recovery from sevoflurane anesthesia in children premedicated with oral midazolam before undergoing herniorrhaphy with or without caudal analgesia

Purpose Oral midazolam is frequently used to treat children, but its effect on recovery from anesthesia is controversial. This study was designed to evaluate the effect of flumazenil on reversal of midazolam during recovery from sevoflurane-induced anesthesia in children who underwent caudal analgesia compared to those who did not.Methods A series of 60 children 1–8 years of age, with an American Society of Anesthesiologists (ASA) physical status of 1 or 2, who were scheduled to undergo herniorrhaphy were randomly assigned to one of four groups: group 1, control/placebo; group 2, control/flumazenil; group 3, caudal/placebo; group 4, caudal/flumazenil. After oral administration of midazolam 0.5 mg · kg⁻¹, anesthesia was induced and maintained with sevoflurane and nitrous oxide in oxygen via a face mask with spontaneous ventilation. The time from the discontinuation of anesthetics to emergence was recorded, and at the time of discharge from the operating room each patient’s recovery characteristics were assessed using a three-point scale.Results Emergence from anesthesia was significantly less agitated in the group of children who underwent caudal analgesia without flumazenil compared to the other three groups. Flumazenil shortened the time to emergence regardless of the application of caudal analgesia, and caudal analgesia delayed the time to emergence regardless of flumazenil administration.Conclusion Caudal analgesia and avoiding the use of flumazenil synergistically resulted in the emergence from anesthesia in a less agitated state for children who underwent herniorrhaphy after oral midazolam premedication.This study was presented in part at the International Anesthesia Research Society’s 77th Clinical and Scientific Congress, New Orleans, March 22, 2003     

Effect of single-dose dexmedetomidine on emergence agitation and recovery profiles after sevoflurane anesthesia in pediatric ambulatory surgery

Purpose  

To study the effects of dexmedetomidine (DEX), a selective α₂-adrenoreceptor agonist, on emergence agitation (EA), recovery profiles, and parents’ satisfaction after sevoflurane anesthesia in pediatric ambulatory surgery.     

Premedication for ambulatory surgery in preschool children: a comparison of oral midazolam and rectal thiopentone

Seventy five ASA 1 and 2 children, aged between six months and five years were randomized to receive oral midazolam 0.5 mg · kg^?1, rectal thiopentone 35 mg · kg^?1 or no premedication to compare the safety and efficacy of, and parental attitudes to, both premedicants. Cardio-respiratory variables were recorded from the time of premedication to awakening from anaesthesia. In addition, anxiety and sedation scores and patients’ acceptance of both premedicant and mask at induction, were all recorded using four-point rating scales. Times to recovery and discharge, and parental satisfaction with the pre-medication their child had received were also recorded Children receiving rectal thiopentone had higher sedation scores and were more accepting of the mask than were the other two groups (P < 0.001). Their acceptance of the premedication was similar to that of the midazolam group. Times to spontaneous eye opening and discharge were longer in the thiopentone group (P< 0.005). Parental preoperative satisfaction rating was higher for thiopentone, but not midazolam, than no premedication (P < 0.05). When asked their premedication preferences for subsequent general anaesthetics, a higher proportion of parents whose children were not premedicated requested an alternative regimen (P < 0.01). In conclusion the study found that pre-medication with rectal thiopentone provided superior induction characteristics to oral midazolam, but with a longer recovery period.     

咪达唑仑术前用药预防短小手术患儿七氟醚麻醉恢复期躁动的效果

目的 评价眯达唑仑术前用药预防短小手术患儿七氟醚麻醉恢复期躁动(EA)的效果.方法 择期扁桃体联合腺样体切除术患儿120例,性别不限,年龄3～9岁,体重15～35 kg,ASA分级Ⅰ或Ⅱ级,采用随机数字表法,将其分为4组(n=30),麻醉前30 min,对照组(C组)口服10％葡萄糖10 ml,不同剂量咪达唑仑组(M1-3组)分别口服0.25、0.50和0.75 mg/kg咪达唑仑与10％葡萄糖混合液10 ml.吸入七氟醚麻醉诱导,静脉输注瑞芬太尼和吸入七氟醚维持麻醉.采用患儿麻醉恢复期躁动量化评分表(PAED)评价患儿EA的发生情况.结果 与C组比较,M2组和M3组PAED评分及EA发生率降低(P＜0.05),M1组差异无统计学意义(P＞0.05);与M1组比较,M2组和M3组PAED评分及EA发生率降低(P＜0.05);与M2组比较,M3组PAED评分及EA发生率差异无统计学意义(P＞0.05).结论 口服咪达唑仑术前用药可预防患儿短小手术七氟醚麻醉恢复期躁动,其适宜剂量为0.50 mg/kg.     

Comparison of recovery profile after ambulatory anesthesia with propofol, isoflurane, sevoflurane and desflurane: a systematic review

In this systematic review we focused on postoperative recovery and complications using four different anesthetic techniques. The database MEDLINE was searched via PubMed (1966 to June 2002) using the search words "anesthesia" and with ambulatory surgical procedures limited to randomized controlled trials in adults (>19 yr), in the English language, and in humans. A second search strategy was used combining two of the words "propofol," "isoflurane," "sevoflurane," or "desflurane". Screening and data extraction produced 58 articles that were included in the final meta-analysis. No differences were found between propofol and isoflurane in early recovery. However, early recovery was faster with desflurane compared with propofol and isoflurane and with sevoflurane compared with isoflurane. A minor difference was found in home readiness between sevoflurane and isoflurane (5 min) but not among the other anesthetics. Nausea, vomiting, headache, and postdischarge nausea and vomiting incidence were in favor of propofol compared with isoflurane (P < 0.05). A larger number of patients in the inhaled anesthesia groups required antiemetics compared with the propofol group. We conclude that the differences in early recovery times among the different anesthetics were small and in favor of the inhaled anesthetics. The incidence of side effects, specifically postoperative nausea and vomiting, was less frequent with propofol. IMPLICATIONS: A systematic analysis of the literature comparing postoperative recovery after propofol, isoflurane, desflurane, and sevoflurane-based anesthesia in adults demonstrated that early recovery was faster in the desflurane and sevoflurane groups. The incidence of nausea and vomiting were less frequent with propofol.     

A comparison of two different doses of ketamine with midazolam and midazolam alone as oral preanaesthetic medication on recovery after sevoflurane anaesthesia in children

BACKGROUND: This investigation prospectively evaluated the effect of oral premedication of two different doses of ketamine with midazolam and midazolam alone on the recovery of children after sevoflurane anaesthesia. METHODS: In a randomized, double-blind study, 79 children (aged 1-8 years, ASA physical status I or II) were assigned to receive one of three premedications in a volume of 0.5 ml x kg(-1): group 1 received midazolam 0.5 mg x kg(-1) (MD); group 2 received midazolam 0.5 mg x kg(-1) with ketamine 1.8 mg x kg(-1) (MK-1); and group 3 received midazolam 0.5 mg x kg(-1) with ketamine 3 mg x kg(-1) (MK-2). The reactions of the children during administration were noted. Anaesthesia was induced by facemask with incremental sevoflurane administration. All children received alfentanil (15 micro g x kg(-1)). Tracheal intubation was facilitated by mivacurium (0.2 mg x kg(-1)). Anaesthesia was maintained with sevoflurane and an additional dose of alfentanil, if necessary. During recovery, the time interval between discontinuation of anaesthesia and arousal (spontaneous ventilation, extubation) were recorded. RESULTS: Emergence (spontaneous ventilation, extubation) and recovery times (discharge, Aldrete score=9) did not differ significantly between groups (P=0.24, P=0.59 and P=0.145, respectively). CONCLUSIONS: The combination of midazolam and ketamine as oral preanaesthetic medication did not significantly affect the recovery time of children after sevoflurane anaesthesia.     

Effects of aminophylline on cognitive recovery after sevoflurane anesthesia

Purpose  

Aminophylline accelerates the recovery from sevoflurane anesthesia. We studied the effects of escalating doses of aminophylline on cognitive and clinical recovery after sevoflurane anesthesia.