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Preoperative Medication for Children
Preoperative Medication for Children KATE SEWALL, M.D.*
In the past several years, great efforts have been made to render the operating room and induction of anesthesia at least acceptable to the young patient who is frequently bewildered and frightened by his sudden separation from familiar places and people, or who is all too familiar with the operating room as he returns for another in a long series of reconstructive procedures. Judging from the long lists of papers dealing with premedication and preoperative preparation of the child, one would suspect that anesthesiologists are not entirely pleased with their efforts so far. The reasons for this are numerous. Anesthetic agents have changed. Halothane, with or without nitrous oxide, has replaced diethyl ether as the agent most commonly used for infants and children. Thus many of the difficulties of the ether inhalation induction hqve assumed secondary importance. Ultrashortacting barbiturates have offered a speedy transfer to unconsciousness regardless of the state of anxiety or wakefulness in the patient. With modern agents, it is possible to anesthetize an unpremedicated, struggling, screaming child within a few minutes. Although this may not be aesthetically pleasing or emotionally advantageous to the patient, it is probably quite safe. Premedication has now assumed greater importance as emotional protection for the child rather than as an adjunct to anesthesia. Protection of the child's emotional welfare begins with an unhurried preoperative visit, preferably from the person who is to administer the anesthetic. Events the child is likely to remember after he leaves his room are explained to him. Some physicians have found this alone to be sufficient; 7 however, not every physician has either the time or the talent to allay the fears of a small child, or for that matter, his parent. Most physicians therefore rely on some sort of pharmacological enforcement of a tranquil state: a drug, or combination of drugs, given by a reliable route to assure a sleeping or sedated and calm patient. It is at this point that most of the confusion arises. '''Assistant Professor of Anesthesiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland Surgical Clinics of North America- Vol. 50, No.4, August, 1970
775
776
KATE SEWALL
First, although dose response curves may be well known, there are individual variations in patients. One is never entirely sure whether a single intramuscular injection of a barbiturate will be just right, too much, or too little for a given child. Again, hospitals differ in the availability and quality of supervision for the medicated child, and this may vary from ward to ward. Heavy sedation may be quite safe if a nurse with knowledge of airway management and resuscitation attends the child; it has no place if the child is left alone in his crib at the end of the hall. The hazards of the trip from the ward to the operating room differ from hospital to hospital and may even vary within a single institution. For instance, within The Johns Hopkins Hospital, a child scheduled for the general operating room is guaranteed a relatively smooth ride through a few quiet corridors. However, the child scheduled for the Wilmer Eye Clinic operating rooms must travel down several floors by elevator and is then wheeled through the main hospital corridor with all its noise and traffic for a distance of about one and one half city blocks. If the second child is to remain calm and unperturbed he will probably require more medication than the first. Finally, the time at which the medication is given is of utmost importance. The child should receive the sedative drugs in his room and then be given a chance to fall asleep before he is moved. In most cases this can be accomplished by ordering premedication an hour to an hour and a half prior to the scheduled time of operation. It is obvious that the time of premedication should be altered according to changes in the operating schedule. A combination of drugs virtually guaranteed to put any child asleep will be worthless if it is administered as he is whisked down the hall on his way to the operating room. Such a child, insulted by a recent needle stick, and miserable in unfamiliar surroundings, will arrive in the operating room frightened and screaming. The hoped for sedative effects of the premedicant drugs will peak well after induction of anesthesia. The unpleasant experience of an intramuscular injection can be eliminated by the use of the oral route, 6 • 8 • 12 but this practice introduces even greater variation in absorption time and greater unpredictability of effect. Drugs used for premedication fall into four major groups: (1) belladonna alkaloids-anticholinergics (atropine and scopolamine); (2) hypnotics-barbiturates; (3) narcotics (meperidine and morphine); and (4) tranquilizers from a variety of parent compounds- phenothiazines, antihistamines, and benzodiazepines. A detailed discussion of the pharmacology of these agents and the relative merits of synthetic substitutes is beyond the scope of this paper, so the following general remarks will be limited to the more common and better known drugs.
THE BELLADONNA ALKALOIDS The belladonna alkaloids are given for two primary reasons: to induce some degree of vagal blockade and thereby decrease the incidence
777
PREOPERATIVE MEDICATION FOR CHILDREN
of reflex bradycardia, and to decrease secretions during induction of anesthesia. Excessive salivation is not particularly troublesome with halothane or thiopental and this action is relatively unimportant. Bradycardia secondary to the vagotonic action of halothane does occur in children who have not received atropine or scopolamine. Atropine is considered the better vagolytic agent of the two. Scopolamine has a relatively greater drying action and has the advantage of causing better sedation with amnesia when used in combination with a barbiturate. The dose of the two drugs is the same. AGE
DOSE OF ATROPINE OR SCOPOLAMINE
Newborn to 1 year 1 to 2 years 2 to 4 years 4 to 6 years 6 to 10 years
0.1 mg. 0.1 to 0.2 mg. 0.2 to 0.3 mg. 0.3 to 0.4 mg. 0.4mg.
This schedule will be considered light by many physicians. Smith, in his textbook Anesthesia for Infants and Children/ 4 recommends 0.2 mg. of atropine or scopolamine in the newborn.
THE BARBITURATES Of this group, pentobarbital (Nembutal) and secobarbital (Seconal) are most commonly used. These drugs cause central nervous system depression, sedation, and sleep, with remarkably little effect on other systems when used in reasonable doses. They are not analgesics. When given alone in the face of moderate to severe pain, delirium frequently ensues. However, the barbiturates have been used for a long time. The actions of the drugs are well known, and the only absolute contraindication to their use is acute intermittent porphyrinuria. The usual dose is 3 mg. per kg. intramuscularly. This is decreased to 1.0 to 1.5 mg. per kg. when used in conjunction with narcotics.
NARCOTICS Aside from analgesic action, narcotics are frequently added to premedication for their calming and mood changing effect in doses that do not cause respiratory depression or sleep. 5 • 14 When given routinely, they may increase the incidence of postoperative nausea and vomiting. Narcotics are indicated as premedication for children who are in pain and for children with cyanotic congenital heart disease. The cyanotic child does well with morphine, 0.2 mg. per kg. intramuscularly, for premedication with no barbiturate added. The usual dose for routine preoperative medication in conjunction with a barbiturate is morphine, 0.1 to 0.15 mg. per kg., or meperidine, 1 mg. per kg.
778
KATE SEWALL
TRANQUILIZERS The advisability of using the tranquilizers for routine preoperative medication, particularly those of the phenothiazine group, is in question. Chlorpromazine, the prototype of this group, is capable of producing a calm state without great impairment of arousal. In this respect, it differs from barbiturates. Certainly, in the care of psychotic, combative individuals, the use of a phenothiazine with its attendant unwanted pharmacological actions is well worth the risk. However, one should remember that part of the initial interest in these drugs was engendered by their ability to cause a state close to "artificial hibernation." The phenothiazines possess strong alpha adrenergic blocking activity; they depress the vasomotor center, causing postural hypotension in many individuals. Of particular importance in pediatric anesthesia, these drugs disrupt hypothalamic temperature control. When they are combined with a good vasodilator, such as halothane, subsequent hypothermia frequently occurs. In addition, the phenothiazines potentiate actions of other depressant drugs. Recovery time may be prolonged, and the drug, once given, stays around for many hours. The phenothiazines as a group possess antiemetic activity on a central basis. For this purpose, they are best given postoperatively if the need arises. Their use as adjuncts to local anesthesia is discussed at the end of this article. The newer benzodiazepine compounds, chlorodiazepoxide (Librium) and diazepam (Valium), are proving to be useful and interesting drugs. The experience with their use in children is fairly limited and confusion remains concerning the optimal dose range. 6 • 11 More investigation remains to be done. Hydroxyzine (Vistaril), an antihistamine, has achieved some popularity. Keller et al. 8 used 0.5 mg. per lb., alone or in conjunction with pentobarbital or meperidine. Again, experience with this drug is relatively limited. At The Johns Hopkins Hospital, the following premedication schedule is recommended for healthy children. AGE
Newborn to 6 months 6 months to 1 year 1 to 2 years 2 to 4 years 4 to 6 years 6 to 10 years
DOSE
Atropine 0.1 mg. Atropine or scopolamine 0.1 mg. Pentobarbital 2 mg. per kg. Scopolamine 0.1 to 0.2 mg. Pentobarbital 3 mg. per kg. Scopolamine 0.2 to 0.3 mg. Pentobarbital 3 mg. per kg. Scopolamine 0.3 to 0.4 mg. Pentobarbital 3 mg. per kg. Scopolamine or atropine 0.4 mg. Pentobarbital 3 mg. per kg.
Drugs are given intramuscularly 1 hour prior to the scheduled time of surgery. Children with cardiac disease are given a lesser dose of pentobarbital (1.5 to 2 mg. per kg.). Those with cyanotic congenital disease (including the newborn) and those in congestive heart failure are given morphine sulfate, 0.2 mg. per kg. intramuscularly, with atropine. Barbiturates are eliminated in this group. Atropine is generally
PREOPERATIVE MEDICATION FOR CHILDREN
779
substituted for scopolamine in bigger children who may be difficult to restrain should postanesthetic delirium occur. If there is any serious doubt about the effects of premedication in an ill child, atropine alone is given, or nothing at all.
MEDICATION FOR LOCAL ANESTHESIA Some procedures, particularly reconstructive surgery around the face and uncomfortable diagnostic procedures such as pneumoencephalograms, are performed with local anesthesia. Great efforts have been made to find a safe and sure combination of drugs that will render a child amenable to such procedures. The "lytic cocktail" [meperidine (Demerol), promethazine (Phenergan), and chlorpromazine (Thorazine), each 2 mg. per kg. intramuscularly] is often used for this purpose. It is extremely effective, but not without difficulties. For it to be used successfully, the healthy, vigorous child usually requires the above dose. This may cause severe depression in the less fit, and resuscitation from too heavy premedication has been necessary on occasion. It is obvious, therefore, that this combination must not be given to a child who is left unattended. In addition, the presence of two phenothiazines (chlorpromazine and promethazine) assures long action of this combination. Its peak effect is seen for 45 minutes to 2 hours after administration; it is not unusual for a child receiving the lytic cocktail to sleep the rest of the day and all night. The alpha adrenergic blocking effects and disruption of temperature regulation require that it be used with extreme care, if at all, in outpatients.
PREMEDICATION FOR THE OUTPATIENT Many short procedures such as cystoscopy, eye examinations, or dental extractions are performed with general anesthesia on an outpatient basis. For such cases, drugs given for premedication are best dictated by what will happen to the child after he leaves the hospital. There are few physicians who will wish to discharge a sleepy, ataxic child to a harassed mother who has other children to care for at home. For this reason, most outpatients are better off with no premedication at all. This allows a rapid return to a fully alert state, a short recovery room stay, and a child who will be able to care for himself and navigate the streets and stairs safely when he goes home. GENERIC AND TRADE NAMES OF DRUGS:
Chlorodiazepoxide (Librium) Chlorpromazine (Thorazine) Diazepam (Valium) Halothane (Fluothane) Hydroxyzine (Vistaril) Meperidine (Demerol) Pentobarbital (Nembutal) Promethazine (Phenergan) Secobarbital (Seconal)
r
780
KATE SEWALL
REFERENCES 1. Burstein, C. L.: Pediatric preanesthetic preparation. Anesthesiology, 14:567-571, 1953. 2. Downes, J. J., and Nicodemus, H.: Preparation for and recovery from anesthesia. Pediat. Clin. N. Amer., 16:601-611, 1969. 3. Eckenhoff, J. B.: Relationship of anesthesia to postoperative personality changes in children. Amer. J. Dis. Child., 86:587, 1953. 4. Eckenhoff, J. B., and Helrich, M. H.: Study of narcotics and sedatives for use in preanesthetic medication. J.A.M.A., 167:415-422, 1958. 5. Freeman, A., and Bachman, L.: Pediatric anesthesia: An evaluation of preoperative medication. Anesthesia and Analgesia-Current Researches, 38:429-437, 1959. 6. Gordon, N.H., and Turner, D. J.: Oral pediatric premedication. Brit. J. Anaesth., 41:136142, 1969. 7. Jackson, K.: Psychological preparation as a method of reducing the emotional trauma of anesthesia in children. Anesthesiology, 12:293-300, 1951. 8. Keller, M. L., Sussman, S., and Rochberg, S.: Comparative evaluation of combined preoperative medications for pediatric surgery. Anesth. Analg., 47:199-206, 1968. 9. Leigh, M. D., and Belton, K.: Premedication in infants and children. Anesthesiology, 7:611-615, 1946. 10. Rachow, H., and Salanitre, E.: A dose effect study of preoperative medication in children. Anesthesiology, 23:74 7-754, 1962. 11. Romagnoli, A., Cuison, S., and Cohen, M.: The use of diazepam in pediatric premedication. Can. Anaes. Soc. J., 15:603-608, 1968. 12. Root, B.: Oral premedication of children with chloral hydrate and scopolamine. Anesth. Analg., 41:194, 1962. 13. Root, B.: Problems of evaluating effects of premedication in children. Anesth. Analg., 41:180-193, 1962. 14. Smith, R.: Preoperative medication. In Anesthesia for Infants and Children. St. Louis, C. V. Mosby Co., 1968. 15. Smith, R., and Jeffries, M.: The evaluation of sedative agents for preoperative use in children. Anesth. Analg., 38:166-172, 1959. 16. Stephen, C. R., Bowers, M. A., Nowill, W. K., and Martin, R. C.: Anticholinergic drugs in preanesthetic medication. Anesthesiology, 17:303-313, 1956. 17. Stetson, J., and Jessup, C. V. S.: Pediatric premedication. Anesth. Analg., 41:203-214, 1962.
The Johns Hopkins Hospital Baltimore, Maryland 21205
In the past several years, great efforts have been made to render the operating room and induction of anesthesia at least acceptable to the young patient who is frequently bewildered and frightened by his sudden separation from familiar places and people, or who is all too familiar with the operating room as he returns for another in a long series of reconstructive procedures. Judging from the long lists of papers dealing with premedication and preoperative preparation of the child, one would suspect that anesthesiologists are not entirely pleased with their efforts so far. The reasons for this are numerous. Anesthetic agents have changed. Halothane, with or without nitrous oxide, has replaced diethyl ether as the agent most commonly used for infants and children. Thus many of the difficulties of the ether inhalation induction hqve assumed secondary importance. Ultrashortacting barbiturates have offered a speedy transfer to unconsciousness regardless of the state of anxiety or wakefulness in the patient. With modern agents, it is possible to anesthetize an unpremedicated, struggling, screaming child within a few minutes. Although this may not be aesthetically pleasing or emotionally advantageous to the patient, it is probably quite safe. Premedication has now assumed greater importance as emotional protection for the child rather than as an adjunct to anesthesia. Protection of the child's emotional welfare begins with an unhurried preoperative visit, preferably from the person who is to administer the anesthetic. Events the child is likely to remember after he leaves his room are explained to him. Some physicians have found this alone to be sufficient; 7 however, not every physician has either the time or the talent to allay the fears of a small child, or for that matter, his parent. Most physicians therefore rely on some sort of pharmacological enforcement of a tranquil state: a drug, or combination of drugs, given by a reliable route to assure a sleeping or sedated and calm patient. It is at this point that most of the confusion arises. '''Assistant Professor of Anesthesiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland Surgical Clinics of North America- Vol. 50, No.4, August, 1970
775
776
KATE SEWALL
First, although dose response curves may be well known, there are individual variations in patients. One is never entirely sure whether a single intramuscular injection of a barbiturate will be just right, too much, or too little for a given child. Again, hospitals differ in the availability and quality of supervision for the medicated child, and this may vary from ward to ward. Heavy sedation may be quite safe if a nurse with knowledge of airway management and resuscitation attends the child; it has no place if the child is left alone in his crib at the end of the hall. The hazards of the trip from the ward to the operating room differ from hospital to hospital and may even vary within a single institution. For instance, within The Johns Hopkins Hospital, a child scheduled for the general operating room is guaranteed a relatively smooth ride through a few quiet corridors. However, the child scheduled for the Wilmer Eye Clinic operating rooms must travel down several floors by elevator and is then wheeled through the main hospital corridor with all its noise and traffic for a distance of about one and one half city blocks. If the second child is to remain calm and unperturbed he will probably require more medication than the first. Finally, the time at which the medication is given is of utmost importance. The child should receive the sedative drugs in his room and then be given a chance to fall asleep before he is moved. In most cases this can be accomplished by ordering premedication an hour to an hour and a half prior to the scheduled time of operation. It is obvious that the time of premedication should be altered according to changes in the operating schedule. A combination of drugs virtually guaranteed to put any child asleep will be worthless if it is administered as he is whisked down the hall on his way to the operating room. Such a child, insulted by a recent needle stick, and miserable in unfamiliar surroundings, will arrive in the operating room frightened and screaming. The hoped for sedative effects of the premedicant drugs will peak well after induction of anesthesia. The unpleasant experience of an intramuscular injection can be eliminated by the use of the oral route, 6 • 8 • 12 but this practice introduces even greater variation in absorption time and greater unpredictability of effect. Drugs used for premedication fall into four major groups: (1) belladonna alkaloids-anticholinergics (atropine and scopolamine); (2) hypnotics-barbiturates; (3) narcotics (meperidine and morphine); and (4) tranquilizers from a variety of parent compounds- phenothiazines, antihistamines, and benzodiazepines. A detailed discussion of the pharmacology of these agents and the relative merits of synthetic substitutes is beyond the scope of this paper, so the following general remarks will be limited to the more common and better known drugs.
THE BELLADONNA ALKALOIDS The belladonna alkaloids are given for two primary reasons: to induce some degree of vagal blockade and thereby decrease the incidence
777
PREOPERATIVE MEDICATION FOR CHILDREN
of reflex bradycardia, and to decrease secretions during induction of anesthesia. Excessive salivation is not particularly troublesome with halothane or thiopental and this action is relatively unimportant. Bradycardia secondary to the vagotonic action of halothane does occur in children who have not received atropine or scopolamine. Atropine is considered the better vagolytic agent of the two. Scopolamine has a relatively greater drying action and has the advantage of causing better sedation with amnesia when used in combination with a barbiturate. The dose of the two drugs is the same. AGE
DOSE OF ATROPINE OR SCOPOLAMINE
Newborn to 1 year 1 to 2 years 2 to 4 years 4 to 6 years 6 to 10 years
0.1 mg. 0.1 to 0.2 mg. 0.2 to 0.3 mg. 0.3 to 0.4 mg. 0.4mg.
This schedule will be considered light by many physicians. Smith, in his textbook Anesthesia for Infants and Children/ 4 recommends 0.2 mg. of atropine or scopolamine in the newborn.
THE BARBITURATES Of this group, pentobarbital (Nembutal) and secobarbital (Seconal) are most commonly used. These drugs cause central nervous system depression, sedation, and sleep, with remarkably little effect on other systems when used in reasonable doses. They are not analgesics. When given alone in the face of moderate to severe pain, delirium frequently ensues. However, the barbiturates have been used for a long time. The actions of the drugs are well known, and the only absolute contraindication to their use is acute intermittent porphyrinuria. The usual dose is 3 mg. per kg. intramuscularly. This is decreased to 1.0 to 1.5 mg. per kg. when used in conjunction with narcotics.
NARCOTICS Aside from analgesic action, narcotics are frequently added to premedication for their calming and mood changing effect in doses that do not cause respiratory depression or sleep. 5 • 14 When given routinely, they may increase the incidence of postoperative nausea and vomiting. Narcotics are indicated as premedication for children who are in pain and for children with cyanotic congenital heart disease. The cyanotic child does well with morphine, 0.2 mg. per kg. intramuscularly, for premedication with no barbiturate added. The usual dose for routine preoperative medication in conjunction with a barbiturate is morphine, 0.1 to 0.15 mg. per kg., or meperidine, 1 mg. per kg.
778
KATE SEWALL
TRANQUILIZERS The advisability of using the tranquilizers for routine preoperative medication, particularly those of the phenothiazine group, is in question. Chlorpromazine, the prototype of this group, is capable of producing a calm state without great impairment of arousal. In this respect, it differs from barbiturates. Certainly, in the care of psychotic, combative individuals, the use of a phenothiazine with its attendant unwanted pharmacological actions is well worth the risk. However, one should remember that part of the initial interest in these drugs was engendered by their ability to cause a state close to "artificial hibernation." The phenothiazines possess strong alpha adrenergic blocking activity; they depress the vasomotor center, causing postural hypotension in many individuals. Of particular importance in pediatric anesthesia, these drugs disrupt hypothalamic temperature control. When they are combined with a good vasodilator, such as halothane, subsequent hypothermia frequently occurs. In addition, the phenothiazines potentiate actions of other depressant drugs. Recovery time may be prolonged, and the drug, once given, stays around for many hours. The phenothiazines as a group possess antiemetic activity on a central basis. For this purpose, they are best given postoperatively if the need arises. Their use as adjuncts to local anesthesia is discussed at the end of this article. The newer benzodiazepine compounds, chlorodiazepoxide (Librium) and diazepam (Valium), are proving to be useful and interesting drugs. The experience with their use in children is fairly limited and confusion remains concerning the optimal dose range. 6 • 11 More investigation remains to be done. Hydroxyzine (Vistaril), an antihistamine, has achieved some popularity. Keller et al. 8 used 0.5 mg. per lb., alone or in conjunction with pentobarbital or meperidine. Again, experience with this drug is relatively limited. At The Johns Hopkins Hospital, the following premedication schedule is recommended for healthy children. AGE
Newborn to 6 months 6 months to 1 year 1 to 2 years 2 to 4 years 4 to 6 years 6 to 10 years
DOSE
Atropine 0.1 mg. Atropine or scopolamine 0.1 mg. Pentobarbital 2 mg. per kg. Scopolamine 0.1 to 0.2 mg. Pentobarbital 3 mg. per kg. Scopolamine 0.2 to 0.3 mg. Pentobarbital 3 mg. per kg. Scopolamine 0.3 to 0.4 mg. Pentobarbital 3 mg. per kg. Scopolamine or atropine 0.4 mg. Pentobarbital 3 mg. per kg.
Drugs are given intramuscularly 1 hour prior to the scheduled time of surgery. Children with cardiac disease are given a lesser dose of pentobarbital (1.5 to 2 mg. per kg.). Those with cyanotic congenital disease (including the newborn) and those in congestive heart failure are given morphine sulfate, 0.2 mg. per kg. intramuscularly, with atropine. Barbiturates are eliminated in this group. Atropine is generally
PREOPERATIVE MEDICATION FOR CHILDREN
779
substituted for scopolamine in bigger children who may be difficult to restrain should postanesthetic delirium occur. If there is any serious doubt about the effects of premedication in an ill child, atropine alone is given, or nothing at all.
MEDICATION FOR LOCAL ANESTHESIA Some procedures, particularly reconstructive surgery around the face and uncomfortable diagnostic procedures such as pneumoencephalograms, are performed with local anesthesia. Great efforts have been made to find a safe and sure combination of drugs that will render a child amenable to such procedures. The "lytic cocktail" [meperidine (Demerol), promethazine (Phenergan), and chlorpromazine (Thorazine), each 2 mg. per kg. intramuscularly] is often used for this purpose. It is extremely effective, but not without difficulties. For it to be used successfully, the healthy, vigorous child usually requires the above dose. This may cause severe depression in the less fit, and resuscitation from too heavy premedication has been necessary on occasion. It is obvious, therefore, that this combination must not be given to a child who is left unattended. In addition, the presence of two phenothiazines (chlorpromazine and promethazine) assures long action of this combination. Its peak effect is seen for 45 minutes to 2 hours after administration; it is not unusual for a child receiving the lytic cocktail to sleep the rest of the day and all night. The alpha adrenergic blocking effects and disruption of temperature regulation require that it be used with extreme care, if at all, in outpatients.
PREMEDICATION FOR THE OUTPATIENT Many short procedures such as cystoscopy, eye examinations, or dental extractions are performed with general anesthesia on an outpatient basis. For such cases, drugs given for premedication are best dictated by what will happen to the child after he leaves the hospital. There are few physicians who will wish to discharge a sleepy, ataxic child to a harassed mother who has other children to care for at home. For this reason, most outpatients are better off with no premedication at all. This allows a rapid return to a fully alert state, a short recovery room stay, and a child who will be able to care for himself and navigate the streets and stairs safely when he goes home. GENERIC AND TRADE NAMES OF DRUGS:
Chlorodiazepoxide (Librium) Chlorpromazine (Thorazine) Diazepam (Valium) Halothane (Fluothane) Hydroxyzine (Vistaril) Meperidine (Demerol) Pentobarbital (Nembutal) Promethazine (Phenergan) Secobarbital (Seconal)
r
780
KATE SEWALL
REFERENCES 1. Burstein, C. L.: Pediatric preanesthetic preparation. Anesthesiology, 14:567-571, 1953. 2. Downes, J. J., and Nicodemus, H.: Preparation for and recovery from anesthesia. Pediat. Clin. N. Amer., 16:601-611, 1969. 3. Eckenhoff, J. B.: Relationship of anesthesia to postoperative personality changes in children. Amer. J. Dis. Child., 86:587, 1953. 4. Eckenhoff, J. B., and Helrich, M. H.: Study of narcotics and sedatives for use in preanesthetic medication. J.A.M.A., 167:415-422, 1958. 5. Freeman, A., and Bachman, L.: Pediatric anesthesia: An evaluation of preoperative medication. Anesthesia and Analgesia-Current Researches, 38:429-437, 1959. 6. Gordon, N.H., and Turner, D. J.: Oral pediatric premedication. Brit. J. Anaesth., 41:136142, 1969. 7. Jackson, K.: Psychological preparation as a method of reducing the emotional trauma of anesthesia in children. Anesthesiology, 12:293-300, 1951. 8. Keller, M. L., Sussman, S., and Rochberg, S.: Comparative evaluation of combined preoperative medications for pediatric surgery. Anesth. Analg., 47:199-206, 1968. 9. Leigh, M. D., and Belton, K.: Premedication in infants and children. Anesthesiology, 7:611-615, 1946. 10. Rachow, H., and Salanitre, E.: A dose effect study of preoperative medication in children. Anesthesiology, 23:74 7-754, 1962. 11. Romagnoli, A., Cuison, S., and Cohen, M.: The use of diazepam in pediatric premedication. Can. Anaes. Soc. J., 15:603-608, 1968. 12. Root, B.: Oral premedication of children with chloral hydrate and scopolamine. Anesth. Analg., 41:194, 1962. 13. Root, B.: Problems of evaluating effects of premedication in children. Anesth. Analg., 41:180-193, 1962. 14. Smith, R.: Preoperative medication. In Anesthesia for Infants and Children. St. Louis, C. V. Mosby Co., 1968. 15. Smith, R., and Jeffries, M.: The evaluation of sedative agents for preoperative use in children. Anesth. Analg., 38:166-172, 1959. 16. Stephen, C. R., Bowers, M. A., Nowill, W. K., and Martin, R. C.: Anticholinergic drugs in preanesthetic medication. Anesthesiology, 17:303-313, 1956. 17. Stetson, J., and Jessup, C. V. S.: Pediatric premedication. Anesth. Analg., 41:203-214, 1962.
The Johns Hopkins Hospital Baltimore, Maryland 21205