AIMS AND OBJECTIVES

1.    To study and compare efficacy of anaesthetic premedication in the form of intranasal dexmedetomidine and ketamine v/s intranasal midazolam v/s intranasal ketamine v/s intranasal midazolam in the paediatric age group

2.To compare the different groups on the basis of proportion of children achieving acceptable parental separation as the primary outcome and sedation onset time, degree of sedation, mask acceptance, emergence delirium, post operative agitation, post operative nausea and vomiting, Perioperative opoid use and hemodynamics as the secondary outcome

BRIEF SUMMARY :

Hospitalisation and surgery can provoke significant stress and anxiety in children. The induction of anaesthesia may be the most distressing procedure a child experiences during the entire perioperative period .It has been shown that children who are extremely anxious and fearful during anaesthetic induction are likely to develop adverse clinical outcomes such as emergence delirium, increased analgesic requirements and negative postoperative behavioural changes such as sleep disturbance, separation anxiety, eating problems, new-onset enuresis and aggression towards authority which can sometimes persist upto 4-6 months after the procedure and is also associated with poor clinical recovery. A stressful perioperative experience can also result in poor compliance with future medical therapy, including anaesthesia. Minimising distress is thus not only an ethical imperative but also important for preventing long-term behavioural problems .Premedication refers to the administration of medication before induction of anaesthesia. In the pharmacological component, the available routes of premedication are rectal, intramuscular, oral, intranasal, topical (eg-before cannulation), intravenous . The benefits of intranasal route include non invasiveness, easy administration, more compliance, requires minimal training, shorter time of onset (rapid absorption), higher bioavailability (no first pass metabolism) so drug delivery is directly to the target organ, decreased systemic adverse effects, better absorption due to highly vascularised subepithelial tissue, no gastric adverse effects, safe and convenient.Owing to the challenges with individual drugs, the need arises to consider ideal drug combinations that can provide us the desired effect with minimal adverse events . A combination of ketamine and midazolam produces 90% successful anxiolysis as compared to <75% when either drug is given alone. The combination also works in achieving a greater degree of sedation and better analgesia and amnesia 

 We are taking a combination of dexmedetomidine with ketamine as it has a faster onset of action, prolonged sedation and also the combination of dexmedetomidine with ketamine reduces its cardiovascular effects and slowers the elimination, as dexmedetomidine is a strong inhibitor of the N-demethylation of ketamine to norketamine. Dexmedetomidine does not appear to be the ideal agent for painful procedures but when used together with ketamine, dexmedetomidine may limit the tachycardia, hypertension, salivation, and emergence phenomena from ketamine, whereas ketamine may prevent the bradycardia and hypotension from dexmedetomidine. A combination of ketamine and dexmedetomidine has low incidence of adverse effects, good analgesic, predictable recovery and no cardiorespiratory depression.