An Audit of Preoperative Behaviour and Premedication Practise at Great Ormond Street Hospital

Abstract

Introduction Despite advances in anaesthesia many children are distressed at induction of anaesthesia (1). The use of paediatric premedication has declined considerably over the last ten years (2). The aim of our audit was to look at preoperative behaviour and premedication practice at our institute. Method One hundred and seventy seven patients undergoing elective procedures in the main theatre suite at the hospital were audited. This therefore excluded cardiac and neuroanaesthesia. Behaviour scores in the anaesthetic room prior to and at induction were assessed by the operating department assistants. We looked at frequency, type, dose and timing of premedication. The induction method, age and previous anaesthesia were noted. Parents routinely accompany children at induction of anaesthesia. Results Overall 75% of children had satisfactory behaviour scores in the anaesthetic room dropping to 47% at induction. The graph shows the age distribution and associated behaviour scores. Of the patients with satisfactory behaviour scores all received their premedication between 20 and 60 min prior to induction. Three patients in the unsatisfactory behaviour group received their premedication outside this optimal time. Children who had had previous anaesthetics (76%) had worse behaviour scores than those with none both in the anaesthetic room and at induction with satisfactory scores of 71% vs. 84% and 44% vs. 51 % respectively. Those having gas inductions (63%) had worse behaviour scores at induction compared with children having intravenous induction with satisfactory scores of 42% vs. 52% respectively. 12% of all children audited received a sedative premedication. 16 received Midazolam 0.5 mg/kg, 3 Temazepam 10 or 20 mg and 1 Triclofos 50 mg·kg−1 all given orally. The premedication rate for children with previous anaesthetic experience was 14% vs. 5% in those with none. Only 5% of children received an atropine premedication 20–40 mcg·kg−1 orally. Only 1 of the 14 children age 6 months and 2 of the 14 children age 6 months−1 year were premedicated with atropine. Discussion As a paediatric tertiary referral centre, many of the patients have previous experience of anaesthetics and have ongoing medical problems Our audit found that many of these children, especially age 1–3, are distressed at induction of anaesthesia despite methods shown to reduce peri‐operative anxiety, including play specialists. It also confirms the perceived trend for decreasing use of sedative and anticholinergic premedication. However several papers report decrease in distress at induction (1) especially in high‐risk groups (2) without undue delays in awakening and discharge using midazolain premedication. Conclusion It was decided that a more child friendly anaesthetic room with pictures, toys and other distractions would be helpful. There may also be a need to increase the use of sedative premedication in high‐risk groups especially preschool children.