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Children's health

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Any advice about pre meds?

12 replies

elliejjtiny · 06/06/2024 15:57

Putting this in children's health and chat, hope that's allowed.

DS4 is 11 and has moderate learning disabilities. Yesterday he had an operation to take some baby teeth out and one adult one. We set off early because we weren't sure how long it would take (not our local hospital) so we got there an hour early. We weren't allowed on the ward until the proper time (understandable) and there was a queue forming when we got there so we went for a walk trying to find all the different wards following the signs etc in the hope that he would be a bit more willing to sit with some colouring or a board game etc before his operation.

1 hour and 3000 steps later we get admitted. We're on the day surgery ward so the facilities are limited because patients are normally only in for about 5 hours max and spend most of the time asleep. All the other children from about 3 years up were happy to sit and do quiet activities, it was just him and the babies and toddlers who were running/crawling around everywhere. We weren't allowed off the ward once he was admitted except when we went down to theatre.

The anaesthetist comes round and after observing him for about a minute says we definitely need a pre med. This is his 23rd operation so we have tried midazolam before with varying degrees of success. I have some misgivings but we try it mixed in with blackcurrant squash and DS takes it ok but immediately starts screaming for ages. I don't blame him to be honest, it tastes vile. I ask if he could have a tiny sip of squash or water to take the taste away but it isn't possible which is fair enough, we don't want to risk anything with the anaesthetic. The midazolam works but it makes him drunk rather than sleepy. I don't know why, it always made him sleepy before when he had it). Keeping him on the bed is nearly impossible as his brain is even more incapable than usual and he can't concentrate on a story or game, he just wants to be running about. We go down to theatre at 11:30 and he is really good for this bit and lets the anaesthetist do her thing without complaint. Just over an hour later he is wide awake in recovery and wanting to make a zoom call to his class from the recovery room! He's still under the influence of midazolam so he thinks he's invincible and we're back to the battle of keeping him on the bed again.

I talked to the anaesthetist about other options and she said there was a different drug, can't remember what it was but it began with C that wasn't as awful tasting but it was less effective. He has another, much bigger, operation coming up in 2 months and I want to try and make things better for him than this time. We will be staying overnight so not on the day surgery ward. We will either be on childrens general surgery or the adolescent ward. Any tips?

OP posts:
stressedespresso · 06/06/2024 16:08

No advice.. solidarity though. Midazolam is good stuff and has worked very well for us with DD but my goodness the taste is really something else! They’ve always offered DD a bit of water to chase it down with (some anaesthetists more cautious re: fasting guidelines than than others, allowing them to sip water until sent for theatre is becoming more common) otherwise I don’t think she would’ve been able to take it. Really hope that you find another solution for your DS

elliejjtiny · 06/06/2024 16:22

Thank you. We've tried it with my autistic 9 year old before and it worked like a dream and he barely complained about the taste. He has pica though and will happily eat plaster off the walls though so maybe that's why he wasn't as bothered by midazolam!

OP posts:
Greybeardy · 06/06/2024 19:19

there are different preparations of midazolam - they don't all taste terrible (not that I've tried them (!), but it's clear from the way kids take them). Might be worth exploring if they have a different preparation to try next time. The drug beginning with 'c' is probably clonidine. There are pros & cons to each of the drugs and for different procedures etc - it's probably worth discussing what the anaesthetist advises each time as the chances are things will be subtly different each time. There are other things apart from the midaz that could have contributed to the way he was in recovery.

Wellwhatsthis · 06/06/2024 19:23

Chloral hydrate? It’s not a very nice drug though and produces a sort of hangover effect.
Or maybe clonidine?
Ask if buccal midazolam is available- it’s more concentrated so smaller volume needed for same dose. It goes in the mouth rather than into the stomach if that makes sense. It works quicker so should be given nearer to the time of procedure.
Dexmedetomidine is another option (just call it dexmed!) but might not be available.

WheelofCheeses · 06/06/2024 20:55

Could be chloral. What you really need is dexmedetomidine but not everywhere uses it and it gets given up the nose like the flu spray.

Hazelmaybe · 06/06/2024 21:29

I’d definitely choose Midas over chloryl hydrate - to me that’s a nasty drug. x

elliejjtiny · 06/06/2024 22:16

Clonidine sounds familiar, I think it was that. Ds is adamant that he is never taking midazolam ever again. It was fortunate that because it was mixed with blackcurrant squash the midazolam was bright purple so he happily took the clear coloured paracetamol after the operation. He had midazolam when he was 6 and for about a year afterwards he refused to take "hospital medicine" in case it was midazolam again. I had to bring our Calpol from home and show him the box before he would take it.

OP posts:
elliejjtiny · 16/06/2024 13:20

I know it's fiction and based in America but I was watching the good dr on tv and a few times they have given midazolam through a cannula. Could this be an option for ds? I did ask about IV sedation years ago but was told no because it would be too traumatic to put in a cannula while he was awake. But he was 3 then and he's 11 now. He does have moderate learning disabilities though.

OP posts:
EmmyPankhurst · 16/06/2024 15:14

Tell the anaesthetist he had a bad reaction to Midazolam (excitation) and doesn't like the taste.

There should be other options available. What they are depends on the hospital.
We use a lot of buccal Midaz (up thread), I don't think it tastes as bad, definitely works quicker and I always bribe with squash/ a drink afterwards. As he gets bigger the tablet option of Temazepam is available (but same drug family as Midaz so same potential issue with excitation).

Ideally you want him chilled out before he gets to the anaesthetic room so IV premeds aren't ideal but if he can tolerate a cannula on the ward without a premed would be possible to give one but labour intensive (anaesthetist would need to go to the ward to give it and stay with him while it started to work).

And if he tolerate an awake cannula does he actually need a premed at all?

Greybeardy · 16/06/2024 15:25

If he can cope with a cannula going in without a pre-med there may not be an advantage to having a pre-med - they can just bung the anaesthetic in. You really need to talk to the anaesthetist at the hospital he's having his next procedure at to make a plan - they will know what drugs are available to them, what may/may not work given the procedure he's having and his medical history. If you mention at pre-assessment it's been difficult this time, then they will probably be able to liaise with the anaesthetist for the list and make a plan that'll hopefully work a bit better.

elliejjtiny · 16/06/2024 15:53

Thank you. We've done anaesthetic with and without midazolam and sometimes it works and sometimes it doesn't. My main problem is that most of his anaesthetics were between aged 1 and 4, then aged 6, 7, 9 and 11 so he matures quite a bit in between and we can't just say to the anaesthetist, this works or this doesn't work. Being on the day surgery ward seems to make it harder as there is no play specialist and it's a smaller confined space so he gets bored and restless very quickly. I always ask if we could not be in the day surgery unit when we end up there and I always get told that the waiting list is much longer and the consultant wants it done asap etc but I think I'm going to have to insist no day surgery unit in future.I

It was the anaesthetist who strongly recommended midazolam this time because he was being lively and she was worried he wouldn't stay still in the anaesthetic room. I agreed because some anaesthetists won't risk trying to anaesthetize a child who won't keep still and I didn't want the operation cancelled. I don't know if he would stay still for a cannula on the ward or not.

OP posts:
bfsham · 16/06/2024 16:26

Intra-nasal premed ?

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