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INTRODUCTION

FOCUS POINTS

  1. Preoperative oral midazolam reduces perioperative anxiety and provides anterograde amnesia within 10 minutes of administration.

  2. Ketamine provides good sedation and analgesia while preserving upper airway muscular tone and respiratory drive. The intramuscular (IM) route of administration is very useful for children who are uncooperative, refuse oral medications, and become combative.

  3. Fentanyl can be administered intranasally to provide both pain relief and sedation prior to a procedure.

  4. Dexmedetomidine is a highly selective alpha-2 agonist that can be given intranasally with ease of separation from parents for most patients at 30 minutes after administration.

  5. Topical preparations of local anesthetics can alleviate pain due to venipuncture or intravenous (IV) catheter insertion.

In the preoperative period, children have significant anxiety and behavioral and pharmacological interventions are used to mitigate these symptoms prior to surgery. Although this is true for adults as well, in the young pediatric patient it is related to a limited understanding of the nature of the illness, the need for surgery, and the unfamiliarity of the environment. Anxiolysis is the primary aim of premedication use, although other clinical goals include amnesia, optimization of preoperative conditions, and prevention of physiological stress.

Nearly 50% of children demonstrate signs of significant preoperative fear and anxiety.1 Heart rate and blood pressure measurements correlate with behavioral ratings of anxiety.2 Anesthesiologists may use either parental presence or sedative premedication to alleviate physiological and psychological effects of preoperative anxiety, since separation from parents and induction of anesthesia are considered the most stress-inducing phases of the perioperative experience. Anesthesiologists who favor parental presence during induction of anesthesia tend to use sedative premedications least frequently, and vice versa.3,4 Both approaches are considered appropriate depending on the clinical scenario.

The most popular premedicant available in the past were long acting (eg, morphine and pentobarbital) but their administration delayed postoperative recovery and increased the incidence of postoperative nausea and vomiting. In addition, these medications were not available via oral route. This resulted in underuse of sedative premedication in many children with anxiety compromising their psychological welfare for the goal of efficiency and rapid discharge. The introduction of oral midazolam as premedication is the main reason pharmacological sedation has regained popularity in modern pediatric anesthesia practice, especially in the ambulatory setting. Oral midazolam remains the most commonly used premedication for pediatric practice, with several other medications (eg, alpha agonists) available depending on the specific clinical needs.

Premedication versus Parental Presence for Induction

Early studies suggested reduced anxiety and improved patient cooperation if parents were present during induction.5,6 The majority of parents prefer to be present during induction of anesthesia regardless of the child’s age or previous surgical experience,7 and regardless of their experience with prior parental presence or premedication of their child in the case of repeated surgery.8 Concerns regarding parental presence for induction (PPI) do include a negative ...

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