BNF for Children 2011-2012

BNFC 2011–2012 15.1.4 Sedative and analgesic peri-operative drugs 637Motion sickness, excessive respiratory secretions,hypersalivation associated with clozapinetherapy section 4.6Hyoscine (Non-proprietary) AInjection, hyoscine hydrobromide 400 micrograms/mL, net price 1-mL amp = £2.80; 600 micrograms/mL, 1-mL amp = £2.94PreparationsFor transdermal and oral preparations see section 4.615.1.4 Sedative and analgesicperi-operative drugs15.1.4.1 Anxiolytics15.1.4.2 Non-opioid analgesics15.1.4.3 Opioid analgesicsImportantThe drugs in this section should be used by experiencedpersonnel only.Premedication Fear and anxiety before a procedure(including the night before) can be minimised by using asedative drug, usually a benzodiazepine. Premedicationmay also augment the action of anaestheticsand provide some degree of pre-operative amnesia.The choice of drug depends on the individual child,the nature of the procedure, the anaesthetic to be used,and other prevailing circumstances such as outpatients,obstetrics, and recovery facilities. The choice also variesbetween elective and emergency procedures. Oraladministration is preferred if possible; the rectal routeshould only be used in exceptional circumstances. Sedativepremedication should be avoided in children with acompromised airway, CNS depression, or a history ofsleep apnoea.Premedicants can be given the night before majorsurgery; a further, smaller dose may be required thefollowing morning if any delay in starting surgery isanticipated. Alternatively, the first dose may be given onthe day of procedure.Oral midazolam is the most common premedicant forchildren; temazepam may be used in older children.The antihistamine alimemazine (section 3.4.1) is occasionallyused orally, but when given alone it may causepostoperative restlessness in the presence of pain.Sedation for clinical procedures Sedation of childrenduring diagnostic and therapeutic procedures isused to reduce fear and anxiety, to control pain, and tominimise excessive movement. The choice of sedativedrug will depend upon the intended procedure andwhether the child is cooperative; some procedures aresafer and more successful under anaesthesia. The childshould be monitored carefully; monitoring shouldbegin as soon as the sedative is given or when thechild becomes drowsy, and should be continued untilthe child wakes up.Midazolam and chloral hydrate (section 4.1.1) aresuitable for sedating children for painless procedures,such as imaging. For painful procedures, alternativechoices include nitrous oxide (section 15.1.2), localanaesthesia (section 15.2), ketamine (section 15.1.1),or concomitant use of sedation with opioid or nonopioidanalgesia (section 4.7).Dental procedures Sedation for dental proceduresshould be limited to conscious sedation whenever possible.Nitrous oxide (section 15.1.2) alone and midazolamare effective for many children. For furtherinformation on hypnotics used for dental procedures,see p. 170.Anaesthesia and skilled tasks See section 15.1.15.1.4.1 AnxiolyticsBenzodiazepinesBenzodiazepines possess useful properties for premedicationincluding relief of anxiety, sedation, and amnesia;short-acting benzodiazepines taken by mouth are themost common premedicants. Benzodiazepines are alsoused for sedation prior to clinical procedures and forsedation in intensive care.Benzodiazepines may occasionally cause marked respiratorydepression and facilities for its treatment areessential; flumazenil (section 15.1.7) is used to antagonisethe effects of benzodiazepines.Midazolam, a water-soluble benzodiazepine, is the preferredbenzodiazepine for premedication and for sedationfor clinical procedures in children. It has a fast onsetof action, and recovery is faster than for other benzodiazepines.Recovery may be longer in children with alow cardiac output, or after repeated dosing.Midazolam can be given by mouth [unlicensed], but itsbitter acidic taste may need to be disguised. It can alsobe given buccally [unlicensed] or intranasally [unlicensed].Midazolam is associated with profound sedationwhen high doses are given or when it is used withcertain other drugs. It can cause severe disinhibition andrestlessness in some children. Midazolam is not recommendedfor prolonged sedation in neonates; drug accumulationis likely to occurOverdosage with midazolamThere have been reports of overdosage in adultswhen high strength midazolam injection has beenused for conscious sedation. The use of highstrength midazolam (5 mg/mL in 2 mL and 10 mLampoules, or 2 mg/mL in 5 mL ampoules) should berestricted to general anaesthesia, intensive care,palliative care, or other situations where the riskhas been assessed. It is advised that flumazenil(section 15.1.7) is available where midazolam isused, to reverse the effects if necessary.Temazepam is given by mouth for premedication inolder children and has a short duration of action. Anxio-15 Anaesthesia