The place of premedication in pediatric practice

Abstract

SummaryBehind the multiple arguments for and against the use of premedication, sedative drugs in children is a noble principle that of minimizing psychological trauma related to anesthesia and surgery. However, several confounding factors make it very difficult to reach didactic evidence-based conclusions. One of the key confounding issues is that the nature of expectations and responses for both parent and child vary greatly in different environments around the world. Studies applicable to one culture and to one hospital system (albeit multicultural) may not apply elsewhere. Moreover, the study of hospital-related distress begins at the start of the patient's journey and ends long after hospital discharge; it cannot be focused completely on just the moment of anesthetic induction. Taking an example from actual practice experience, the trauma caused by the actual giving of a premedication to a child who absolutely does not want it and may struggle may not be recorded in a study but could form a significant component of overall effect and later psychological pathology. Clearly, attitudes by health professionals and parents to the practice of routine pediatric premedication, vary considerably, often provoking strong opinions. In this pro-con article we highlight two very different

Administration of midazolam as sedative premedication for paediatric patients

“…While relieving of preoperative anxiety should become an indispensable part of surgical treatment, it is essential that decision for premedication be individualised (10). Studies report that sedative premedication is more important and effective than alternative preoperative anxiety management strategies.…”

“…However, extreme caution should be exercised about giving midazolam premedication to children that are at high risk of respiratory failure under anaesthesia as it can result in further decrease of the respiratory function (16). Midazolam can impair the explicit memory but preserve the implicit memory (10).…”

“…The present day practice underscores reducing presurgical stress, controlling autonomous reflexes, especially n. vagus reactions, and eliminating side effects of anaesthetics. At present, the prevailing view is that midazolan is an optimal choice for sedative premedication (10). The shift in focus in modern anaesthesiology is related to the fact that the use of new generation anaesthetics eliminates the need to control autonomous reflexes and side effects of anesthetics.…”

“…E. g. sevoflurane does not cause salivation, nor does it impact catecholamine or promote n. vagus activity. Vagal activity remains for infants up to 12 months, but it is reduced after administration of atropine (10).…”

“…This benefit outweighs its potential side-effects that include, among others, postanesthesia anxiety, diplopia, amnesia, hiccupping, anger, and sleep disorders. Serious midazolam induced side-effects are rare, and midazolam, when not combined with other sedative medications, produces no significant respiratory effects (10). Midazolam can be used for treating both preoperative and postoperative anxiety.…”