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Anaesthesia Induction and Recovery of
Uncooperative Children:
How to manage these challenges?
Dr. Vivian Yuen
Consultant
Department of Anaesthesiology
Queen Mary Hospital, Hong Kong
Honorary Clinical Assistant Professor
University of Hong Kong
Queen Mary Hospital
 Tertiary hospital
 Teaching hospital
 University of Hong Kong
 ~1400 beds
Preoperative Anxiety
 Common clinical phenomenon
 Occurs in up to 60% of all young children
undergoing surgery
Kain ZN et al. Arch Pediatr Adolesc Med; 1996:1238-45
Davidson AJ et al. Paediatric Anaesthesia; 2006: 919-27
Anaesthesia Induction
 Based on behavioral and physiological
responses, anesthesia induction appears to
be the most stressful procedure that a child
experiences during the pre- or perioperative
period
Kain ZN et al. Arch Pediatr Adolesc Med 1996; 150:1238-45
Kain ZN et al J Clinical Anesthesia1996; 8:508-14
 Up to 25% of children have been noted to
require physical restraint to facilitate anesthetic
induction
Lumley MA et al. J Pediatr Psycho 1993; 18: 481-497.
Negative Behavioral Changes
Kain et al. Anesth Analg 1999; 88:1042-47.
Kain ZN et al. Arch Pediatr Adolesc Med 1996; 150:1238-45
Preop Anxiety and Postop Behavior
Kain et al. Anesth Analg 1999; 88:1042-47.
Kain ZN et al. Arch Pediatr Adolesc Med 1996; 150:1238-45
Preop Anxiety and Postop Pain
Kain ZN Pediatrics 2006; 118:651-8
Davidson AJ et al. Paediatr Anaesth; 2006: 919-27
Risk factors:
 Younger age
 Behavioral problems with previous healthcare
attendances
 Longer duration of procedure
 More than 5 previous hospital admissions
 Anxious parents at induction
Preoperative anxiety in children –
QMH study
 ~ 2 weeks before elective surgeries
 While waiting for meeting with
anesthesiologist
 R.A. approached 217 parents,151 of them &
59 of their children age 6-17 participated
 Data from 144 parents and 51 children
 51 parent-child pairs
Measures
 Preoperative Anxiety - Parents and Children
 Locus of control (LOC) – parents and children
 Internal LOC
 External LOC
 Attachment Style
 Children’s early experiences in interacting with
caregivers will lead to formation of different attachment
styles
 Secure
 Insecure – ambivalent
 Insecure - avoidance
Results
 Children with insecure attachment experienced
significantly higher level of pre-op anxiety
(t = -2.31, p = .03)
 Children with high external LOC experienced
significantly higher level of pre-op anxiety
(t = -3.39, p = .00)
 Children with insecure attachment reported significantly
higher level of external LOC
(t = -2.90, p = .01)
Perceived Child Anxiety
as Mediator
Perception of Child
Anxiety
Parental LOC
Parental Anxiety
Child External LOC as Mediator
Child External LOC
Parental Anxiety
Child Anxiety
How to Manage DAI?
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Restrain
Oral Premedication
Intranasal Premedication
IM Premedication
Parental Presence Induction
Distraction
Video games / i-phone
YouTubeTM video
Hypnosis
 PPAI – does not reduce parental anxiety
 PPAI – does not reduce child anxiety
Non-pharmacological Intervention
 Cochrane review of 17 trials
 Ineffective:
 Parental presence, hypnosis, music
 Effective intervention:
 Computer packages
 Hand-held video games
 Clowns
 Low sensory environment
PPIA vs Midazolam
Kain ZN et al. Anesthesiology 1998:1147-56
Kain ZN et al. Anesthesiology 2003: 58-64.
YouTube video
Gomes SH. Paediatr Anaesth. 2006: 801-802
Patel A et al. Paediatr Anaesth; 2006: 1019-27
Patel A et al. Paediatr Anaesth; 2006: 1019-27
 N= 408
 Group 1: Control
 Group 2: PP
 Group 3: ADVANCE – family centre behavioral
preparation
 Group 4: midazolam
PPIA vs Midazolam
Kain ZN et al. Anesthesiology 1998:1147-56
 N= 60
 Aged 3-8
 Group I: 3mg melatonin
 Group II: 0.5mg/kg melatonin
 Group III: 0.75mg midazolam
 Group IV: placebo
Incidence of ED
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
Midazolam
melatonin 0.05
melatonin 0.2
melatonin 0.4
Transmucosal Dexmedetomidine
Anttila, M et al. Br J Clin Pharmacol 2003; 56:691-3
 N=6
 Dexm 84μg
 IV and IN
 F= 65%
 (35-93%)
Methods
Group M
Intranasal placebo
Oral Midazolam in paracetamol syrup
Group D0.5
Intranasal Dexmedetomidine 0.5g/kg
Oral paracetamol syrup
Group D1
Intranasal Dexmedetomidine 1g/kg
Oral paracetamol syrup
Definition of Sedation
 Sedation:
continuum from the awake
state
Awake
Minimal
sedation
Moderate
sedation
Deep
sedation
GA
Sedation at Separation and
at Induction
*
*
*
#
#significantly different between Group M and Group D0.5 at 0.05 level
*significantly different between Group M and Group D1 at 0.05 level
Mean SBP
Premedication Period
*
* significantly different between Group M and Group D1
14%
at 0.05 level
Mean HR
Premedication Period
11%
16%
Significant Time effect Group D0.5 and D1
Change in SBP from baseline during intraoperative
period and PACU
Change in Heart Rate from baseline during
intraoperative period (IntraOp) and PACU
#
*
*
# significantly different between Group M and Group D0.5 at 0.05 level
* significantly different between Group M and Group D1 at 0.05 level
 Identify the optimal time to insert an
intravenous cannula after 1 µg/kg intranasal
dexmedetomidine (InDex)
 Duration of action
Methods
Group A -D
Intranasal Dexmedetomidine 1 g/kg
Group A:
IV at 30 min
Group E
Intranasal Placebo
Group D:
IV at 75 min
Group B:
IV at 45 min
Group C:
IV at 60 min
Group E:
IV at 45 min
Proportion of children with
satisfactory sedation
Sedation at time of IV
cannulation (IVC)
 74 out of 79 children sedated at some point
 Median onset timel25 mins (95% CI 25-30)
 91% (CI 85-98%) achieved sedation 45 min
Proportion of children remained sedated
1.0
Median duration 85min
(CI 95% 55-100min)
0.8
0.6
0.4
0.2
0.0
0
20
40
60
80
100
120
140
Duration of sedation after onset of sedation detected (min)
% change of SBP
Time After Premedication
% change of HR
HR change from baseline
Time After Premedication
Intranasal Dexmedetomidine
Dose comparison: 1 vs. 2 µg/kg
Group 1
(n=58)
Group 2
(n=58)
2.8 ± 1.8
3.0 ± 2.1
(1 – 7)
(1 – 8)
Ages 1-4
47 (81%)
45 (77.6%)
Ages 5-8
11 (19%)
13 (22.4%)
14.3 ± 5.7
15.0 ± 6.1
(7 – 43)
(7 – 38)
52 : 6
48 : 10
(89.7%:10.3%)
(82.8%:17.2%)
Age (years)
Age distribution
Body weight (kg)
Sex, M:F
Intranasal Dexmedetomidine
Dose comparison: 1 vs. 2 µg/kg
100.0%
80.0%
84.6%
60.0%
65.5%
57.4%
53.4%
60.0%
40.0%
*
Group 1
Group 2
0.0%
Overall
* p = 0.015
Age 1-4
N = 13
N = 11
N = 45
N = 47
N = 58
20.0%
N = 58
36.4%
Age 5-8
1.0
Proportion of children not sedated
Group 1
Group 2
0.8
Median onset time
Group 1: 30 (25 – 30)
Group 2 : 25 (20-25)
0.6
0.4
0.2
0.0
0
10
20
30
40
50
60
Time from study drug administration (min)
70
Proportion of children remaining sedated
1.0
Group 1
Group 2
0.8
Group 1: 45 (45-135)
Group 2: 95 (45 – 135)
0.6
0.4
0.2
0.0
0
10
20
30
40
50
60
70
80
90 100 110 120 130 140
Duration of sedation after onset of sedation detected (min)
Intranasal Dexmedetomidine
Dose comparison: 1 vs. 2 µg/kg
% change of SBP
20
10
0
-10
-20
Group 1
-30
Group 2
-40
-50
0 min
15 min
30 min
45 min
60 min
Time After Premedication
75 min
Intranasal Dexmedetomidine
Dose comparison: 1 vs. 2 µg/kg
% change of HR
20
10
0
-10
-20
Group 1
-30
Group 2
-40
-50
0 min
15 min
30 min
45 min
60 min
Time After Premedication
75 min
Nasal Drug Adminstration
Intranasal Dexmedetomidine for Premedication
--ADVANTAGES- Natural sleep
 No paradoxical reaction
 Minimal haemodynamic effect
 No unpleasant sensation upon administration
 Intranasal or other transmucosal routes require less
cooperation from children
 Alternative to premedication
Disadvantages
 Only 50-60% attained satisfactory sedation with
1µg/kg or 2µg/kg
 Sedated children may be aroused upon stimulation
 Optimal level of sedation in different age groups
 Unknowns
 Optimal dose
 Pharmacokinetics
 ?anxiolysis
 ?outcome measures
Strategies
 Know your patients and parents
 Premedications
 Non-pharmacological interventions
 Movies / cartoons
 Video games
 Low sensory environment
 ?PPAI
EMERGENCE DELIRIUM
Emergence Delirium
 Dissociated state of consciousness
 Inconsolable
 Does not make eye contact
 Irritable
 Uncompromising
 Last 5 -15 min
 Self-limiting
 Incidence: 25% - 80%
Risk Factors ED
 1 – 5 yr
 No previous surgery
 Eye / ENT procedures
 Inhalation agents (sevo / iso)
 Poor adaptability to change
 Short time to awakening
 Preoperative anxiety
 Distress at induction
Prevention of ED
 Identify high risk patients
 Ensure good pain control
 Propofol anaesthesia
 α2 agonist
Other causes of
Emergnce Agitation
 Obstructed airway
 Hypoxaemia
 Hypercarbia
 Hyptoentsion
 Hypoglycaemia
 Increase ICP
 Bladder distension
Author
Type of study,
No of patients
Dose
Incidence of ED
Ibacache et al
Anesth Analg 2004
Prospective
randomized, n=90
Pacebo or 0.15g/kg
or 0.3g/kg
37%
17%
10%
Hanafy et al
Eg J Anaesth 2004
Prospective
randomized, n=46
Placebo or
0.5 g/kg
78%
9%
Guler et al
Pediatr Anesth 2005
Prospective
randomized, n=60
Placebo or
0.5 g/kg
17%
5%
Shukry et al
Pediatr Anesth 2005
Prospective
randomized, n=50
Placebo or
0.2 g/kg/hr
60.8%
26%
Isik et al
Pediatr Anesth 2006
Prospective
randomized, n=42
Placebo or
1 g/kg
47.5%
4.8%
Saadawy I et al
Acta Anaesthesiol
Scand 2009
Prospective
randomized, n=60
Placebo or
1g/kg caudal
27%
7%
Thank you!