• Anaesthesia for the uncooperative child
    • Few are uncooperative unless stressed or anxious
    • Post-op behavioural changes can be seen including enuresis, temper tantrums and night time crying which may last up to 1 year
    • 5 main fears
      • Separation
      • Environment
      • Pain
      • Surgical procedure
      • Anaesthesia
    • Psychological interventions
      • Pre-hospital programmes
      • Play therapy
      • Parental presence at induction (anxious parents often not beneficial!)
      • Music, hypnosis, lighting, distraction (bubbles), 'blow up the balloon'
    • Pharmacological interventions
      • Midazolam
        • Oral 0.5mg/kg
          • Onset in 5-10, peak 20-30, wanes after 45 mins
        • S/L or I/N 0.2mg/kg
          • Effective in 10 mins
        • IV 0.05-0.2 mg/kg
          • Onset in 2 mins, recovery in 2 hrs
        • Rectal 0.3mg/kg
      • Ketamine
        • Oral 5-8mg/kg
          • Onset 10-15, peak 20-30
        • IM 4-5mg/kg
          • Onset in 5 mins, offset 45 mins
      • Fentanyl
        • Lollipop
          • 15-20μcg/kg
            • Onset 20 mins, peak 30-40 mins
            • Has some unwanted S/E
    • Strategies
      • Anxious
        • Distraction
        • Premedication
        • Postpone procedure (if restraint likely to be required and elective surgery)
        • Send back to the ward for discussion or pre-med
      • Combative
        • Involve parents and staff
        • Discuss pre-med, restraint or both
        • Ask parents what worked previously
        • IM ketamine ideal as can be given on ward (remember resus/airway equipment etc)
        • Do first on list
    • Consent and restraint
      • Parents can consent for child up to 18
      • Patients under 16 can consent if competent
      • Restraining should be last resort
      • Make an agreement with parents pre-induction
      • Minimal force used
      • Sufficient staff
      • Debrief with staff, parents and child afterwards
    • Age differences
      • Infants
        • Readily accept surrogates, less separation anxiety
        • Respond to soothing voice and being held
      • 1-3 yrs
        • Separation anxiety common
        • Allow parent in anaesthetic room
        • Distract with toys/stories
      • 3-6 yrs
        • Concerns about mutilation
        • Play therapy helpful
      • 7-12 yrs
        • More explanation and participation
        • Play, stories, choosing mask and DVDs may be helpful
      • Adolescents
        • Involve in the anaesthetic plan
        • Have more body awareness and independence
      • Mental disorders
        • Wary of strangers
        • Difficult to build rapport
        • May require restraint, sedation or both
    • Communication strategies
      • Quiet, reassuring voice
      • Don't be condescending
      • Listen to child's expressions/feelings
      • Don't laugh unless you know the child is being humorous
      • Don't tease the child
      • Use appropriate language
      • Avoid terms likely to cause anxiety
    • CEACCP
      Link:ceaccp.oxfordjournals.org/content/10/2/48.full.pdf