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LETTERS TO THE EDITOR

Premedication with Midazolam in Pediatric Anesthesia

Department of Anaesthesia Stafforshire General Hospital Stafford, United Kingdom ST16 3SA

In the study of Viitanen et al (1), unfortunately, only children 1–3 yr old are included. We feel it would have been better if children of all age groups were included.

According to their study, routine oral premedication with midazolam delays recovery and emergence. But some groups of children may benefit from preoperative sedation before day surgery. These include the unduly anxious child, the child presenting for repeated procedures at short intervals, and the child with learning difficulties with whom it may be difficult to gain rapport. In recent years, considerable interest has been focused on the use of midazolam for sedating these groups of children. With a dose of 0.5–0.75 mg/kg it is effective in terms of rapid onset sedation and anxiolysis, which is needed in children. The main advantage claimed for midazolam premedication is that it does not delay recovery after day surgery and is not associated with an increased incidence of inpatient admission (2). In this usual preanaesthetic dose, it produces amnesia with few side effects, and mental function returns to normal within 4 h, making it a popular choice for ambulatory surgery (3). Further midazolam given as premedicant may combat the emergence delirium which may occur after sevoflurane anaesthesia in children including agitation, restlessness, combativeness and extreme fright (4).

In conclusion, I strongly support their study and discourage the routine use of midazolam as a premedication in children.

References

1. Viitanen H, Annila P, Viitanen M, Tarkkila P. Premedication with midazolam delays recovery after ambulatory sevoflurane anesthesia in children. Anesth Analg 1999;89:75–9.[Abstract/Free Full Text]
2. Brennan LJ. Modern day-case anaesthesia for children. Br J Anaesth 1999;83:91–103.[Free Full Text]
3. Kennedy SK, Longnecker DE. History and principles of anaesthesiology. In: Gilman AG, Rall TW, Nies AS, Taylor P, eds. Vol 1. The pharmacological basis of therapeutics. New York: Pergamon Press, 1991:269–84.
4. Wells LT, Rasch DK. Emergence " delirium" after sevoflurane anaesthesia: a paranoid delusion? Br J Anaesth 1999;83:1308–10.

Response

Department of Anesthesiology University of Tampere, Medical School 33101 Tampere, Finland

We appreciate Dr. Kumar’s letter and fully agree with him that routine premedication with midazolam is not necessary in children. However, it can be very beneficial in many circumstances and should not be fully rejected, even in day-case anesthesia.

The reason for studying only 1–3-yr-old children in our study stems from the fact that this age group of children often has the most problematic recovery from anesthesia, namely postoperative agitation (1) and psychological disturbances at home (2), as a result of their inexperience in social contact and reduced benefit from psychological preparation (3). In our own study, we could not detect improvement on the quality of recovery in children after midazolam premedication except for improved pattern of sleep the night after surgery (4). Therefore, we do not altogether agree with Dr. Kumar that midazolam may combat the emergence delirium after sevoflurane anesthesia. Incidentally, in the case report by Wells et al. (5) on delirium after sevoflurane anesthesia, all of the children had been given midazolam before anesthesia. Could midazolam also have been a cause for postoperative confusion caused by amnesia?

Acknowledgments

I thank Dr Chris Secker, FRCA, Consultant Anaesthetist, Department of Anaesthesia, Staffordshire General Hospital, for his encouragement and teaching on this topic.

References

1. Beskow A, Westrin P. Sevoflurane causes more postoperative agitation in children than does halothane. Acta Anaesthesiol Scand 1999;43:536–41.[Web of Science][Medline]
2. Kotiniemi LH, Ryhänen PT, Moilanen IK. Behavioural changes in children following day-case surgery: a 4-week follow-up of 551 children. Anaesthesia 1997;52:963–9.[Web of Science][Medline]
3. Kain ZN, Mayes LC, O’Connor TZ, Cichetti DV. Preoperative anxiety in children. Arch Pediatr Adolesc Med 1996;150:1238–45.[Abstract/Free Full Text]
4. Viitanen H, Annila P, Viitanen M, Tarkkila P. Premedication with midazolam delays recovery after ambulatory sevoflurane anesthesia in children. Anesth Analg 1999;89:75–9.
5. Wells LT, Rasch DK. Emergence " delirium" after sevoflurane anesthesia: a paranoid delusion? Anesth Analg 1999;88:1308–10.[Free Full Text]

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