Patients with dynamically responsive cyanotic CHD (ie, tetralogy of Fallot) benefit from premedication before coming to the operating room. In these children, the inherent anxiety of transfer to unfamiliar surroundings, change in temperature, and parental separation can trigger infundibular spasm and reduce pulmonary blood flow, thereby leading to a "tet spell." This transient increase in pulmonary vascular resistance dramatically decreases pulmonary blood flow and increases the flow of desaturated blood to the body via VSD. Acute hypoxemia is not an optimal state in which to initiate induction of anesthesia. Therefore, sedation with oral midazolam or nasal dexmedetomidine is useful to allay preoperative anxiety and reduce the risk of provoking a hypoxemic spell. Premedication can make the perioperative experience for a child less frightening, produce variable degrees of amnesia, and decrease the risk of emergence delirium. Pharmacologic premedication is one of many tools a pediatric anesthesiologist has to ensure a positive perioperative experience for the patient and their family. Studies have shown promising results with nonpharmacologic interventions including handheld video games, low sensory stimulation, and virtual reality.

References

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• Wang E, Thomas JJ, Rodriguez ST. Virtual reality for pediatric periprocedural care. Curr Opin Anaesthesiol. 2021;34:285-291.
• Wise-Faberowski L, Asija R, McElhinney DB. Tetralogy of Fallot: everything you wanted to know but were afraid to ask. Paediatr Anaesth. 2019;29:475-482.