PRE-ANESTHESIA SEDATIVES ------------------------ Halcion In the past week I've given Halcion 0.125 - 0.25 mg to 4 kids ages 6 - 12 (including my own 10 year old) as a pre-local anesthetic sedative with great results - happy, co-operative kids and happy moms. I keep it at the office - if I have a kid who is really having difficulty co-operating I offer the mom a 0.25 mg tab of generic Halcion, with the instruction: "Give 1/2 tablet now, and give the other half in about 90 minutes if your child is not showing any signs of sedation (eg. ataxia, stupor). Bring your child back in about 2 and a half hours and we'll take care of the problem. The kids are easy to deal with, and as a bonus Halcion gives them some amnesia of the procedure (eg. ED&C of warts). Halcion is has the great advantage of rapid onset and rapid resolution of action. My 10 year old was bouncing around the kitchen making brownies 4 hours after taking 0.25 mg Halcion prior to local anesthesia and laser Rx of plantar warts - she was zonked at 2 hours when the local was injected into her feet. KC Smith MD FRCPC ----------------- I was going to write in a non-dermatologic warning about this popular but devastating drug, Halcion. And now, I have an excuse! Several years ago there was a piece in the New York Times condemning its use and abuse-in adults. The memory loss following just one dose may be profound, and last several days (remember President Bush?). People also wake up at night while on it and do very very crazy things. It also exacerbates and precipitates depression-William Styron (of Confessions of Nat Turner fame) wrote a fabulous book, Darkness Visible, a Memoir of Madness, which included his and others experience with this drug. Please read it before you prescribe this drug. Diane Thaler ------------ I'm aware of the hype about Halcion - as I recall the American Trial Lawyers Association (that fountain of public spirited and unbiased scientific information) got involved. Out of tens of millions of doses of just about any medication I'm sure a pastiche of horror stories could be concocted, but on close examination the "horror stories" might not really be the fault of the medication, or might be related to inappropriate or prolonged use of the medication, or the use of the medication in combination with other things like alcohol or other drugs. I stand by my recommendation of Halcion - rapid onset and resolution and a bit of amnesia are very useful properties; and I think that this is a very humane way to take care of kids who otherwise would have a lot of pain and fear. One of the moms was a pediatric nurse, and she in particular was very pleased and impressed with the results, and might suggest this at the hospital for some kids who need but have difficulty co-operating with things like lumbar punctures and bpne marrows. KC Smith MD FRCPC ----------------- Try the same doses sublingually; avoid the hepatic first pass and have faster onset. No problems with one time use; all the George Bushian problems pop up with chronic use. Daniel Mark Siegel MD, MS -------------------------- One caution, at least in the states. I believe that the Academy of Peds has issued guidelines on conscious sedation in children. Even oral sedation must be performed in a setting where pulse oximetry and resuscitation equipment is available. I may have the details wrong so don't quote me but I do clearly remember when looking into this that I decided against oral sedation in PWS laser kids. Mark Ling, M.D., Ph.D. ---------------------- There are lots of kids with epilepsy walking around on doses of benzodiazepines equivalent to 0.25 mg Halcion and doing fine. I don't thing the suggestion that pulse oximetry and availability of resuscitation equipment would be reasonable in this use of the medication, at this dose level. I know I use the phrases "as a practical matter" and "in my experience" a lot, but here I go again: As a practical matter, in my experience Halcion is a very safe, helpful and humane pre-medication for normal kids undergoing unpleasant procedures. In my experience pediatricians are all too often dogmatic and unreasonable (look at how official pediatrics responded to the availability of Zovirax suspension for chickenpox - you'd think they were a bunch of industrial veterinarians, yakking on and on about "cost effectiveness" -- never mind the benefits to the individual patients and their families.) But I digress. KC Smith MD FRCPC ----------------- In regard to conscious sedation in either children or adults at least in my community there are standards for the use of "conscious sedation" in either children or adults and these standards do include availability of resuscitation equipment and O2 measurement. Mostly the standards are promulgated through state mandated hospital policies but these become the "standards of care" which the courts would judge us by. Apparently there remains more freedom to exercise one's judgement a short drive across the border from here than remains in Rochester, NY (I'm beginning to wonder which restricts the freedom of choice more: a nationalized system like Canada's or private practice in the era of HMO's and Medicare under the watchful eyes of the liability attorney's). Pat Condry ---------- Do those guidelines apply even with doses so low that there is negligible risk of imparement of airway protective reflexes? No one will be allowed to prescribe or give Benedryl to an atopic child at night unless they have pulse oximetry and resuscitation equipment. If this is true, it is another example of why we should not have guidelines that interfere with the good medical judgement of a physician. Walter H. Wood, M.D. -------------------- I agree with Dr. Smith about the absurdity of monitoring kids with awake sedation, which would include Phenergan Expectorant and zillions of OTC cough and cold preparations (actually Phenergan is a great sedative). Philip Hughes, M.D. ------------------- 1. I don't agree that 0.125 - 0.25 mg Halcion po 2 hours before a procedure is "concious sedation" as an anesthesiologist would define it - I'm simply using a short acting benzodiazepine at a relatively low oral dose as an anxiolytic. Dr. Gaylord Wardell - chief of anesthesia at my hospital - tells me that "concious sedation" is defined as (usually iv) sedation to the point where the patient is barely arousable. He says if an anesthesia candidate were asked for an example of "concious sedation" for an 8 year old on an oral exam and suggested "0.25 mg Halcion" -- "He'd be laughed at." Plus, you'd never get away with billing for "concious sedation" if all you did was give the kid a bit of Halcion. 2. re: community standards - Is it the "community standard" to terrorize and traumatize little kids who have difficulty co-operating with unpleasant procedures, rather than giving them an anxiolytic to help them cope and to reduce the risk that they will try to avoid medical care in the future? - Is it the community standard to use benign, painless (and generally useless) treatments to avoid getting into a hassle with the kid and the parent, rather than giving the kid safe, effective, appropriate treatment? Kevin C. Smith MD FRCPC ----------------------- I agree fully with your feelings about the issue: I think there are many ways to accomplish this goal. I'm just warning folks that as always, what is right and sensible may have nothing to do with what is claimed in a court of law. Mark Ling, M.D., Ph.D. ---------------------- Walter, why would anyone want to give Benadryl to an atopic child. Or any child, for that matter? Maybe one of the pharmacologists on the list can tell us where in the histamine blocking pecking order Benadryl is, I may be incorrectly remembering it is quite low. Also, which of the antihistamines are most likely to perk up instead of slow down little brains. And while I am on a roll, don't some of them have a serotonin blocking effect, so that not only are the little kids wired, they are in a terrible mood to boot. DIane Thaler ------------ Diane - you know that depression often follows pain and trauma - by minimizing pain and emotional trauma I'm REDUCING the long-term risk of depression (and of dermatologist-phobia!). I agree that Halcion and similar meds are probably used chronically more than they should, but used appropriately in in particular on a one-time basis they can be very valuable. By the way, I was wondering: "If sublingual Halcion is useful, would sublingual Versed (midazolam) be better (comes on faster, goes away faster)" so in the great tradition of dermatological self-experimentation -- (remember the guy 100 years ago who proved that syphilis was an infectious disease by injecting himself and getting syphilis - at least that's how he SAID he got it) -- last night I squirted 2.5 mg of Versed into my mouth. Yechh! Tasted like battery acid. I can still taste it this morning. BOTTOM LINE: anyone who can tolerate sublingual Versed should be able to tolerate injection of local anesthetic. In case anyone was wondering, the Versed started working in 10 minutes, peaking at 30-45 minutes; but I wouldn't recommend it, in particular not for kids, who'd probably spew it all over the room. Kevin C. Smith MD FRCPC ----------------------- It has been a while since I had to use any, but I believe that Versed is available in a popsicle form for pre-anesthesia in children. I have heard reports from anesthesiologist friends of mine that it is or will be available in a lollypop. Edward Zabawski, DO, R.Ph ------------------------- Versed is routinely used in children, at a dose of .5-.75 mg/kg po in heavy juice or soda, such as grape. It supposedly works in 20 minutes, and my husbands impression is that it makes the children feel "cheerfully drunk." He suggests you use it in the under 5 year olds, as the older children can get unhinged by the ?pleasant high. Fentanyl is out as a lollipop. Kevin, you might give Halcion a try as well, and see if one dose does your 3 day memory in, as has been reported. And please, not more than one time......or you might be writing the sequel to Styron's book. Diane Thaler ------------ Better check that dose - 0.5 - 0.75 mg / kg sounds kind of high - the dose in healthy adults is 0.07 - 0.25 mg / kg im or iv; but perhaps (as seems to be the case with Halcion) kids are less sensitive to Versed, and maybe po you lose some on the first pass through the liver. I'm sure that 0.76 mg / kg would be effective, and it would probably come on in 20 minutes -- can you tell me how long it takes to go away? Personally for now I'll stick with Triazolam (generic Halcion) because its cheap and easy to administer. Kevin C. Smith MD FRCPC ----------------------- It is simply the choice of benadryl as the antihistamine that gives me pause. My understanding is that its soporific effect is unpredictable, it is a relatively poor histamine blocker (compared to hydroxyzine, doxepin, and probably the non-sedatings), and puts people, adults and children, into very foul moods. I also use antihistamines for their soporific effect, so, agreed. Diane Thaler ------------ There is a fentanyl lollypop for kids which is supposed to be useful, but I've never heard of a Versed one. Mind you, Versed is made by those same party animals at Roche who created Rohypnol ("Roofies") so who knows what they'll come up with next. KC Smith MD FRCPC ----------------- Kevin, the high dose for P.O. Versed is correct. Drugs like morphine are poor p.o. as well, though the pharmacologists will hopefully clue us in more to this mechanism. You almost had a believer in me today, I was about to try the Halcion in a large 5 year old with a pyogenic granuloma-but instead, I sent him and mom out to lunch with EMLA applied as a big glop, by me. He absolutely felt nothing (lidoepi/scalpel/ed) one and one half hours later. The mom did help by mushing the glop back into place over lunch. Diane Thaler ------------