Does my child need a premedication?
Surgery, and its associated general anesthesia, can create significant familial stress that may start in the days or weeks leading up to a procedure and will likely peak in the perioperative period. The stress generated by a surgical procedure can be felt even after the recovery period has concluded. Therefore, it is important for parents/caregivers to work alongside their medical-surgical teams to minimize preoperative anxiety and stress for their child. Unfortunately, there are potential short- and long-term side effects of elevated anxiety during the surgical experience such as a difficult induction of anesthesia, increased pain, and negative postoperative behavioral changes. [1]
The most common points of heightened anxiety during the perioperative period include peripheral IV placement (usually for older children) and/or mask induction of general anesthesia. Typical strategies to mitigate stress during mask induction include premedication, parental presence, and/or distraction techniques. Premedication, or the administration of an anti-anxiety medication, before entering the operating room can be beneficial for some children.
What is a premedication?
A premedication is typically a medication that reduces preoperative anxiety and stress in a child. There are many types of medications that can be given in a variety of ways, most commonly by mouth, by nasal spray, or by intramuscular injection (“shot”). All commonly used premedications may be given intravenously (through an IV) as well. Ideally, the “best” premedication would have a quick onset of action, relatively short duration, minimal side effects, and easily accepted by the child. Despite all of the available medical literature, there is no “perfect” medication. The choice must be child and procedure specific.
What are the most commonly used premedications?
Midazolam:
Midazolam is historically the most commonly utilized premedication for pediatric and adult patients. It is part of the benzodiazepine class and is usually given orally or nasally (nasal spray). It has a relatively fast onset of action when given orally, approximately 20 minutes, and a short duration of action. [2-6] However, when given orally, some children will spit it out as it has a very bitter, odd taste. It has an even quicker onset of action, approximately 10 minutes, when given via nasal spray but can cause discomfort/burning sensation.4 The biggest risk or side effect of midazolam is a paradoxical drug reaction characterized by extreme agitation. [3,4,6] It also may contribute to crankiness and agitation upon waking up from anesthesia, also known as emergence delirium. [5] It will cause memory loss of the time during the medication is working – so your child may not remember anything about going to sleep, being in the operating room, etc.
Ketamine:
Ketamine is a phencyclidine derivative that can has both sedating and pain-reducing effects. [2-4] It is most commonly given intramuscularly (“shot”), intranasally, or orally. It has a very rapid onset of action when given intramuscularly and is a great choice for children that are uncooperative with oral or intranasal medication administration or are too large for typical doses of alternate medications. The most common side effects associated with ketamine are significant drooling/salivation, nausea/vomiting, and visual/auditory hallucinations. [3,4] Like midazolam, ketamine will also cause memory loss during the time that the medication is working.
Dexmedetomidine:
Dexmedetomidine is an alpha2 adrenergic agonist medication that is usually given intranasally when used as a premedication. [2-4] Like ketamine, dexmedetomidine can cause sedation and also has some pain-reducing effects. [2,4,5] The biggest drawback is that it can take up to 30 minutes for the intranasal medication to take effect. However, it is typically well tolerated (the nasal spray does not hurt or burn) and causes minimal side effects. [3]
Lee J, Lee J, Lim H, et al. Cartoon distraction alleviates anxiety in children during induction of anesthesia. Anesth Analg 2012;115(5):1168-73. DOI: 10.1213/ANE.0b013e31824fb469.
Azemati S, Keihani M, Sahmeddini MA, et al. Comparing the Sedative Effects of Intranasal Dexmedetomidine, Midazolam, and Ketamine in Outpatient Pediatric Surgeries: A Randomized Clinical Trial. Iran J Med Sci 2024;49(7):421-429. DOI: 10.30476/ijms.2023.99122.3118.
Khurmi N, Patel P, Kraus M, Trentman T. Pharmacologic Considerations for Pediatric Sedation and Anesthesia Outside the Operating Room: A Review for Anesthesia and Non-Anesthesia Providers. Paediatr Drugs 2017;19(5):435-446. DOI: 10.1007/s40272-017-0241-5.
Oriby ME. Comparison of Intranasal Dexmedetomidine and Oral Ketamine Versus Intranasal Midazolam Premedication for Children Undergoing Dental Rehabilitation. Anesth Pain Med 2019;9(1):e85227. DOI: 10.5812/aapm.85227.
Pasin L, Febres D, Testa V, et al. Dexmedetomidine vs midazolam as preanesthetic medication in children: a meta-analysis of randomized controlled trials. Paediatr Anaesth 2015;25(5):468-76. DOI: 10.1111/pan.12587.
Swati, Shah RK, Tandon S, Mathur R, Sharma T, Rathor AS. Comparative Evaluation of Oral and Intranasal Administration of Midazolam as Preanesthetic Medication in Pediatric Dental Patients Treated under General Anesthesia. Int J Clin Pediatr Dent 2024;17(8):881-886. DOI: 10.5005/jp-journals-10005-2941.
