Introduction

This guideline is to be implemented for patients who are undergoing anaesthesia and require premedication at the Royal Children's Hospital. The guideline describes the premedication process for a patient presenting to Day of Surgery or for a patient on an Inpatient unit requiring transfer to Theatres or Medical Imaging.

The need for sedative premedication is part of the pre-anaesthetic assessment undertaken by the anaesthetist. If the admission or ward nurse identifies that a child may potentially require premedication prior to anaesthesia, the nurse may contact the treating anaesthetist. The In Charge anaesthetist may be contacted if the treating anaesthetist is unavailable and there is clinical urgency to do so.

Aim

The aim of this guideline is to assist nurses working in the Perioperative department and In- patient Units to assess and safely manage patients requiring premedication.

Definition of Terms

• Child Life Therapy: Provides preparation for procedures and procedural support in Preop and Inpatient units. Including medical play and support in PACU post anaesthesia and surgery.
  
• EMR: Electronic Medical Record
  
• In Charge Anaesthetist: the senior anaesthetist responsible for the management and flow of the perioperative suite.
  
• PACU: Post Anaesthetic Care Unit
  
• PARC: Pre-admission resource centre
  
• Preop-Hold: Holding Bay prior to surgery
  
• Preop Lead Nurse: Nurse coordinating the pre-operative hold area
  
• Premedication: The administration of a sedative medication prescribed by an anaesthetist prior to anaesthesia. This can be oral, intranasal, intravenous, intramuscular and or topical
  
• Inpatient unit: RCH wards
  
• UMSS:University of Michigan Sedation Scale

Assessment

Patients presenting for anaesthesia and surgery may require a premedication for many reasons including to:

• Manage procedural anxiety in children
• Reduce pre and postoperative behavioural changes
• Decrease incidence of emergence agitation and delirium
• Enable a smooth induction of anaesthesia
• Increase patient cooperation
• Previous difficult experience with surgical journey including combative inductions and unplanned code greys.

Relative contraindications for a premedication

• Difficult airway
• Risk of aspiration
• Allergy or adverse reaction to premedication agent
• Central or obstructive sleep apnoea
• Raised intracranial pressure or altered GCS
• Acute systemic illness-sepsis
• Severe renal or hepatic impairment
  

It is the role of the surgical team, PARC, pre-admission, Pre-Op, PACU and Inpatient unit nurses to escalate the patient to the treating or In-Charge anaesthetist if they identify that the patient may benefit from a premedication. The anaesthesia team will also identify and prescribe appropriate premedication upon conducting their preoperative consult.

Key Contacts

Preop Lead Nurse: 52037

In Charge Anaesthetist: 52000

Child Life Therapy (CLT) can assist with alternative methods for managing preoperative anxiety, referrals can be made for children to be seen by CLT prior to induction of anaesthesia.

CLT can assist with the following techniques:

• Providing pre-admission information such as information factsheets and video links https://www.rch.org.au/be-positive/
• Sensory toys
• Communication aids such as anaesthetic passports and patient communication/distraction devices.
• Adjustment of environment such as light or sound reduction or movement to a quieter space
• Relaxation techniques such as deep breathing or clinical hypnosis
• Securing family/carer involvement

Special Considerations

In extraordinary circumstances, patients who require premedication outside the perioperative environment or inpatient unit will be coordinated by the Pre-Admission and Anaesthesia teams. This may also include collaborating with the Code Grey team. For premedications administered outside the perioperative environment or in the consult rooms, patients should be placed in theatre trolley or cot as soon as safely possible.

Patients who require premedication prior to arrival at RCH will be coordinated by the pre-admission resource team and pre-admission/treating anaesthetist. The premedication information will be discussed and coordinated with the patient's family. Referrals to child life therapy are also highly recommended.

Patients should then be transferred to preop hold or directly to the anaesthesia/operating room as soon as possible for closer monitoring. The preop clinical lead nurse is the primary communication point for notification and discussion of premedications and will liaise with the senior treating anaesthetist as required.

Pre-operative oral paracetamol

A paracetamol nurse-initiated premedication (15 mg/kg oral) is recommended for all patients undergoing anaesthesia unless otherwise indicated by the treating anaesthetist. Careful consideration and escalation is required for patients whom paracetamol is contraindicated – please see contraindications below.

ALL children having surgery should be offered local anaesthetic cream AND oral paracetamol preoperatively UNLESS:

1. It is distressing to the child 
2. Parents refuse
   
3. There is instruction otherwise from the anaesthetist on the list.
   

This does not apply to:

1. patients having general anaesthesia for medical imaging as it is a non-painful procedure, or
2. oncology patients unless approved by the treating anesthetist. 
   

Prior to administering paracetamol please check that a dose has not already been given in the last four hours. This includes checking the MAR for regular, PRN and once only orders as well as asking the parents about any medications administered prior to hospital presentation.

A secure chat communication or phone call with the anaesthetist if the child or parents refuse paracetamol/LA cream is recommended. If they are planned to have a sedative premedication it can be given at the same time as the paracetamol. 

Contraindications to oral paracetamol

• Risk of aspiration with oral medication
  
• Allergy or adverse reaction to paracetamol 
  
• Severe hepatic impairment
• Patients having PET scan (suspension contraindicated)
• Patients on a ketogenic diet (suspension contraindicated) 

Paracetamol dosing

Fasting

The patient undergoing anaesthesia and surgery should be appropriately fasted as per RCH fasting guidelines. For emergency cases or situations where fasting status is unclear, contact treating anaesthetist or In Charge anaesthetist on 52000.

Oral premedication can be mixed and given with clear fluids for example undiluted cordial (1-5mLs) or clear apple juice (5-30mLs) or sucrose.

It is acceptable to administer oral paracetamol in tablet or suspension formulation while patient is fasting for theatre. 

RCH Clinical Practice Guideline: Fasting

Administration

The administration of the premedication should follow the medication management procedure at RCH.

RCH Policies and Procedure: Medication Management 

Safety Checks

Prior to the administration of the prescribed premedication the nurse must ensure that

• Oxygen and suction are in working order and portable oxygen and suction are available in consult rooms
• Appropriately sized face mask available
• Oxygen saturation monitor available
• MET or Resuscitation trolley with reversal agents available
• Transfer Oxygen, Suction and Monitoring checked and ready for transfer from ward as appropriate
• Ensure all medications administered are signed off on the MAR to prevent accidental double dosing of medications such as paracetamol. 
• All pre-hospital medications given by the parents should also be documented appropriately. 
  

Timing of Premedication

Most premedications will require a minimum of 30 minutes for the desired effect to be experienced by the patient.

In most circumstances the premedication order will be timed for ‘on-call’. In which case, ensure that premedication is given as soon as possible after the anaesthetist or theatre calls for the patient to come to pre-op hold. Other times, the anaesthetist may contact pre-op hold or the inpatient unit to request the premedication to be administered. Please consider changes to the theatre list and keep up to date with changes in patient order. This will help prevent delays in receiving premedications and also decrease the incidence of patients receiving premedications too early.

Nursing Care

Once Pre-medication is administered ensure that the cot sides, trolley sides and beds are appropriately secured. If the child is sitting with/on parents/carer, ensure that the parents/carer understand that the child will become increasingly sedated and will need to be securely placed in cot/trolley/bed.

It is the responsibility of the nurse administering the premedication to ensure they closely monitor for signs of increased sedation and or patient deterioration.

Observation and Monitoring

Ensure line of sight nursing when a premedication is administered. The patient and oxygen saturation monitor should be visible to the nurses caring for children who have received premedications.

In the case where a patient receives a premedication in a consult room, a pre-admission nurse should be allocated to continuously observe and appropriately monitor the patient. Once the patient has become sedated or cooperation has increased, they should be transferred to the pre-op hold area for closer monitoring and observation.

In some circumstances the anaesthetist may deem it appropriate to exceed the recommended maximum dose of a premedication. In these cases, ongoing presence of the anaesthetist is not mandated, however it is recommended that either the anaesthetist or a delegate (trainee or in charge anaesthetist) is nominated and available to support preop hold as required in consultation with the preop clinical nurse lead.

The requirement for anaesthesia staff presence should be discussed with the treating anaesthetist and or in-charge anaesthetist to ensure the safety of the patient and to maintain or provide airway support if required.

Monitoring of observations should commence once the patient is able to cooperate or has had an increased sedation score >2 UMSS. Monitoring should include but not be limited to heart rate, respiratory rate, oxygen saturation and sedation score. If surgery is delayed or cancelled, continue with patient monitoring until they return to baseline or are transferred to theatre.

Observation and Continuous Monitoring

Transfer of pre-medicated patients to the Perioperative Suite and Medical Imaging

Patients who have received a premedication in the inpatient unit require:

• Nurse escort with oxygen, suction, emergency face masks and bags
• Continuous saturation and heart rate monitoring on transfer
• Handover to Pre-Op hold or PACU nurse

RCH Nursing Guideline: Nursing Clinical Handover 

RCH Policies and Procedure: Clinical handover

Dosing 

 Depending on the clinical assessment of the child by the anaesthetist, it may be appropriate for a combination of sedative premedications to be administered such as Midazolam and Clonidine.

For additional clonidine information, please see RCH medication guideline:  https://rch0365it.sharepoint.com/sites/pharmacy/SitePages/Medication-Guideline--Clonidine.aspx

Management of complications following administration of a premedication

The desired effect of a premedication is to increase sedation and manage anxiety. The nurse must assess, monitor, manage and escalate patient deterioration according to the RCH Medical Emergency Response Procedure. The nurse must be vigilant in assessing and managing signs of respiratory distress, obstruction and apnoea, as well as increased sedation.

The sedative effect may be exaggerated in some patients. It is important to contact the anaesthetist if the patient is deeply sedated UMSS 4 or has other vital sign parameter changes. The in-charge anaesthetist is a good second tier to call if the treating anaesthetist is not available. In most situations the best way to proceed is to continue to induce anaesthesia hence the need for the anaesthetist to be called as soon as possible.

In Pre-Op Hold and PACU the internal emergency response call should be initiated for clinical deterioration. This includes the activation of the red emergency buzzer and ensuring the MET trolley is taken to the location where assistance is required. The activation of the internal response bell will ensure PICU outreach will also be in attendance.

RCH Department Guideline: Local Procedure, Recovery Escalation

Inpatient units, for acute deterioration a MET call should be initiated. It is recommended that the treating or in charge anaesthetist be contacted for further advice.

RCH Policies and Procedure: Medical Emergency Response

Reversal of Premedication Agents

The decision to reverse should be made by the anaesthetist depending on the context of support required. It is reasonable to provide supportive care to maintain patient safety for the duration of the effect, rather than to reverse the sedation. Patients who receive naloxone or flumanezil are likely to require observation and monitoring for an extended period as there may be recurrence of sedation.

Companion Documents

RCH Nursing Guidelines

• Routine post anaesthetic observation
• Observation and Continuous Monitoring

RCH Clinical Practice Guidelines

• Fasting
• Normal Ranges for Physiological Variables
  

RCH Departmental Guidelines

• Sedative Premedication Guideline

• Naloxone and Flumazenil in the Post Anaesthestic Care Unit.pdf - Naloxone_Flumazenil CPG reversal flowchart.pdf

RCH Policies and Procedures

• Medication Management
• Clinical handover
• Medical Emergency Response Procedure
• Procedural Sedation - Ward and Ambulatory Areas Procedure
  

https://www.rch.org.au/pharmacy-intranet/medicines-information/Medication_guideline__Intranasal_Dexmedetomidine/

Please remember to read the disclaimer.

The development of this nursing guideline was coordinated by Tania Ramos, CNC, Nursing Research, Rachel Chapman, Deputy Director of Anaesthesia, Anaesthesia and Pain Management, Ebony Larter, CSN, Possum & Nick Martin, Consultant Anaesthetist,Anaesthesia and Pain Management, approved by the Nursing Clinical Effectiveness Committee. First published June 2024.