Virtually add sedating / analgesic medications can be used to sedate children prior to anesthesia, the important determinants are 1) available route 2) available agents 3) type/length of procedure 4) medical condition of the patient 5) psychological considerations (both family and patient) and 6) cost. The need for premedication does not begin until ~ 9 months at the earliest. Oral midazolam is the most commonly used agent in the US (0.25 to 1 mg/kg, not to exceed 20 mg). Alternatives when no IV access is yet available include nasal sufentanil (0.25 – 0.5 ucg/kg) and IM ketamine (3-4 mg/kg). Clonidine has also been successfully used in the pediatric patient population
Combination such as IM ketamine/atropine/midazolam (2-4 / 0.02 / 0.05 mg/kg) and oral ketamine/atropine/midazolam (4-6 / 0.02 / 0.5 mg/kg) have also been used to provide enhanced sedation. Ketamine up to 10 mg/kg IM may sometimes be required.
Oral agents are disadvantageous in that bioavailability may differ, and they require cooperation on the part of the child. Nasal and IM medications may be painful.
Anticholinergics are painful when given IM and are thus not routinely given. That said, in children < 6 months of age, PO or IM atropine (0.02 mg/kg) may reduce the incidence of hypotension during volatile induction.
Preoperative Anxiolysis in Children
- Moderate Sedation: PO midazolam (0.25 – 1 mg/kg)
- Alternative to PO: nasal sufentanil (0.25 – 0.5 ucg/kg), rectal
- Deep Sedation: AIRWAY EMERGENCY. Minimize stimulation. Inhalational induction in all children, most adults. Downsize ETT. No paralysis