|
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 |
|
Amethocaine (angel) |
· Timing: 45 mins · Note: vasodilates |
|
EMLA |
· Timing: 60 mins · Note: vasoconstricts |
|
Coolsense |
· Timing: 30 seconds · Note: offset within 30 seconds |
|
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 |
Feedback welcome at ketaminenightmares@gmail.com