Paediatrics – needle phobia vs aspiration risk

 

Principles:

Establish rapport

Child:

·      Conversation

·      Games

·      Songs

Parent:

·      Past experiences

·      Expectations

·      Preferences

·      Fears

Explain the situation

Dilemma:

·      Needle -> distress

·      No needle -> risk of aspiration

Priorities:

1.    Safety

2.    Comfort

Options:

1.    Awake + IV

2.    Topicalise + IV

3.    Topicalise + pre-medicate + IV

4.    Topicalise + pre-medicate + nitrous + IV

5.    Inhalational induction

6.    Intramuscular induction

Make a plan (e.g.)

Pre-induction:

·      Topicalise: amethocaine cream 60 mins pre-op

·      Pre-medicate: midazolam PO 0.5mg/kg 30 mins pre-op

·      Prepare: cannulation + drugs + airway + monitoring

Induction:

·      Positioning: whatever is least distressing

·      Distraction: whoever is most effective

·      ±Further pre-med: N2O 50% for 90 seconds

·      If successful cannula: -> induce anaesthesia

·      If fail 3 attempts or distressed +++ -> inhalational induction

 

Topicalisation:

Amethocaine (angel)

·      Timing: 45 mins

·      Note: vasodilates

EMLA

·      Timing: 60 mins

·      Note: vasoconstricts

Coolsense

·      Timing: 30 seconds

·      Note: offset within 30 seconds

 

Pre-medication:

Midazolam

·      Dose: 0.5mg/kg PO (max 20mg)

·      Timing: 30 mins

·      Problem: bitter taste, risk of paradoxical reaction, resp depression

Clonidine

·      Dose: 4mcg/kg PO

·      Timing: 60 mins

·      Problem: not as effective

Dexmedetomidine

·      Dose: 3mcg/kg IN (max 200mcg)

·      Timing: 30 mins

·      Problem: not widely available

Ketamine

·      Dose: 5mg/kg

·      Timing: 20 mins

·      Ketamine + midazolam -> fastest onset

·      Problem: psychotomimetic symptoms

 

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