ORAL KETAMINE PREMEDICATION IN CHILDREN
Isamade ESE-mail: Department of Anaesthesia, Jos University Teaching Hospital, Jos, Nigeria.
Email: eisamade@yahoo.co.uk
Premedication is the administration of drugs prior to anaesthesia to facilitate smooth induction of anaesthesia. Anaesthesia and surgery can be stressful and traumatic experiences for children leading to long term psychological impairment1,2,3. Children coming for surgeries are usually uncooperative; it is not unusual for children to become combative, and refuse anaesthesia and surgery. This may be due to fear of pain and general anxiety over the operation and separation from parents. The preschool children and those with disabilities are most at risk. Common strategies adopted to overcome this problem include involvement of parents (as much as possible) and premedication. The aims of premedication in children are to relieve anxiety, reduce the trauma associated with separation from their parents and facilitate smooth induction of anaesthesia2. There are various combinations of drugs and routes of administration of premedication, however there is still no satisfactory way to ensure smooth induction of anaesthesia in children. Premedication may be administered by oral, intravenous, intramuscular, buccal/transmucosal, nasal or rectal routes but the oral route is preferred in children1.
Oral premedication is favoured in children because apart from ease of administration and being the physiologic route, it also avoids pain of injection and cannulation, and therefore has better acceptance. Oral midazolam and other benzodiazepines are useful options but oral ketamine is increasingly used as an alternative. In this issue of the journal, Oyedepo et al4 found oral ketamine (prepared from the parenteral formulation with addition of simple syrup and purified water) effective and safe premedication in children undergoing day case surgery; it provided satisfactory sedation and anxiolysis, with easy separation from parents and acceptance of face mask without side effects. In this ‘era of orifices’, oral premedication is a welcome development. Nasal ketamine for paediatric premedication has also been described5 but it is not routine practice yet.
The authors described oral premedication for paediatric age group as an uncommon practice amongst anaesthetists in Nigeria4. This leads to avoidable emotional/psychological distress of both parents and their children. Whether this unpopularity of paediatric oral premedication in Nigeria is just a personal observation or a study finding is not clear, and the reason for the uncommon practice is not disclosed; as oral premedication is common practice in paediatric anaesthesia in most parts of the world3. A previous study in Nigeria by Amanor–Boadu and Soyannwo6 also found oral ketamine (parenteral formulation flavoured by Ribena juice) an effective premedication in children.
It is desirable that premedication does not prolong recovery, and has minimal side effects. It would have been useful to know for how long the authors searched for side effects in the children following oral ketamine premedication. The study was in day case surgeries, so the period of post operative observation of one hour in post anaesthesia care unit (PACU) as reported may be inadequate to rule out complications. Further observation on the ward and a home telephone call to parents/guardians to enquire about possible side effects may be necessary to rule out delayed side effects; some parents have reported nightmares, restless sleep or negative memories one week after oral ketamine premedication7.
A need exists in our sub-region for safe and effective oral premedication to alleviate distress in children undergoing surgery. It reduces both patient and parental anxiety, provides anterograde amnesia and reduces postoperative behavioural changes and adverse outcomes in children7. Ketamine has the added advantage of providing analgesia; it is cheap and readily available in our environment in parenteral formulation, but the taste is not palatable. Therefore to be used for oral premedication in children, it could be flavoured by additives as the taste of the drug is important when used as oral premedication in children. Oral midazolam may be combined with oral ketamine for a quicker onset of action7,8. It is hoped that the study of Oyedepo et al4 will serve as a wakeup call for anaesthetists in the subregion to cultivate the practice of routine oral premedication in children.
References
- Turhanoglu S, Kararmaz A, Ozyilmaz M A, Kaya S, Tok D. Effect of different doses of oral ketamine for premedication of children. Eur J Anaesthesiol 2003; 20(1): 56- 60.
- Weldon BC, Watcha MF, White PF. Oral midazolam in children: effect of time and adjunctive therapy. Anesth Anal 1992; 75:51-55.
- Meursing AEE. Psychological effects of anaesthesia in children. Current opinion Anaesthesiol 1989; 2:335-8.
- Oyedepo OO, Nasir AA, Abdur-Rahman LO, Kolawole IK, Bolaji BO, Ige OA. Efficacy and safety of oral ketamine premedication in children undergoing day case surgery. J West Afr Coll Surg 2016; 6(1):1-
- Weksler N, Ovadia L, Muafi G, Star A. Nasal ketamine for paediatric premedication. Can J Anaesth. 1993;40:119.doi:10.1007/BF 03011307.
- Amanor-Boadu SD., Soyannwo OA. Ketamine and midazolam as oral premedication in children. Afr J Biomed Res. 2001; 4:13-16.
- Funk W, Jakob W, Reidl T and Toeger K. Oral preanaesthetic medication for children: double blind randomised study of a combination of midazolam and ketamine Vs midazolam or ketamine. Br J Anaesth 2000; 84:335-40.
- Darlong V, Shende D, Subramanyam MS, Sunder R, Naik A. Oral ketamine or midazolam or low dose combination for premedication in children. Anaesth Intensive Care. 2004; 32(2):246-9.