Paediatric Anxiolytic Premedication Dose Guideline

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This document is designed to guide the prescription and administration of sedative pre-medication in children requiring elective or emergency surgery. It covers both standard options and second line options in children where a single agent may not produce adequate sedation and anxiolysis. This guidance was developed by Royal Aberdeen Children’s Hospital and has been approved for use in Raigmore Hospital to provide continuity across the North of Scotland.

Oral Premedication: Standard Options

  • Please administer at the prescribed time, or as soon as requested by telephone instruction.
  • The child should be appropriately monitored and not left unattended at any point after administration.
Drug Oral Dose Onset Additional Information
Midazolam

0.5 mg/kg
(maximum 20mg)

 30 minutes
  • Use the ORAL SUSPENSION. The IV preparation tastes bitter, even when administered in juice.
  • Where there is concern a child may refuse/spit out their premedication, the BUCCAL preparation (EPISTATIS) via the ORAL route may be better tolerated.
  • Paradoxical agitation in some children.
  • Short duration of action.
Clonidine 4 micrograms/kg
(maximum 300 micrograms)		 60 minutes
  • Useful if previous paradoxical reaction to midazolam and can reduce emergence delirium.
  • Use the IV preparation. This is colourless, odourless and tasteless, so may be accepted by children who refuse midazolam.
  • Co-operation and sedation can easily be lost with noise or movement, as the child remains rousable.
  • Side effects include bradycardia and hypotension, which are not significant in the otherwise healthy child.
Lorazepam Age 5 to 11 years:
50 to 100 micrograms/kg
(maximum 4mg)
Age 12 to 18 years:
1 to 4mg		 60 minutes
  • Prolonged duration of action.
  • Use ORAL Lorazepam. These are available as 1mg tablets, which can be halved if needed.

Options for children with: previous failed premedication, Severe anxiety, Autistic spectrum disorder

  • Sedative effects of drug combinations are additive and vary between patients. Doses are for guidance only.
  • When using one of the combinations below, reduce the dose of one of the agents eg. Midazolam to 0.3 mg/kg, Clonidine to 2 micrograms/kg or Ketamine to 3 mg/kg
  • Consider dose reductions where BMI is high. Avoid if any concern regarding respiratory depression.
Drug Oral Dose Onset Additional Information
Clonidine +
Midazolam

Clonidine 2 to 4 micrograms/kg
(maximum 300 micrograms)
+
Midazolam 0.3 to 0.5 mg/kg
(maximum 20mg)

 45 to 60 minutes
  • Clonidine can reduce emergence delirium.
  • Side effects of clonidine include bradycardia and hypotension, which are not significant in the otherwise healthy child.
  • Use the IV preparation for clonidine.
  • Give oral clonidine first in order to facilitate subsequent oral midazolam after 20 to 30 minutes. This is an option for children who may refuse flavoured medication.
  • Prolonged duration of action.
Ketamine +
Midazolam

Ketamine 3 to 5 mg/kg
(maximum 400mg)
+
Midazolam 0.3 to 0.5 mg/kg
(maximum 20mg)

 30 minutes
  • Works well for children with severe autism or challenging behaviour.
  • Use the concentrated 50mg/mL IV preparation for ketamine.
  • Ketamine has an unpleasant, pungent taste. Mix or follow with juice.
  • Side effects of ketamine include salivation, nausea and a dissociative state.
  • Prolonged duration of action.
Ketamine
+
Clonidine

Ketamine 3 to 5 mg/kg
(maximum 400mg)
+
Clonidine 2 to 4 micrograms/kg
(maximum 300 micrograms)

 45 to 60 minutes
  • Refer to above information.

Last reviewed: 23 March 2021

Next review: 23 March 2023

Approved By: TAM Subgroup of ADTC

Reviewer Name(s): Consultant Anaesthetist and Paediatric Pharmacist

Document Id: TAM470