The Indian Anaesthetists’ Forum

LETTERS TO EDITOR
Year
: 2020  |  Volume : 21  |  Issue : 2  |  Page : 166--168

“MOKA ICE-CUBES”: A novel mixture for paediatric oral premedication


Tushar Chokshi1, Bhavna Gupta2,  
1 Department of Anaesthesiology, Baroda Kidney Institute and Lithotripsy Center, Vadodara, Gujarat, India
2 Department of Anaesthesiology, All India Institute of Medical Science, Rishikesh, Uttarakhand, India

Correspondence Address:
Dr. Bhavna Gupta
Department of Anaesthesiology, All India Institute of Medical Science, Rishikesh, Uttarakhand
India




How to cite this article:
Chokshi T, Gupta B. “MOKA ICE-CUBES”: A novel mixture for paediatric oral premedication.Indian Anaesth Forum 2020;21:166-168


How to cite this URL:
Chokshi T, Gupta B. “MOKA ICE-CUBES”: A novel mixture for paediatric oral premedication. Indian Anaesth Forum [serial online] 2020 [cited 2020 Nov 29 ];21:166-168
Available from: http://www.theiaforum.org/text.asp?2020/21/2/166/295390


Full Text



Sir,

MOKA ice cubes contain mixture of 2 ml each of Midazolam, Ondansetron, Ketamine, and Atropine with apple juice/coconut water and deep freezing the mixture in attractive ice cubes formation to make it more appealing for pre medication in paediatric age group.

After taking due written informed consent, 500 paediatric patients, age group (2–15 years and the American Society of Anesthesiologists Class I) undergoing elective surgeries, were included over 5 years. Elective surgical procedures ranged between the duration from 30 min to 3 h and included circumcision, hernia repair, lymph node removal, and hernia repair. Routine investigations were done according to need of surgery. All peadiatric patients were received 2 h prior to surgery in preoperative area and were provided MOKA ice-cubes according to age and weight described in [Table 1] and were monitored clinically and using pulse oximeter.{Table 1}

According to our observations, 99% kids were sedated well after about 45 min to 1 h, and separation from their parents was possible without any difficulty. None of the kids had apnea or required any airway instrumentation or had any major side effects. Haemodynamics were stable and peripheral oxygen saturation was well maintained in preoperative area.

Most anesthesiologists use either the presence of parents or sedative premedication in order to alleviate anxiety. Separation anxiety is usually not achieved before the age of one and often pharmacological and behavioral interventions are used to treat preoperative anxiety in children.[1] Although midazolam in dosage 0.5–0.75 mg/kg has been used alone for procedural sedation, yet dose-dependent respiratory depression, and paradoxical agitation can occur.[2] We used lesser dosage of individual drug (midazolam and ketamine), owing to their synergistic properties. Ondansetron is a highly potent and selective serotonin 5-HT3 receptor antagonist and has a favorable safety profile. When administered orally, it is rapidly absorbed by the gastrointestinal tract, achieving peak plasma concentrations after 1–2 h.[3] Oral ketamine alone and in combination with midazolam has been used for premedication in healthy children.[4] Dosage of up to 15 mg/kg oral ketamine has been used for sedation in paediatric radiotherapy cases, and provide prompt analgesia however side effects including vomiting, emergence phenomenon, involuntary movements, and delayed recovery are frequently seen.[5] We did not encounter any adverse respiratory event and parent's, staff, and anaesthesiologist's satisfaction was paramount. The combination of oral ketamine (5–6 mg/kg) and midazolam (0.2 mg/kg) does not seem to prolong recovery time for procedures longer than 30 min. Anticholinergic agents are commonly used to prevent the undesirable bradycardia associated with some anaesthetic agents, to minimize the autonomic vagal reflexes, and to reduce secretions. Atropine is more commonly used and is a better vagolytic agent. Anticholinergic agents are useful adjuvant to ketamine owing to its anti-sialagogue and central sedative effects. The recommended oral dose of anticholinergic atropine is 0.1–0.2 mg/kg. None of the above-mentioned drug, if given alone provides favourable condition to separate kids from their patients, although efficacy of sedation with either midazolam or ketamine is fair enough. Oral absorption of these drugs is 16%–25% alone, therefore dosing is done accordingly to attain efficacy. Side effects of each individual drug are lesser than given by alternative intravenous or intra muscular routes.

We have ice cubes of prefixed dosages available in our deep freezers in OT complex, [as described in [Table 1], though ice cubes can be frozen according to individual's child weight as well. We followed fixed dose regime and all kids had satisfactory anxiolysis, adequate sedation, easy separation from parents, and face mask acceptance, with no side effects. We have also used this combination successfully in 25 paediatric patients during COVID times, and it is associated with calm and sleepy child. It is often seen that crying children are associated with more risk of aerosolization and chances of spread of infection, which becomes imperative during COVID era.

To conclude, MOKA ice-cube is a novel mixture of Midazolam, Ondansetron, Ketamine, and Atropine and provides easy, simple, attractive yet effective premedication in the paediatric age group and is without any complications till date.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Kain ZN, Mayes LC, O'Connor TZ, Cicchetti DV. Preoperative anxiety in children. Predictors and outcomes. Arch Pediatr Adolesc Med 1996;150:1238-45.
2Kumar S. Sathish MB. Premedication with midazolam in pediatric anesthesia. Anesth Analg. 2000:90:498.
3Cohen IT. An overview of the clinical use of ondansetron in preschool age children. Ther Clin Risk Manag 2007;3:333-9.
4Gutstein HB, Johnson KL, Heard MB, Gregory GA. Oral ketamine preanesthetic medication in children. Anesthesiology 1992;76:28-33.
5Bhatnagar S, Mishra S, Gupta M, Srikanti M, Mondol A, Diwedi A. Efficacy and safety of a mixture of ketamine, midazolam and atropine for procedural sedation in paediatric oncology: A randomised study of oral versus intramuscular route. J Paediatr Child Health 2008;44:201-4.