1. Alyssa Brzenski

2. Case You are called by a parent of a child who you took care of a week and a half ago. The child, a 4 year old boy, came to IR for the first of many sclerotherapy of a Venous Malformation of the LLE. Per mom, the boy has been having night terrors and although he was previously potty trained has been wetting the bed almost every night.

3. Case(cont) During the case the boy came back to the IR room with his mom, who was anxious at the time. He underwent a “rocky” mask induction. The remainder of the anesthetic was uneventful and he was discharged home following the procedure.

4. Preoperative Anxiety

5. Post-op Delirium

6. Pre-operative Anxiety

7. Risk Factors Age Prior stressful medical encounters Temperament- shy and inhibited Anxious parents

9. Low Sensory Environment

10. Parental Inductions

11. Parental Induction vs Premed

12. Distraction

13. Pharmacologic Interventions Midazolam Ketamine Precedex

14. Methods of Administration Oral Intranasal Sublingual/Bucosal Rectal Intramuscular

15. Midazolam Short acting benzodiazepine Imidazole ring allows for easy absorption across mucous membranes

16. Oral Midazolam Low bioavailability(27%) due to first pass metabolism Dose= 0.2-0.5mg/kg Onset in 10 minutes Peak effect in 20 minutes

17. Oral Midazolam Decreases anesthetic requirements Delays emergence and Stage I PACU recovery, but not discharge from the hospital Decreases post-op maladaptive behavior

18. Other Routes for Midazolam Intravenous- 0.05-0.1 mg/kg Nasal Midazolam- 0.2 mg/kg Significant stinging during administration Potential for neurotoxicity via the cribiform plate- use only preservative free Intramuscular- 0.1-0.15mg/kg Onset within 10 minutes Rectal- 0.5-1mg/kg Associated with hiccups (22%)

19. Ketamine Phencyclidine Produces sedation and analgesia while preserving respiratory drive and upper airway tone Increased sympathetic stimulation, direct cardiac depressant Associated with increased oral secretions, nystagmus, increased post-op nausea and vomiting Less post-op delirium in kids

20. Intramuscular Ketamine A good option for the child who refuses to take oral medication or who is combative Dose = 2-5 mg/kg Can add atropine/glyco to reduce secretions Can add midazolam Significantly prolongs recovery during short procedures

21. Ketamine Intravenous- 1mg/kg Oral- 5-6mg/kg sedates within 12 minutes Nasal- 6mg/kg Potentially neurotoxic Rectal- 5mg/kg sedates within 30 minutes

22. Precedex α-2 agonist- sedation with maintence of spontaneous respiration

23. Intranasal Precedex

24. Conclusion Perioperative anxiety can be associated with increased pain scores, post-operative delirium and prolonged regression and maladaptive behaviors There should not be a 1 size fits all approach However, a tailored plan should be made for high risk patients while being cognizant of pre-operative and post-operative/PACU effects.

25. Sources Kain Z, et al. Predicting Which Child-Parent Pair Will Benefit from Parental Presence During Induction of Anesthesia: A Decision- Making Approach. Anesthesia and Analgesia. 2006; 102:81-4. Green S, Cote C. Ketamine and Neurotoxicity: Clinical Perspectives and Implications for Emergency Medicine. Annals of Emergency Medicine. 2008; 1-9. Yuen VM, Hui TW, Irwin MG, Yuen MK. A Comparison of Intranasal Dexmedetomidine and Oral Midazolam for Premedication in Pediatric Anesthesia: A Double-Blinded Randomized Controlled Trial. Anesthesia and Analgesia. 2008; 106: 1716-21. Kain Z, et al. Preoperative Anxiety, Postoperative Pain, and Behavioral Recovery in Young Children Undergoing Surgery. Pediatrics. 2006; 118: 651-8. Kain Z, et al. Preoperative Anxiety and Emergence Delirium and Postoperative Maladaptive Behaviors. Anesthesia and Analgesia. 2004; 99: 1648-54. Kain Z, et al. Preoperative Anxiety in Children: Predictors and Outcomes. Arch Pediatric and Adolescent Medicine. 1996; 150: 1238-45. Kain Z, et al. Sensory Stimuli and Anxiety in Children Undergoing Surgery: A Randomized, Controlled Trial. Anesthesia and Analgesia. 2001; 92: 897-903. Patel A, et al. Distraction with a Hand-Held Video Game Reduces Pediatric Preoperative Anxiety. Pediatric Anesthesia. 2006; 16: 1019-27.