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[Rectal, oral and nasal premedication using midazolam in children aged 1-6 years. A comparative clinical study]
1Klinik für Anaesthesiologie der Medizinischen Fakultät der RWTH Aachen.
Insights
Rectal midazolam offers the fastest sedation for children, while oral midazolam is best accepted but less predictable. Rectal administration is preferred for its effectiveness and fewer side effects in pediatric premedication.
Area of Science:
- Pediatric Anesthesiology
- Pharmacology
- Clinical Research
Background:
- Midazolam is a common pre-anesthetic medication for preschool-aged children.
- Noninvasive administration routes, including oral, rectal, and nasal, are utilized.
- Comparing the efficacy and acceptance of different midazolam routes is crucial for optimizing pediatric sedation.
Purpose of the Study:
- To prospectively compare the effects of oral, rectal, and nasal midazolam in pediatric premedication.
- To assess sedation, acceptance, mood, and physiological parameters across different administration routes.
- To determine the optimal route of midazolam administration for pre-school children undergoing surgery.
Main Methods:
- A prospective study involving 90 children undergoing general anesthesia.
- Children were assigned to oral (0.4 mg/kg), rectal (0.5 mg/kg), or nasal (0.2 mg/kg) midazolam based on preference.
- Sedation, acceptance, mood, emotion, resistance, pain, nausea/vomiting, and vital signs were assessed.
Main Results:
- Oral midazolam (MO) was significantly better accepted by children than nasal (MN) or rectal (MR).
- Rectal midazolam (MR) demonstrated the fastest onset of sedation.
- Nasal midazolam (MN) induced an immediate euphoric effect rather than sedation, and oral midazolam (MO) showed less predictable effects, causing delays and increased postoperative nausea/vomiting.
Conclusions:
- Rectal midazolam offers the fastest sedative onset and is recommended if accepted by the child due to high success and few side effects.
- Oral midazolam is well-accepted but less predictable, potentially leading to delayed transport and increased postoperative nausea/vomiting.
- Nasal midazolam produces an immediate euphoric effect, and its acceptance is poor, making it less suitable for sedation.
Abstract:
Midazolam is often used for the premedication of children in the pre-school age group. Different noninvasive routes of administration have been described. In a prospective study we compared the effects of oral, rectal, and nasal midazolam in commonly used dosages. PATIENTS AND METHODS. Ninety children undergoing surgery under general anesthesia were assigned to oral (0.4 mg/kg) (MO), rectal (0.5 mg/kg) (MR), or nasal (0.2 mg/kg) midazolam (MN), according to the child's and/or parent's preferred route of administration, after having obtained the parent's informed consent. It was applied on the ward before transport to the operating room. The following parameters were assessed by the observer and the anesthesiologist at different times: sedation, acceptance (child, anesthesiologist), mood, emotion, resistance, pain, nausea and vomiting, blood pressure, and heart and respiratory rates. The Wilcoxon test (P less than 0.05) was used for statistical analysis. RESULTS. All groups were comparable with respect to age, weight, and surgery experience. There was no difference in the anesthesiologist's acceptance of the premedication or the cooperation of the children. The children accepted MO significantly better compared to MN and MR. The fastest onset of sedation was found after MR. Immediately after MN many children became euphoric, and it turned out that the effect of MN was rather euphoric than sedative. The effect of MO was good in many children, but less predictable. This led to a significant delay in transport to the operating room. MO children experienced more nausea and vomiting (P less than 0.05) in the postoperative period. There were no differences in physiological parameters. DISCUSSION AND CONCLUSIONS. The results can be explained by the different characteristics of absorption and patient acceptance. The route of administration according to the child's or parent's choice can be recommended but does not guarantee success. MR had the fastest onset of sedative action due to faster absorption of the drug. MN had a euphoric effect that resulted almost immediately. Oral premedication was best accepted, nasal administration worst. MO produced more side effects than MR and MN in the postoperative period. If the child accepts the rectal route of administration, this should be preferred because of the high success rate and few side effects.