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Preinduction of anesthesia in children with rectally administered midazolam
R M Spear1, M Yaster, I D Berkowitz
1Children's Hospital of San Diego, California.
Insights
Rectal midazolam effectively sedates pediatric patients for anesthesia induction, facilitating separation from parents without significant vital sign changes. Doses of 1.0 mg/kg ensure adequate sedation, but higher doses may delay PACU discharge.
Area of Science:
- Anesthesiology
- Pediatric Medicine
- Pharmacology
Background:
- Preinduction medication is crucial for pediatric anesthesia.
- Rectal administration offers a non-invasive route for pediatric sedation.
- Midazolam is a commonly used benzodiazepine for procedural sedation.
Purpose of the Study:
- To evaluate the efficacy of rectally administered midazolam for preinduction anesthesia in pediatric patients.
- To determine the optimal sedative dose of rectal midazolam for facilitating anesthesia induction.
- To assess the safety and impact on vital signs and postanesthesia care unit (PACU) discharge.
Main Methods:
- Two-phase study involving 67 pediatric patients (ASA physical status 1 or 2).
- Phase 1: Dose-finding for midazolam (0.4-5.0 mg/kg) to assess sedation and facilitation of induction.
- Phase 2: Randomized, double-blind study of doses (0.3, 1.0, 2.0, 3.0 mg/kg) to determine optimal sedation and PACU discharge.
Main Results:
- Rectal midazolam facilitated calm separation and anesthesia induction at all tested doses.
- Doses >= 1.0 mg/kg provided adequate sedation, with 0.3 mg/kg resulting in patient struggle.
- No significant changes in vital signs (blood pressure, heart rate, SpO2, ETCO2) were observed 10 minutes post-administration.
- PACU discharge was delayed (>60 min) in patients receiving doses >= 2.0 mg/kg.
Conclusions:
- Rectal midazolam is effective for preinduction sedation in pediatric patients, improving the anesthesia induction process.
- A dose of 1.0 mg/kg appears optimal for balancing adequate sedation and timely PACU discharge.
- Higher doses (>= 2.0 mg/kg) ensure sedation but may prolong recovery, necessitating careful dose selection.
Abstract:
The authors evaluated the efficacy of rectally administered midazolam for preinduction (i.e., premedication/induction) of anesthesia in 67 pediatric patients, ASA physical status 1 or 2, undergoing a variety of elective surgical procedures. In phase 1, 41 children weighing 12 +/- 3 kg (range 7-20 kg) and 31 +/- 16 months (range 8-67 months) of age (mean +/- SD) received midazolam, 0.4-5.0 mg.kg-1, in an attempt to produce unconsciousness. Only one child lost consciousness (4.5 mg.kg-1). However, at all doses, inhalational induction of anesthesia was facilitated because children were tranquil and calmly separated from their parent(s). There were no clinically significant changes in arterial blood pressure, heart rate, oxyhemoglobin saturation, and end-tidal carbon dioxide concentration, 10 min after drug administration. In phase 2, 26 children weighing 17 +/- 4 kg (range 10-26 kg) and 44 +/- 19 months (range 17-84 months) months of age undergoing tonsil and/or adenoid surgery were studied to determine the optimal sedative dose of rectally administered midazolam. Patients received 0.3, 1.0, 2.0, or 3.0 mg.kg-1 of midazolam in a randomized, double-blind fashion. One third (3 of 9) of patients receiving 0.3 mg.kg-1 struggled during mask induction. All patients receiving greater than or equal to 1.0 mg.kg-1 were adequately sedated (P less than 0.008). Discharge from the postanesthesia care unit (PACU), however, was delayed (greater than 60 min) in children receiving greater than or equal to 2.0 mg.kg-1 (P less than 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)