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Csar Osorio E.

Becado Anestesiologa y Reanimacin


HCUCH

Contenidos
Introduccin
Temores

Factores Predisponentes
Reacciones segn edades
Ansiedad, Outcome y situacin perioperatoria

Escalas de ansiedad
Manejo por el Anestesilogo
Tratamiento Farmacolgico y No Farmacolgico

Conclusiones

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 metaanalysis 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
< 1 ao

< 9 meses menos propensos a experimentar


ansiedad de separacin de los padres.
Responden a voces suaves, balanceos.

1-3 aos

Principal problema ansiedad de separacin.


No entienden los procesos. Inducciones mas
tormentosas. Responden bien a la distraccin
( juegos, historias)

3-6 aos

mayor conciencia sobre mutilacin corporal,


puede requerir tranquilizacin. Explicaciones
simples concretas sobre ciruga y anestesia,
suelen ser efectivas en reducir ansiedad

Lena Tan BMBS MRCP FRCA, George H Meakin MD FRCA, Anaesthesia for the uncooperative Child, Continuing Education
in Anaesthesia, Critical Care & Pain | 2010

7-12 aos

Adolescentes
Alt. Mentales
Desarrollo
Conductuales

Requieren mas explicacin y participacin.


Eleccin de la anestesia. Juegos, historias, videos
son tiles

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.
Temerosos, desconfiados de los extraos.
Mas frecuentes conductas agresivas y combativas en
la induccin anestsica que requieren medidas
extremas de sedacin y/o contencin

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
perioperatoria

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
postoperatorio

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


operatorio
-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.
-VO en caso de contar con acceso VVP
-IM en caso de nio combativo (absorcin errtica)
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

BDZ: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
-I.V: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: (Nunca en Bolo)

Intranasal 1-1,5 mcg/kg


I.V. 0,2-0,7 mcg/kg en infusin

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 metaanalysis of randomized controlled trials, Pediatric Anesthesia 24 (2014) 863874

Ketamina
-Bloqueador receptor NMDA
-Ansioltico, analgsico, sedacin
-Liposoluble, rpida absorcin i.v, 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 metaanalysis 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):8390

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

Manejar la ansiedad en el nio !!!


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