Premedication guideline for paediatric patients prior to general anaesthesia

The American Society of Anaesthesiologists defines the continuum of sedation [1] as follows;

Minimal Sedation – Normal response to verbal stimulation

Moderate Sedation – Purposeful response to verbal/tactile stimulation

Deep Sedation - Purposeful response to repeated painful stimulation

General Anaesthesia – No response even with painful stimulus

It is anticipated that sedation premedication would result in minimal to moderate sedation. On occasion a deeper level of sedation may be desirable, this should be provided by staff trained in airway support as necessary.

The Anaesthetist (or practitioner prescribing the premedication) is responsible for:

• Ensuring the sedative premedication is prescribed correctly on the prescription chart, and where possible in line with the current guideline
• Ensuring that the patient, parents or carers are aware of the possible effects of the premedication, including post operative effects such as prolonged sedation.

The Nurse (or practitioner administering the premedication) is responsible for:

• Ensuring that the prescription is checked and prepared appropriately
• Ensuring that the patient is in a safe environment when the premedication is given
• Ensuring that the premedication is safely and effectively administered
• Communicating any problems with the prescription or administration of the premedication to the anaesthetist and/or prescribing practitioner
• Maintaining a safe environment for the patient once the premedication is administered, including appropriate monitoring.

The use of sedative premedication in paediatric patients is intended to reduce preoperative patient anxiety and to increase cooperation with the general anaesthetic process.

The advantages of using sedative premedication must outweigh the possible disadvantages such as paradoxical reactions, prolonged hospital stay, potential additive effects with other medications which the patient may already be taking.

Any patient who is listed for a procedure may require sedative premedication. It is anticipated that most patients will be over the age of 1 year.

Where sedative premedication is to be administered to a patient, this will be discussed with the patient and the parent/carer, by the anaesthetist at the preoperative visit.

This discussion will include, but may not be limited to, the timing of the premedication, and its potential effects both preoperatively and postoperatively.

All patients should be included in the discussion regarding their perioperative care as much as possible given their level of comprehension.

• Anticipated difficult airway
• Increased aspiration risk
• Obstructive sleep apnoea
• Severe renal or hepatic impairment
• Reduced Glasgow Coma Scale
• Previous allergic or behavioural reaction to the type of premedication proposed

Should the anaesthetist feel that a reduced dose of sedative premedication is appropriate in the presence of one of the above contraindications this should be clearly communicated to the nursing staff responsible for the patients care.

The above medication table is not exhaustive but covers the commonly seen sedative premedications.[2]

The anaesthetist may use a combination of sedative premedication drugs to achieve the desired level of sedation, within an appropriate time frame.

Please consider onset time when prescribing 2 or more agents. EG if prescribing clonidine and midazolam, consider giving clonidine first and midazolam after 20 minutes so both reach effect at same time. Staggering may also make midazolam more palatable.

Patients with autism: frequently patients with autism experience post procedure agitation if given midazolam alone. Please co prescribe with clonidine or administer clonidine in theatre to help counter act the agitation. Ketamine/clonidine combination works well.

The recommended doses/kg and maximum doses can be exceeded, but this is the responsibility of the prescribing anaesthetist. This must be discussed with a consultant anaesthetist and should be clearly documented and communicated with the responsible nurse.

Care should be taken when prescribing in the overweight child, with consideration made regarding ideal body weight vs. actual body weight.

The administration of IM ketamine should performed by an anaesthetist in an environment in which it is safe to do so. It should contain appropriate monitoring and anaesthetic equipment. The administrating anaesthetist must have sight of the child at all times.

Repeat premedication doses may be required, especially if the child has not taken the original dose effectively. This should be written up by the anaesthetist and administered with the appropriate monitoring as necessary.

Assuming the necessary drug checks have taken place, the premedication can be administered to the patient in 10-20mls of diluting juice, water, or clear apple juice, or directly by syringe.

Once the premedication has been administered the patient should remain on the wards under direct supervision of a responsible adult.

If the patient becomes drowsy or falls asleep oxygen saturation should be continuously monitored by pulse oximetry including during transfer to the theatre department.

An oxygen cylinder, face mask and ambu-bag should be available on the patient’s bed or trolley for transfer.