Effects of sevoflurane anaesthesia on recovery in children: a comparison with halothane

We prospectively studied one hundred ASA physical status I-II children, ages six months to six years, undergoing myringotomy surgery. Children were randomly assigned to one of four anaesthetic groups receiving either halothane or sevoflurane for anaesthesia and oral midazolam premedication or no premedication. We found that children anaesthetized with sevoflurane had significantly faster recovery times and discharge home times than those who received halothane. Patients given oral midazolam premedication had significantly longer recovery times, but no delay in discharge home compared with those not premedicated. However, children anaesthetized with sevoflurane and no premedication had an unacceptably high incidence (67%) of postoperative agitation. The use of oral midazolam preoperatively did decrease the amount of postoperative agitation seen with sevoflurane. We conclude that although sevoflurane does shorten recovery times, the degree of associated postoperative agitation makes it unacceptable as a sole anaesthetic for myringotomy surgery.     

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.     

Oral midazolam is an effective premedication for children having day-stay anaesthesia.

The effect of oral premedication was studied in a double-blind, randomised trial of 200 children undergoing day-stay anaesthesia. Midazolam 0.25 mg/kg, midazolam 0.5 mg/kg, diazepam 0.5 mg/kg or a placebo was given orally one hour prior to anaesthesia. Patient state was assessed at nine stages, from administration of the premedication up to and including induction of anaesthesia, using a four-point behavioural scale. Patient state was also assessed postoperatively in the recovery area and the day-stay ward. There was no difference between the four groups until induction of anaesthesia. At this stage 82% of children were either asleep or awake and calm. Patients who received midazolam 0.5 mg/kg were more likely to be asleep or awake and calm at induction rather than other groups (P = 0.05). Children receiving midazolam 0.5 mg/kg or diazepam 0.5 mg/kg slept longest in the post anaesthetic recovery room (P less than 0.005), and spent most time there (P less than .005). There was no difference between groups in the length of time spent in the day-stay ward or in the number of overnight admissions. The study shows that a high proportion of unsedated children are calm at induction of anaesthesia and that oral midazolam is an effective premedication in children for day-stay anaesthesia.     

Postoperative agitation in preschool children following emergence from sevoflurane or halothane anesthesia: A randomized study on the forestalling effect of midazolam premedication versus parental presence at induction of anesthesia

ObjectiveThe effect of midazolam premedication on forestalling postoperative agitation in children is not yet concluded. The purpose of this study was to compare the effects of midazolam premedication and parental presence during anesthetic induction on the incidence of postoperative agitation in pediatric patients.MethodsOne hundred sixty-seven children between 2 years and 7 years of age, undergoing anesthesia for outpatient surgery, were enrolled and randomly divided into four groups: sevoflurane anesthesia with parental presence without premedication, sevoflurane anesthesia with oral midazolam premedication, halothane anesthesia with parental presence without premeditation, and halothane anesthesia with oral midazolam premedication. The children randomized to the premedication groups took oral midazolam 0.5 mg/kg 20–30 minutes before anesthetic induction. For patients in the groups without premedication, one of the parents was present throughout the induction of anesthesia. One recovery room nurse blinded to the group assignment observed the patients and recorded the agitation scores all through their stay in the postanesthesia care unit.ResultsPostoperative agitation was significantly less in patients who received halothane anesthesia with oral midazolam premedication (p < 0.002).ConclusionBased on our data, the presence of a parent at induction of sevoflurance anesthesia was as effective as midazolam premedication in decreasing the incidence of postoperative agitation. Midazolam premedication, however, decreased postoperative agitation when halothane was used as the anesthetic agent.     

A randomized trial of caudal block with bupivacaine 4 mg x kg-1 (1.8 ml x kg-1) plus morphine (150 microg x kg-1) vs general anaesthesia with fentanyl for cardiac surgery

BACKGROUND: Regional anaesthesia has been used effectively in paediatric patients undergoing cardiac surgery and is thought to be safe. METHODS: Thirty patients ASA physical status II-III undergoing scheduled palliative or corrective cardiac surgery, receiving premedication with midazolam and anaesthetic induction with sevoflurane, fentanyl and pancuronium were randomly allocated to two groups. In group 1, patients received bupivacaine 0.22% 4 mg.kg-1 (1.8 ml.kg-1) and morphine 150 microg x kg-1 by the caudal route. After a 20-min period for the block to take effect, sevoflurane 0.5-1.0% and fentanyl 5 microg x kg-1 were administered for maintenance of anaesthesia. In group 2, the anaesthetic technique was the same as in group 1, without a caudal block and fentanyl 25 microg x kg-1 was administered at the moment of surgical incision. RESULTS: Cardiovascular and haemodynamic responses of patients receiving caudal block showed minor variations during the 20-min period between caudal and general anaesthesia. Fentanyl requirements during surgery were lower (P = 0.001) in patients with caudal block than patients with general anaesthesia. Extubation time was shorter (P = 0.034) in the caudal group. Two patients in the general anaesthesia group and one in the caudal group died because of postoperative complications. CONCLUSIONS: Caudal block with bupivacaine 0.22% 4 mg.kg-1 (1.8 ml.kg-1) and morphine 150 microg x kg-1 was safe and effective for paediatric patients undergoing cardiac surgery. However, patients might have a better outcome with a reduction of morphine dosage and administration of a muscle relaxant of shorter duration of action than pancuronium.     

Comparison of caudal morphine and tramadol for postoperative pain control in children undergoing inguinal herniorrhaphy

OBJECTIVES: We compared the quality and duration of analgesia, the effect on perioperative sevoflurane requirement after a single, presurgical caudal block with either tramadol or morphine in children undergoing inguinal herniorrhaphy. Our study was also designed to evaluate the preemptive analgesic efficacy of morphine administered caudally in children. METHODS: Patients were randomly divided into three groups to receive 2 mg.kg-1 tramadol (group T, preemptive group) or morphine sulphate 0.03 mg.kg-1 (group M, preemptive group). The patients in control group (group C, postincisional group) received morphine sulphate 0.03 mg.kg-1 at the end of surgery, caudally. Cardiorespiratory data, sedation and pain were recorded for 24 h following recovery from anaesthesia. RESULTS: There were no differences between the three groups in baseline blood pressure or heart rate; or duration of anaesthesia, surgery. The inhaled sevoflurane concentration was significantly lower in group M and group T than in the control group. The quality and duration of postoperative pain relief did not differ between the three groups. There were no intergroup differences in postoperative nausea, vomiting, or other complications. CONCLUSION: Caudal tramadol (2 mg.kg-1) provided reliable postoperative analgesia similar to caudal morphine (0.03 mg.kg-1) in quality and duration of pain relief in our study children who were undergoing herniorrhaphy. We also concluded that presurgical caudal morphine or tramadol reduced perioperative sevoflurane requirements and either presurgical or postsurgical caudal morphine did not make any difference to postoperative analgesia.     

A randomised placebo-controlled trial of the effects of midazolam premedication on children's postoperative cognition

This randomised, placebo-controlled study assessed the effects of midazolam premedication on children's postoperative cognition and physical morbidity. In all, 179 children aged 5-10 years were randomly assigned to receive buccal midazolam (0.2 mg x kg(-1)) or placebo before sevoflurane-nitrous oxide anaesthesia for multiple dental extractions. They performed tests of choice reaction time, attention, psychomotor co-ordination and memory pre-operatively (baseline), before discharge and at 48 h. The reaction time of both groups was significantly slower before discharge compared to baseline, with the midazolam group being significantly slower than placebo. Psychomotor co-ordination was also significantly impaired postoperatively after midazolam. Performance on both tests had recovered to baseline by 48 h. Midazolam was also associated with significant anterograde amnesia, both postoperatively and at 48 h, for information presented in the interval between premedication and surgery. The results show significant short-term impairment of children's cognitive function and amnesia enduring for 48 h after low-dose midazolam premedication.     

Effects of sevoflurane on cerebral blood flow and cerebral metabolic rate of oxygen in human beings: a comparison with isoflurane

BACKGROUND AND OBJECTIVE: Isoflurane is commonly used for neurosurgery but the effects of sevoflurane on human cerebral blood flow and cerebral metabolic rate of oxygen have not been fully evaluated. We therefore assessed the effects of sevoflurane and isoflurane on global cerebral blood flow and cerebral metabolic rate of oxygen in patients without noxious stimuli or neurological disorders. METHODS: General anaesthesia was induced with midazolam (0.2 mg kg(-1)) and fentanyl (5 microg kg(-1)) in 20 ASA I patients undergoing knee joint endoscopic surgery. Epidural anaesthesia was also performed to avoid noxious stimuli during surgery. Cerebral blood flow and cerebral arteriovenous oxygen content difference was measured using the Kety-Schmidt method with 15% nitrous oxide as a tracer before and after administration of either sevoflurane or isoflurane (1.5 minimum alveolar concentration, 60 min) and cerebral metabolic rate of oxygen was then calculated. RESULTS: Sevoflurane and isoflurane both increased cerebral blood flow (17%, P < 0.05; 25%, P < 0.05, respectively) and decreased cerebral metabolic rate of oxygen (26%, P < 0.01; 38%, P < 0.01, respectively). There were no significant differences in cerebral blood flow and cerebral metabolic rate of oxygen between sevoflurane and isoflurane. CONCLUSIONS: Sevoflurane and isoflurane similarly increased cerebral blood flow and decreased cerebral metabolic rate of oxygen in human beings anaesthetized with midazolam and fentanyl.     

Oral midazolam premedication and postoperative behaviour in children

We examined the effect of oral midazolam premedication on postoperative behaviour. Seventy children (ASA Physical Status 1 and 2; aged 1–10 yrs) were assigned randomly in a prospective, blinded fashion to receive either midazolam 0.5 mg·kg⁻¹ (maximum 10 mg) or placebo. Behaviour assessments were made prior to medication, during induction of anaesthesia and 15 min following arrival to recovery room. The baseline behavioural evaluation scores were not significantly different. The children receiving midazolam cried significantly less during induction (P≤0.02). At one week follow-up, eight of 35 subjects receiving placebo had experienced adverse behaviour changes (nightmares, night terrors, food rejection, anxiety, negativism); 19 of 35 of the midazolam group experienced these changes (P≤0.02). At four week follow-up, most behaviour changes had resolved. Children given preoperative oral midazolam were less likely to cry and fight while being anaesthetized, and preoperative sedation was associated with increased incidence of adverse postoperative behaviour changes.     

Midazolam premedication delays recovery from propofol-induced sevoflurane anesthesia in children 1–3 yr

PURPOSE: To study the effect of midazolam premedication on the recovery characteristics of sevoflurane anesthesia induced with propofol in pediatric outpatients. METHODS: Sixty children, one to three years, presenting for ambulatory adenoidectomy were randomly assigned , in a double-blind fashion, to receive either 0.5 mg x kg(-1) midazolam (Group M) or placebo (Group P) p.o. 30 min before anesthesia. Anesthesia was induced with 10 microg x kg(-1) atropine, 10 microg x kg(-1) alfentanil, and 3-4 mg x kg(-1) propofol i.v.. Tracheal intubation was facilitated with 0.2 mg x kg(-1) mivacurium. Anesthesia was maintained with nitrous oxide/oxygen (FiO2 0.3) and sevoflurane with controlled ventilation. Recovery characteristics were compared using the modified Aldrete scoring system, the Pain/Discomfort scale and measuring specific recovery end-points (emergence, full Aldrete score, discharge). A postoperative questionnaire was used to evaluate the children's well-being at home until 24 hr after discharge. RESULTS: Emergence from anesthesia (22 +/- 9 vs 16 +/- 6 min (mean +/- SD), P = 0.005) and achieving full Aldrete scores (30 +/- 11 vs 24 +/- 16 min, P = 0.006) were delayed in patients receiving midazolam. Children in the placebo group were given postoperative analgesia sooner than those in the midazolam group (18 +/- 11 vs 23 +/- 8 min, P = 0.009). More children premedicated with midazolam suffered from arousal distress (20% vs 3%, P = 0.04) and scored higher on the Pain/Discomfort scale (P = 0.004) at 20 min after arrival in the recovery room. Discharge was not affected by premedication and well-being at home was similar in the groups. CONCLUSIONS: Oral premedication with midazolam delays early recovery but not discharge after ambulatory sevoflurane anesthesia induced with propofol in children one to three years. Midazolam did not improve the quality of recovery.     

Effects of fentanyl on the incidence of emergence agitation in children receiving desflurane or sevoflurane anaesthesia

BACKGROUND AND OBJECTIVE: In children, emergence agitation frequently complicates sevoflurane and desflurane anaesthesia. The effect of intravenous fentanyl 2.5 microg kg(-1) was examined on the incidence of emergence agitation in children who received desflurane or sevoflurane after midazolam premedication and intravenous thiopental induction. METHODS: One hundred and twenty children (2-7 yr) undergoing adenoidectomy or tonsillectomy, or both, were studied. All children were premedicated orally with midazolam 0.5 mg kg(-1). After intravenous induction with thiopental and atracurium to facilitate endotracheal intubation, patients were randomly assigned to one of four groups: Patients in Groups 1 and 3 received physiological saline solution, whereas patients in Groups 2 and 4 received intravenous fentanyl 2.5 microg kg(-1) during induction. Anaesthesia was maintained with sevoflurane in Groups 1 and 2 and with desflurane in Groups 3 and 4. After discontinuation of the volatile anaesthetic, the times to tracheal extubation and response to verbal stimuli (emergence time), and emergence behaviours were recorded. RESULTS: The time to tracheal extubation was significantly shorter in Groups 3 (5.2+/-1.7 min) and (6.4+/-2.1 min) than in Groups 1 (8.1+/-2.1 min) (P = 0.0001 and 0.006, respectively) and 2 (8.8+/-1.9 min) (P = 0.0001). The emergence time was significantly shorter in Group 3 (10.0+/-3.9 min) than in Groups 1 (13.8+/-4.9 min) (P = 0.017) and 2 (14.9+/-4.1 min) (P = 0.003). The incidence rate of severe agitation was 13% in Groups 1 and 3, and 7 and 10% in Groups 2 and 4, respectively (P > 0.05). CONCLUSIONS: After midazolam premedication and intravenous induction of anaesthesia with thiopental administration of intravenous fentanyl 2.5 microg kg(-1) did not provide any clinically significant benefit on emer gence agitation in children who receive sevoflurane or desflurane anaesthesia.     

Comparison of a combination of midazolam and diazepam and midazolam alone as oral premedication on preanesthetic and emergence condition in children

BACKGROUND: Preanesthetic anxiety and emergence agitation are major challenges for anesthesiologists in pediatric anesthesia. Thus, midazolam has been used as premedication for children. However, midazolam alone is not effective for emergence agitation. The present study tested the effect of a combination of midazolam and diazepam on the preanesthetic condition and emergence behavior in children. METHODS: Forty-two children were allocated to one of three groups: the NoPre group received no premedication; the Mi group received midazolam 0.5 mg kg(-1) orally; and the Mi + Di group received midazolam 0.25 mg kg(-1) and diazepam 0.25 mg kg(-1) orally. When anesthesia was induced with 7% sevoflurane in 100% oxygen, qualities of mask induction and sedation were rated. Anesthesia was maintained with sevoflurane (3-5%) in 100% oxygen. During emergence from anesthesia, the score of the child's emergence behavior was rated. RESULTS: Children in the Mi and Mi + Di groups were more sedated than those in the NoPre group. A combination of midazolam and diazepam provided a better quality of mask induction, when compared with no premedication. Also, the children in the Mi + Di group were less agitated than those in the other groups during the emergence. CONCLUSION: Children in the Mi + Di group were significantly more sedated at induction of anesthesia and less agitated during emergence from anesthesia.     

Effect of oral midazolam premedication on the awakening concentration of sevoflurane, recovery times and bispectral index in children

BACKGROUND: We sought to determine the influence of preoperative oral midazolam on: (i) measures of anaesthetic emergence; (ii) recovery times and (iii) intraoperative bispectral index (BIS) measurements during sevoflurane/N2O anaesthesia in paediatric patients. METHODS: Fifty-two patients, aged 1-10 years, ASA I-II, were enrolled in a prospective double-blinded study. Patients were randomized to receive either midazolam 0.5 mg.kg(-1) (M) or midazolam vehicle (P) as premedication. After inhalation induction and intubation, expired sevoflurane was stabilized at 3% in 60% N2O and the corresponding BIS (BIS I) recorded. At the completion of surgery, sevoflurane was stabilized at 0.5% and the BIS (BIS E) again recorded. Awakening time, expired sevoflurane/N2O awakening concentrations and recovery times were recorded. RESULTS: There were no significant differences between groups in awakening time, sevoflurane or N2O awakening concentrations, time to PACU discharge, time to hospital discharge or in BIS I and BIS E measurements.     

Diclofenac and flurbiprofen with or without clonidine for postoperative analgesia in children undergoing elective ophthalmological surgery

We conducted a prospective, randomized study to compare the efficacy of preoperative diclofenac, flurbiprofen, and clonidine, given alone, as well as the combination of diclofenac and clonidine, and flurbiprofen and clonidine in controlling postoperative pain in 125 children. The patients (ASA I, 2-12 years) undergoing elective ophthalmological surgery were allocated to one of five groups: rectal diclofenac 2 mg.kg(-1) following oral placebo premedication, i. v. flurbiprofen 1 mg.kg(-1) following placebo premedication, oral clonidine premedication, rectal diclofenac 2 mg.kg(-1) following clonidine, and i.v. flurbiprofen 1 mg.kg(-1) following clonidine. The children received clonidine (4 microg.kg(-1)) or placebo 105 min before anaesthesia. Diclofenac or flurbiprofen was given immediately after induction of anaesthesia. Anaesthesia was induced and maintained with sevoflurane and nitrous oxide in oxygen. Postoperative pain was assessed by a blinded observer using a modified objective pain scale (OPS). No opioids were administered throughout the study. Rectal diclofenac 2 mg.kg(-1) i.v. flurbiprofen 1 mg.kg(-1), oral clonidine 4 microg.kg(-1) provided similar OPS scores and requirement for supplementary analgesics during 12 h after surgery. Combination of oral clonidine and one of these nonsteroidal analgesics minimized postoperative pain. Our findings suggest that this combined regimen may be a promising prophylactic approach to postoperative pain control in children undergoing ophthalmological surgery.     

Oral premedication with fentanyl may be a safe and effective alternative to oral midazolam

BACKGROUND AND OBJECTIVE: Although midazolam is commonly given orally to infants and small children for premedication, the taste is sometimes unacceptable even when mixed with syrup. We tested the efficacy and safety of oral fentanyl compared with oral midazolam in a randomized open-label study. METHODS: Fifty-one children, aged 12-107 months and weighing 10-25 kg, were randomly assigned to fentanyl or midazolam treatment groups. Midazolam (5 mg) or fentanyl (0.1 mg) was given orally from a small bottle with a small orifice 30 min before transfer to the preoperative holding room. The excitation-sedation conditions of the patients were assessed before and after general anaesthesia. RESULTS: The preoperative scores did not differ significantly between the two groups. No major complications were observed in either group. Postoperative vomiting occurred in 5 of 27 (18.5%) patients treated with oral fentanyl and in none of 24 of those treated with midazolam. CONCLUSIONS: Oral administration of fentanyl 30 min before entrance to the holding room for an operation from a bottle with a small orifice is a premedication option for children between 1 and 8 yr of age.     

Premedication with midazolam delays recovery after ambulatory sevoflurane anesthesia in children.

We studied the effect of oral premedication with midazolam on the recovery characteristics of sevoflurane anesthesia in small children. In a randomized, double-blinded study, 60 children (1-3 yr, ASA physical status I or II) undergoing ambulatory adenoidectomy received either midazolam 0.5 mg/kg (Group M) or placebo (Group P) PO approximately 30 min before the induction of anesthesia. All children received atropine 0.01 mg/kg IV and alfentanil 10 microg/kg IV before the induction of anesthesia with sevoflurane up to 8 vol% inspired concentration in N2O 67% in O2. Tracheal intubation was facilitated with mivacurium 0.2 mg/kg. Anesthesia was continued with sevoflurane adjusted to maintain hemodynamic stability. In the postanesthesia care unit, predetermined recovery end points (emergence, recovery, discharge) were recorded. A pain/ discomfort scale was used to determine the quality of recovery. A postoperative questionnaire was used to evaluate the well-being of the patient at home 24 h after surgery. Emergence (spontaneous eye opening), recovery (full points on the modified Aldrete scale), and discharge were achieved later in Group M than in Group P (15+/-6 vs. 11+/-3 min [P = 0.002], 25+/-17 vs. 16+/-6 min [P = 0.01], and 80+/-23 vs. 70+/-23 min [P = 0.03]). Side effects, postanesthetic excitement, and analgesic treatment did not differ significantly between groups. At home, more children in Group P (30%) experienced disturbed sleep during the night compared with those in Group M (4%) (P = 0.007). IMPLICATIONS: In this randomized, double-blinded, placebo-controlled study, premedication with midazolam 0.5 mg/kg PO delayed recovery in children 1-3 yr of age after brief (<30 min) sevoflurane anesthesia. Except for more peaceful sleep at home, premedication did not affect the quality of recovery.     

Modulation der Streßantwort bei Kindern während der präoperativen Vorbereitung

Anxiolysis with drugs and psychoprophylaxis are both recognised methods of preoperative preparation. The beneficial effects of anxiolytics, however, appear to be difficult to prove. In this study a comparison was made of heart rate (HR), blood pressure (BP), and norepinephrine, epinephrine, and cortisol levels. In group I 19 children recieved only psychological treatment, while in group II 21 children received 0.2?mg/kg midazolam orally. Measuring points were directly before medication, 30?min afterward, and at induction of anaesthesia. During the observation period the patients (5–10 years old) remained calm. At the beginning of the study the parameters of all patients were within a normal range; 30?min after premedication the HR and BP were significantly higher in group I than in group II. In contrast to group I, epinephrine levels in group II were lower at the beginning of anaesthesia than before premedication. In both groups, norepinephrine levels were the same at induction of anaesthesia as before premedication. Cortisol decreased only in patients who received midazolam. HR, BP, as well as humoral stress parameters indicate that midazolam in a dose of 0.2?mg/kg orally is sufficient to reduce preoperative stress in children.     

Melatonin vs. midazolam premedication in children: a double-blind, placebo-controlled study

BACKGROUND AND OBJECTIVE: Unlike midazolam, melatonin premedication is not associated with cognitive impairment in adults despite its anxiolytic properties. The use of melatonin as a premedicant in children has not been reported. This randomized, double-blind, placebo-controlled study compared the perioperative effects of different doses of melatonin and midazolam in children. METHODS: Seven groups of children (n = 15 in each) were randomly assigned to receive one of the following premedicants. Midazolam 0.1, 0.25 or 0.5 mg kg(-1) orally, melatonin 0.1, 0.25 or 0.5 mg kg(-1) orally each mixed in 15 mg kg(-1) acetaminophen, or placebo only (15 mg kg(-1) acetaminophen). Anxiety and temperament were evaluated before and after administration of the study drug, on separation from parents and on the introduction of the anaesthesia mask. At week 2 postoperatively, the behaviour of the children was measured by the Post Hospitalization Behaviour Questionnaire. RESULTS: Melatonin or midazolam each in doses of 0.25 or 0.5 mg kg(-1) were equally effective as premedicants in alleviating separation anxiety and anxiety associated with the introduction of the anaesthesia mask. A trend was noted for midazolam to prolong recovery times as the dosage increased. The use of melatonin was associated with a lower incidence (P = 0.049) of excitement at 10 min postoperatively, and a lower incidence (P = 0.046) of sleep disturbance at week 2 postoperatively than that observed with midazolam and control groups. No postoperative excitement was noted in the melatonin groups at 20, 30 and 45 min. DISCUSSION: Melatonin was not only as effective as midazolam in alleviating preoperative anxiety in children, but it was also associated with a tendency towards faster recovery, lower incidence of excitement postoperatively and a lower incidence of sleep disturbance at week 2 postoperatively.     

Clonidine vs. midazolam as premedication in children undergoing adeno-tonsillectomy: a prospective, randomized, controlled clinical trial

BACKGROUND: Clonidine administration in the setting of paediatric anaesthesia is associated with a number of desirable effects, e.g. preoperative sedation, analgesia and reduced anaesthetic requirements. The aim of the current study was to compare postoperative outcome variables using a prospective, randomized, double-blind design after premedication with clonidine or midazolam. METHODS: One hundred paediatric ASA physical status 1 patients (age 1-11 year) scheduled for adeno-tonsillectomy were assigned to receive rectal premedication with midazolam (300 microg kg(-1) and atropine 40 microg kg(-1); group M, n = 52) or clonidine (5 microg kg(-1 and) atropine 40 microg kg(-1); group C, n = 48) prior to a standardized sevoflurane anaesthetic. The incidence of immediate postoperative pain (0-2 h), as assessed by repeated Objective Pain Scale (OPS) scores, was chosen as the primary end-point of the study. Degree of sedation (modified Vancouver sedation scale 0-3), occurrence of postoperative vomiting (POV), and incidence of shivering and immediate postoperative confusion were registered as secondary end-points. After hospital discharge parents were instructed to continue the evaluation of pain, sedation, POV and sleep pattern during a 24-h period. Parents were also asked for their preference concerning the postoperative behaviour of their child (calm, sedated vs. alert, active). RESULTS: In the early postoperative period patients in the clonidine group had a significantly lower sum of 5 OPS scores (median = 8.0) compared to group M (median = 11.5) (P = 0.011). Administration of clonidine was also associated with a slightly higher sum of sedation scores (median = 13) in the early postoperative period compared to children receiving midazolam (median = 12) (P < 0.001). No episode of shivering was observed in the clonidine group but was present in five of the patients in the midazolam group (P = 0.057). In younger children (< 5 years) the incidence of postoperative confusion was lower in the clonidine group (P = 0.001). No difference in the frequencies of POV incidences, degree of postoperative pain, need for analgesics, or sleep pattern during the first 24 postoperative hours could be observed between the groups according to the parental evaluation. Children premedicated with clonidine were more calm and sedated compared to children in the midazolam group (P = 0.024) as judged by their parents. A significant majority of parents (75%; P < 0.001) preferred a calm and sedated child during the first postoperative 24-h period. CONCLUSION: Rectal premedication with clonidine was associated with a significant reduction of pain in the early postoperative period compared to midazolam and was also associated with moderately increased sedation during the first 24 postoperative hours. The sedative effect of clonidine is in agreement with the unambiguous finding of a parental preference for a calm and sedated child during the first 24 postoperative hours.     

Parental presence during induction enhances the effect of oral midazolam on emergence behavior of children undergoing general anesthesia

Background:  Pre-anesthetic anxiety and emergence agitation are major challenges for anesthesiologists in pediatric anesthesia. Thus, sedative premedication and parental presence during induction of anesthesia (PPIA) are used to treat pre-anesthetic anxiety in children. The aim of the present study was to test if a combination of mother presence and midazolam premedication is effective for improving emergence condition in children undergoing general anesthesia.
Methods:  Sixty children were allocated to one of three groups: a sedative group (0.5 mg/kg oral midazolam), a PPIA group or a sedative and PPIA group. When anesthesia was induced with 7% sevoflurane in 100% oxygen, qualities of mask induction were rated. Anesthesia was maintained with sevoflurane (1.5–2.5%) in 60% oxygen and intravenous fentanyl 4 μg/kg. During emergence from anesthesia, the score of the child's emergence behavior was rated.
Results:  The children in the midazolam group showed a better quality of mask induction compared with those in the PPIA group, the addition of parental presence to oral midazolam did not provide additional improvement of mask induction. In contrast, the children in the midazolam + PPIA group were less agitated than those in the other groups at emergence from anesthesia.
Conclusion:  Parental presence during induction of anesthesia enhanced the effect of oral midazolam on emergence behavior of children undergoing general anesthesia.