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Dra.

Macarena Lobos
Becada Anestesiologa
U. De Chile
Manejo Ansiedad Peri Operatoria
Introduccin
> 40% de los nios entre 2-10 aos presentan algn
grado de ansiedad durante la induccin anestsica
> 30% resistencia en la induccin
Comportamiento mas comn es la resistencia no
verbal, tratar de alejar la mascara


Y. Sun et al. Is dexmedetomidine superior to midazolam as a premedication in children? A meta-
analysis of randomized controlled trials, Pediatric Anesthesia 24 (2014) 863874

Temores
Separacin
de los
padres
Ambiente
desconocido
Dolor Ciruga Anestesia
Lena Tan BMBS MRCP FRCA, George H Meakin MD FRCA, Anaesthesia for the uncooperative Child, Continuing
Education in Anaesthesia, Critical Care & Pain | 2010
Factores predisponentes
Lena Tan BMBS MRCP FRCA, George H Meakin MD FRCA, Anaesthesia for the uncooperative Child, Continuing
Education in Anaesthesia, Critical Care & Pain | 2010
Segn edad, reacciones diferentes
< 9 meses menos propensos a experimentar
ansiedad de separacin de los padres.
Responden a voces suaves, balanceos.
< 1 ao
Principal problema ansiedad de separacin.
No entienden los procesos. Inducciones mas
tormentosas. Responden bien a la distraccin
( juegos, historias)
1-3 aos
mayor conciencia sobre mutilacin corporal,
puede requerir tranquilizacin. Explicaciones
simples concretas sobre ciruga y anestesia,
suelen ser efectivas en reducir ansiedad
3-6 aos
Lena Tan BMBS MRCP FRCA, George H Meakin MD FRCA, Anaesthesia for the uncooperative Child, Continuing
Education in Anaesthesia, Critical Care & Pain | 2010
Requieren mas explicacin y participacin.
Eleccin de la anestesia. Juegos, historias, videos
son tiles
7-12 aos
Control de su cuerpo, independencia y
privacidad.
Preocupaciones sobre dolor, conciencia durante
ciruga y perdida del control.
Suficiente con explicar la situaciones. Incluirlos
en el plan anestsico.
Adolescentes
Temerosos, desconfiados de los extraos.
Mas frecuentes conductas agresivas y combativas en
la induccin anestsica que requieren medidas
extremas de sedacin y/o contencin
Alt. Mentales
Desarrollo
Conductuales
Lena Tan BMBS MRCP FRCA, George H Meakin MD FRCA, Anaesthesia for the uncooperative Child, Continuing
Education in Anaesthesia, Critical Care & Pain | 2010
Ansiedad y situacin peri operatoria
M.A. Fortier et al. Perioperative anxiety in children, Pediatric Anesthesia 2010, 20: 318322
Ansiedad y Outcomes
> dolor a las 24 hr.
> requerimientos
analgsicos
> delirium post op.
Alt. Conductuales:
Ansiedad generalizada,
ansiedad de
separacin
Enuresis
Llanto nocturno
Rabietas
Alt. apetito


M.A. Fortier et al. Perioperative anxiety in children, Pediatric Anesthesia 2010, 20: 318322
Lena Tan BMBS MRCP FRCA, George H Meakin MD FRCA, Anaesthesia for the uncooperative Child, Continuing
Education in Anaesthesia, Critical Care & Pain | 2010
Davidson and McKenzie, Distress at induction: prevention and consequences, Current Opinion in
Anesthesiology 2011, 24:301306

Importante establecer el nivel de ansiedad,
Desafo:
Tiempo limitado
Necesidad de recurso humano y de infraestructura
Nios pequeos no son capaces de expresar su nivel
de ansiedad de manera verbal

Strom, Preoperative evaluation, premedication, and induction of anesthesia in infants and children, Curr
Opin Anesthesiol 2012, 25:321325
Escalas Ansiedad
Escalas ms usadas STAI y m-YPAS
Escala de ansiedad de Yale modificada (mPYAS)
fue desarrollada en 1995, modificada 1997
mide 5 items, validada.
STAI es dificultosa de realizar en el ambiente clnico

Davidson and McKenzie, Distress at induction: prevention and consequences, Current Opinion in
Anesthesiology 2011, 24:301306
Brooke N. Jenkins, MS,* Michelle A. Fortier, PhD, et al. Development of a Short Version of the Modified Yale
Preoperative Anxiety Scale, Anesthesia & Analgesia, September 2014, Volume 11, Number 3


Elimin el componente parental
Disminuy el tiempo de aplicacin de la escala en la mitad,
sin prdida significativa del nivel de ansiedad
Incrementa la aplicacin clnica

Brooke N. Jenkins, MS,* Michelle A. Fortier, PhD, et al. Development of a Short Version of the Modified
Yale Preoperative Anxiety Scale, Anesthesia & Analgesia, September 2014, Volume 11, Number 3

Evaluacin conductual post estrs op.
Diferentes escalas utilizadas en los trabajos
Cuestionario para medir alteraciones conductuales
post hospitalizacin (PHBQ)
Escala de calidad de vida ( The PedsQL)
Nios sometidos a cx. ORL al 7 da tienen peor
funcionamiento que el anlisis pre ciruga, sin
embargo, mejora a los 30 das

Davidson and McKenzie, Distress at induction: prevention and consequences, Current Opinion in
Anesthesiology 2011, 24:301306
Manejo Anestsico
Pre medicacin con sedantes
Presencia de los padres en la induccin
Intervenciones conductuales
Michael OSullivan MRCS FCA(RCSI), Gail K Wong FANZCA, Preinduction techniques to relieve anxiety in
children undergoing general anaesthesia, Continuing Education in Anaesthesia, Critical Care & Pain j
Volume 13 Number 6 2013
Manejo no farmacolgico
Cognitivas
Terapia de juego
Ambientales
Modificacin de equipamiento
Intervenciones sociales
Programas pre-hospitalarios
Lena Tan BMBS MRCP FRCA, George H Meakin MD FRCA, Anaesthesia for the uncooperative Child,
Continuing Education in Anaesthesia, Critical Care & Pain | 2010
Davidson and McKenzie, Distress at induction: prevention and consequences, Current Opinion in
Anesthesiology 2011, 24:301306
Michael OSullivan MRCS FCA(RCSI), Gail K Wong FANZCA, Preinduction techniques to relieve anxiety in
children undergoing general anaesthesia, Continuing Education in Anaesthesia, Critical Care & Pain j
Volume 13 Number 6 ,2013

Presencia de padres
Controversial
Presencia de padres con alto nivel de ansiedad
puede resultar:
Aumento ansiedad del nio
Induccin anestsica prolongada
Estrs adicional para el anestesista

Lena Tan BMBS MRCP FRCA, George H Meakin MD FRCA, Anaesthesia for the uncooperative Child,
Continuing Education in Anaesthesia, Critical Care & Pain | 2010
Davidson and McKenzie, Distress at induction: prevention and consequences, Current Opinion in
Anesthesiology 2011, 24:301306
Michael OSullivan MRCS FCA(RCSI), Gail K Wong FANZCA, Preinduction techniques to relieve anxiety in
children undergoing general anaesthesia, Continuing Education in Anaesthesia, Critical Care & Pain j
Volume 13 Number 6 ,2013

Manejo farmacolgico
Reservadas para nios no cooperadores
Las vas ms comunes : vo, intranasal y rectal.
IV en caso de contar con acceso
IM en caso de nio combativo
Consideraciones:
Rechazo de la droga
Fallar o causar una reaccin paradojal
Obstruccin de VA, depresin respiratoria en lugares
no monitorizados
Necesidad de mayor equipamiento, personal de
enfermera
Midazolam
Pre medicacin ms comn en nios
Benzodiacepina hidrosoluble
Ventajas: rpido inicio de accin, sedacin efectiva,
amnesia anterograda, ansiolisis.
Desventajas: reaccin paradojal (<1%), sabor amargo
Dosis:
Oral 0,5- 0,75 mg/kg efecto 5-10 min, peak 20-30 min
Intranasal 0,2 mg/kg
Sublingual 0,2 mg/kg
Ev 0,1- 0,2 mg/kg

Lena Tan BMBS MRCP FRCA, George H Meakin MD FRCA, Anaesthesia for the uncooperative Child,
Continuing Education in Anaesthesia, Critical Care & Pain | 2010
Strom, Preoperative evaluation, premedication, and induction of anesthesia in infants and children,
Curr Opin Anesthesiol 2012, 25:321325

Agonistas alfa2
Clonidina
Sedacin y analgesia
Ventajas: bien tolerado, efecto predecible, beneficiosa
en dolor crnico
Desventajas: lento inicio de accin (45 min)
Dosis:
Oral 4 mcg/kg
Intranasal 2 mcg/kg

Lena Tan BMBS MRCP FRCA, George H Meakin MD FRCA, Anaesthesia for the uncooperative Child,
Continuing Education in Anaesthesia, Critical Care & Pain | 2010
Strom, Preoperative evaluation, premedication, and induction of anesthesia in infants and children,
Curr Opin Anesthesiol 2012, 25:321325

Agonistas alfa2
Dexmedetomidina
Potente y selectivo agonista alfa dos (1600:1)
Sedacin y analgesia.
Vida media corta
Desventaja: inicio de accin
Dosis:
Intranasal 1-1,5 mcg/kg
EV 0,2-0,7 mcg/kg

Lena Tan BMBS MRCP FRCA, George H Meakin MD FRCA, Anaesthesia for the uncooperative Child,
Continuing Education in Anaesthesia, Critical Care & Pain | 2010
Strom, Preoperative evaluation, premedication, and induction of anesthesia in infants and children,
Curr Opin Anesthesiol 2012, 25:321325
Y. Sun et al. Is dexmedetomidine superior to midazolam as a premedication in children? A meta-
analysis of randomized controlled trials, Pediatric Anesthesia 24 (2014) 863874

Ketamina
Bloq. NMDA
Ansioltico, analgsico, sedacin
Liposoluble, rpida absorcin ev, im, intranasal y
oral
Desventaja: Aumento secreciones, hiperventilacin,
alucinaciones
Dosis:
Vo 5-8 mg/kg inicio 10.15 min
IM 4-8 mg/kg nio combativo
EV 1-2 mg/kg
Lena Tan BMBS MRCP FRCA, George H Meakin MD FRCA, Anaesthesia for the uncooperative Child,
Continuing Education in Anaesthesia, Critical Care & Pain | 2010
Strom, Preoperative evaluation, premedication, and induction of anesthesia in infants and children,
Curr Opin Anesthesiol 2012, 25:321325

Otros
Fentanilo
Rpida absorcin va tansmucosa
Inicio de accin 15-20 min
Se asocia a depresin respiratoria, prurito y aumento
PONV
Dosis:
Oral 15-20 mcg/kg
Intranasal 15-20 mcg/kg
Lena Tan BMBS MRCP FRCA, George H Meakin MD FRCA, Anaesthesia for the uncooperative Child,
Continuing Education in Anaesthesia, Critical Care & Pain | 2010
Strom, Preoperative evaluation, premedication, and induction of anesthesia in infants and children,
Curr Opin Anesthesiol 2012, 25:321325

Conclusiones
Fundamental identificar a los pacientes con factores
predisponentes
Disminuir los tiempos de situaciones ms
estresantes (separacin, induccin, etc.)
Prevenir Disminuir outcome adversos
Evaluar caso a caso presencia de padres
Biliografa
Y. Sun et al. Is dexmedetomidine superior to midazolam as a premedication
in children? A meta-analysis of randomized controlled trials, Pediatric
Anesthesia 24 (2014) 863874
Lena Tan BMBS MRCP FRCA, George H Meakin MD FRCA, Anaesthesia for the
uncooperative Child, Continuing Education in Anaesthesia, Critical Care & Pain
| 2010
M.A. Fortier et al. Perioperative anxiety in children, Pediatric Anesthesia
2010, 20: 318322
Davidson and McKenzie, Distress at induction: prevention and consequences,
Current Opinion in Anesthesiology 2011, 24:301306
Michael OSullivan MRCS FCA(RCSI), Gail K Wong FANZCA, Preinduction
techniques to relieve anxiety in children undergoing general anaesthesia,
Continuing Education in Anaesthesia, Critical Care & Pain j Volume 13 Number 6
2013
Bibliografa
Peggy Yip, Philippa Middleton, Allan M Cyna, Alison V Carlyle, Non-
pharmacological interventions for assisting the induction of
anaesthesia in children, The Cochrane Library 2010, Issue 11
F. Rangel vila et al, La ansiedad de los padres incrementa la
ansiedad preoperatoria en el paciente peditrico cuando este va
a someterse a ciruga ambulatoria, Rev Esp Anestesiol Reanim.
2012;59(2):83-90
Strom, Preoperative evaluation, premedication, and induction of
anesthesia in infants and children, Curr Opin Anesthesiol 2012,
25:321325
Lerman, Preoperative assessment and premedication in
Paediatrics, Eur J Anaesthesiol 2013; 30:645650
Brooke N. Jenkins, MS,* Michelle A. Fortier, PhD, et al.
Development of a Short Version of the Modified Yale
Preoperative Anxiety Scale, Anesthesia & Analgesia, September
2014, Volume 11, Number 3