The effect of videotaped preoperative information on parental anxiety during anaesthetic induction for elective paediatric procedures

Introduction: It has long been recognised that parents of children scheduled for elective surgery experience high levels of pathological anxiety (1). Providing parents with information about anaesthesia, surgery and postoperative recovery has been identified as a tool for reducing anxiety (2–4). The purpose of this study was to determine whether audiovisual information, describing the process of undergoing and recovering from anaesthesia, could reduce anxiety levels and desire for information in parents before their child's induction of anaesthesia. Methods: The study was approved by our local ethics committee. 111 Parents were recruited into this study. Of these 56 were randomised to a control group and 55 to an intervention group. All parents completed the Amsterdam Preoperative Anxiety and Information Scale (APAIS) questionnaire on admission to hospital on the day of surgery and then again just before accompanying their child to the anaesthetic room. This is a tool for assessing preoperative anxiety and need for information, which has previously been validated in the parents of children presenting for surgery (5). In addition to the normal preoperative preparation, parents randomised into the intervention group watched a short 8 min information video after completing the first questionnaire. The video illustrated the events and procedures surrounding a child's admission to hospital for day‐case surgery, including the induction of anaesthesia. Results: There was no statistically significant difference in child demographics, type of surgical procedure, parental demographics, parental experience or STAI‐Trait scores between the two groups (P > 0.1). A repeated measures ANOVA for APAIS scores revealed a significant group × time interaction for all three measures, Anxiety Scale (F (1,109) = 6.2; P < 0.05), Need for Information Scale (F (1,109) = 7.7; P < 0.01) and total score (F (1,109) = 11.1; P < 0.001). Further analysis revealed that the intervention group demonstrated a reduction in anxiety (effect size 0.47), need for information (effect size 0.53) and total scores (effect size 0.63) as measured by the APAIS, compared with controls ( Figure 1 ).

Figure 1 Open in figure viewer PowerPoint APAIS scores: means and standard error bars for anxiety, desire for information and total, pre and postvideo.     

Perioperative Quality Initiative consensus statement on preoperative blood pressure,risk and outcomes for elective surgery

Background

A multidisciplinary international working subgroup of the third Perioperative Quality Initiative consensus meeting appraised the evidence on the influence of preoperative arterial blood pressure and community cardiovascular medications on perioperative risk.

Consensus statement on clear fluids fasting for elective pediatric general anesthesia

Pediatric anesthetic guidelines for the management of preoperative fasting of clear fluids are currently 2 hours. The traditional 2 hours clear fluid fasting time was recommended to decrease the risk of pulmonary aspiration and is not in keeping with current literature. It appears that a liberalized clear fluid fasting regime does not affect the incidence of pulmonary aspiration and in those who do aspirate, the sequelae are not usually severe or long‐lasting. With a 2‐hour clear fasting policy, the literature suggests that this translates into 6‐7 hours actual duration of fasting with several studies up to 15 hours. Fasting for prolonged periods increases thirst and irritability and results in detrimental physiological and metabolic effects. With a 1‐hour clear fluid policy, there is no increased risk of pulmonary aspiration and studies demonstrate the stomach is empty. There is less nausea and vomiting, thirst, hunger, and anxiety, if allowed a drink closer to surgery. Children appear more comfortable, better behaved and possibly more compliant. In children less than 36 months this has positive physiological and metabolic effects. It is practical to allow children to drink until 1 hour prior to anesthesia on the day of surgery. In this joint consensus statement, the Association of Paediatric Anaesthetists of Great Britain and Ireland, the European Society for Paediatric Anaesthesiology, and L'Association Des Anesthésistes‐Réanimateurs Pédiatriques d'Expression Française agree that, based on the current convincing evidence base, unless there is a clear contraindication, it is safe and recommended for all children able to take clear fluids, to be allowed and encouraged to have them up to 1 hour before elective general anesthesia.     

Predicting which children benefit most from parental presence during induction of anesthesia

BACKGROUND: The purpose of this large-scale prospective cohort study (n = 426) was to identify child and parent characteristics that are associated with low anxiety and good compliance during induction of anesthesia when parents are present. METHODS: Outcome variables included child's anxiety and child's compliance during induction of anesthesia. Predictor variables included demographics, temperament, trait (baseline) anxiety, coping style, and locus of control. RESULTS: Results of a linear regression model (overall proportion of variance accounted for equals 39.5%) showed that significant predictors of anxiety during induction of anesthesia while parents are present included: the child's age (DeltaR(2) = 0.315, P = 0.0001), behavior during previous medical visits (DeltaR(2) = 0.025, P = 0.001), child's activity level (DeltaR(2) = 0.016, P = 0.007), parent's state (contextual) anxiety (DeltaR(2) = 0.022, P = 0.001) and parent's locus of control (DeltaR(2) = 0.009, P = 0.036). A linear regression model that was constructed with compliance of the child as the outcome revealed similar findings. CONCLUSIONS: Children who benefit from parental presence are older, had lower levels of activity in their temperament, and had parents who were calmer and who valued preparation and coping skills for medical situations. The practical implications of these findings are discussed.     

父母陪伴对患儿七氟醚麻醉诱导时焦虑状态的影响

目的 评价父母陪伴对患儿七氟醚麻醉诱导时焦虑状态的影响.方法 全麻患儿120例,年龄2～12岁,体重12～32kg,ASA分级Ⅰ或Ⅱ级,采用分层随机法,将患儿随机分为2组(n=60):试验组(父母陪伴)和对照组(无父母陪伴).术前1 d分别与患儿及其父母沟通,均详细告知其麻醉诱导步骤和注意事项.术日试验组患儿由父母带人童趣化小儿麻醉诱导间一同玩耍,对照组则由医务人员带入一同玩耍.采用8%七氟醚和纯氧流量6 L/min预充呼吸环路60s后,试验组由父母将水果香味面罩贴于患儿面部并通过语言和动作安抚患儿,试验组则由医务人员进行,吸入8%七氟醚进行麻醉诱导.于术前访视、手术等候、诱导间玩耍15 min和麻醉诱导开始(T1～4)时行改良耶鲁术前焦虑评分(mYPAS),麻醉诱导期间采用麻醉诱导期合作度评分量表评价其麻醉诱导配合程度.记录麻醉诱导期间不良反应的发生情况.结果 与对照组比较,试验组T3,4时mYPAS评分降低(P＜0.05);对照组有3例诱导失败,试验组麻醉诱导均成功,两组麻醉诱导合作程度差异无统计学意义(P＞0.05);试验组2例咳嗽,对照组3例咳嗽、1例呕吐,两组不良反应发生率比较差异无统计学意义(P＞0.05).结论 父母陪伴可减轻患儿七氟醚麻醉诱导时的焦虑状态.

Abstract：

Objective To investigate the effect of parental presence on the anxiety of children during induction of anesthesia with sevoflurane. Methods One hundred and twenty children (ASA Ⅰ or Ⅱ ) aged 2-12 yr weighing 12-32 kg were assigned to one of 2 groups using a random number table ( n = 60 each): control group (group C) and parental presence group (group P). Preoperatiave visit was made the day before surgery in both groups. In group P a parent played with toys with the children for 15 min before induction of anesthesia, while in group C a nurse played with them. Anesthesia was induced with 8% sevoflurane in O2 delivered at 6 L/min through a scented face mask held by the parent or anesthesiologist talking with them in soft words. Modified Yale preoperative anxiety scale (mYPAS) was used to measure anxiety of the children during preoperative visit, before and during induction of anesthesia. Induction compliance checklist (ICC) was used to measure behavioral compliance during induction. ICC score ＞ 5 implied failure of induction of anesthesia with sevoflurane. Adverse events were recorded. Results The mYPAS scores were significantly lower before and during induction of anesthesia in group P than in group C (P ＜ 0.05), but there was no significant difference in ICC scores between the 2 groups ( P ＞0.05). There was no failure of induction in group P while in group C there were 3 failures. Cough occurred in 2 patients in group P but in 3 patients in group C. One patient vomited during induction of anesthesia in group C.Conclusion Parental presence is effective in reducing anxiety of children during induction of anesthesia.     

亲子视频对幼儿麻醉诱导期配合程度及焦虑的影响

目的探讨观看亲子视频对幼儿麻醉诱导配合程度及焦虑的影响。方法将120例1~3岁患儿采用随机数字表法分为对照组和干预组各60例。对照组按常规术前访视及护理,干预组在此基础上,术前访视时录制亲子视频,术日患儿接入手术室后观看亲子视频,在观看的过程中进行静脉麻醉诱导。记录术前1d访视时(T0)、麻醉诱导时(T1)、手术切皮时(T2)平均动脉压(MAP)和心率(HR)的变化,同时采用麻醉诱导期合作量表(ICC)和改良耶鲁术前焦虑量表(mYPAS)评估患儿配合程度及焦虑。结果T1时,干预组MAP和HR显著低于对照组(P0.05);干预组ICC及mYPAS评分显著低于对照组(均P0.01)。结论观看亲子视频可有效减少患儿麻醉诱导期的焦虑和不配合程度,维持生命体征稳定。     

The eXpectations of Parents regarding Anesthesiology Study (XPAS) from a parental perspective: a two-phase observational cross-sectional cohort study

Background

Uncertainty concerning anesthetic procedures and risks in children requiring anesthesia may cause concerns in parents and caregivers.

Aims

To explore parental expectations and experiences regarding their child's anesthesia using questionnaires designed with parental input.

Methods

This observational cross-sectional cohort study included parents (including caregivers) of children undergoing anesthesia in a tertiary pediatric referral university hospital. The study consisted of two phases. In Phase 1, we developed three questionnaires with parental involvement through a focus group discussion and individual interviews. The questionnaires focused on parental satisfaction, knowledge, concerns, and need for preparation regarding their child's anesthesia. In Phase 2, independent samples of parents completed the questionnaires at three time points: before the preanesthesia assessment (T1), 2 days after the preanesthesia assessment (T2), and 4 days after the anesthetic procedure (T3).

Results

In Phase 1, 22 parents were involved in the development of the questionnaires. The three questionnaires contained 43 questions in total, of which 10 had been proposed by parents. In Phase 2, 78% (474 out of 934) parents participated at T1, 36% (610 out of 1705), at T2 and 34% (546 out of 1622) at T3. Parental satisfaction scores were rated on a visual analogue scale for the preanesthesia assessment with a median of 87/100, and with a median of 90/100 for the anesthetic procedure (0: not satisfied and 100: satisfied). Parental concerns were rated with a median of 50/100 (0: no concerns and 100: extremely concerned). Parental answers from the questionnaire at T2 revealed significant knowledge deficits, with only 73% reporting that the anesthesiologist was a physician. Parents preferred to receive more information about the procedure, especially regarding the intended effects and side effects of anesthesia.

Conclusions

Overall, parental satisfaction scores regarding the pediatric anesthesiology procedure were high, with a minority expressing concerns. Parents indicated a preference for their child's anesthesiologist to visit them both before and after the anesthetic procedure. Parental expectations regarding anesthesia did not completely correspond with the information provided; more information from the clinician about the intended effects and side effects of anesthesia was desired.     

The effect of a preoperative education programme on perioperative anxiety in children: an observational study

The distress of children at the induction of anesthesia (DAI) is unpleasant for all involved and potentially harmful. Many strategies such as premedication or parental presence at induction have been described to minimize it. A preoperative education programme [the 'Saturday Morning Club' or (SMC)] has been in existence in our institution for a number of years and an observational study of children undergoing day case surgery was undertaken to assess the influence of attendance at the SMC on DAI. Ninety-four children aged between 2 and 16 years of age were included in the study; 21 attended the SMC and 73 did not. Patient anxiety using the modified Yale Preoperative Anxiety Scale was measured by blinded observers on the day ward, in the preoperative waiting room and at induction of anesthesia. Parental anxiety at the same locations was self reported using a visual analogue scale. Attendance at the SMC had a favorable effect on patient anxiety levels in all three locations but only reached statistical significance in the waiting room ( P  = 0.007, Mann–Whitney U- test) . At present there is little evidence to support the use of preoperative education programmes in the UK and further studies are required to determine their benefit.     

Risk factors for anxiety at induction of anesthesia in children: a prospective cohort study

BACKGROUND: In children anxiety at induction of anesthesia is a common and important aspect of the psychological impact of anesthesia and surgery. Previous studies examining risk factors for increased anxiety have found contradictory results. This may be due to using small, or highly selective population samples, or failure to adjust for confounding variables. Results may also be culturally or institutionally specific. The aim of this study was to identify possible risk factors in a large representative cohort of children. METHODS: One thousand two hundred fifty children aged 3-12 years were recruited. Anxiety at induction of anesthesia was assessed using the modified Yale preoperative anxiety scale. Children with an anxiety score of greater than 30 were classified as having high anxiety. Anesthetists were blinded to the assessment. Data recorded included age, gender, past healthcare history, family details, use of sedative premedication, anesthesia details, admission details, parental anxiety and child temperament. An unadjusted analysis was performed to identify possible risk factors for high anxiety. An adjusted regression analysis was then performed including the potential risk factors identified in the unadjusted analysis. RESULTS: The incidence of high anxiety at induction was 50.2%. In the adjusted analysis, younger age, behavioral problems with previous healthcare attendances, longer duration of procedure, having more than five previous hospital admissions and anxious parents at induction were all associated with high anxiety at induction. Hospital admission via the day stay ward was associated with less anxiety. Sedative premedication was associated with less anxiety in children with ASA status greater than one. However, the variability explained by factors included in the model was low (5.3%). CONCLUSIONS: Some simple preoperative questions can help identify children at risk of heightened anxiety at induction of anesthesia; however, it remains difficult to precisely predict which child will experience high anxiety.     

不同禁饮食时间对硬膜外麻醉病人血液动力学的影响

目的观察不同禁饮食时间与硬膜外麻醉病人血液动力学变化的关系。方法30例择期下肢或下腹部手术成年病人,分为两组。A组,术前禁饮食8h;B组术前禁饮食12h。以食管超声多普勒技术持续监测：心脏指数(CI)、每博输出量指数(SI)、左室射血时间(LVET)、射血加速度(ACC)、峰速度(PV)、血管阻力指数(SVRI)。同时监测平均动脉压(MAP)、心率(HR)、中心静脉压(CVP)。结果(1)与基础值相比,A组的SI、CI、ACC下降不显著,B组在硬膜外注药10min后ACC、CI、PV开始出现显著降低。(2)与A组相比,B组在硬膜外注药10min后SI、CI、ACC、PV显著降低,CI、ACC、MAP的变化幅度显著大于A组。结论术前禁饮食12h的病人在硬膜外麻醉诱导期会引起显著的血液动力学紊乱。     

The development of pediatric anesthesia and intensive care in Scandinavia

The initiation and development of pediatric anesthesia and intensive care have much in common in the Scandinavian countries. The five countries had to initiate close relations and cooperation in all medical disciplines. The pediatric anesthesia subspecialty took its first steps after the Second World War. Relations for training and exchange of experiences between Scandinavian countries with centers in Europe and the USA were a prerequisite for development. Specialized pediatric practice was not a full‐time position until during the 1950s, when the first pediatric anesthesia positions were created. Scandinavian anesthesia developed slowly. In contrast, Scandinavia pioneered both adult and certainly pediatric intensive care. The pioneers were heavily involved in the teaching and training of anesthetists and nurses. This was necessary to manage the rapidly increasing work. The polio epidemics during the 1950s initiated a combination of clinical development and technical innovations. Blood gas analyses technology and interpretation in combination with improved positive pressure ventilators were developed in Scandinavia contributing to general and pediatric anesthesia and intensive care practice. Scandinavian specialist training and accreditation includes both anesthesia and intensive care. Although pediatric anesthesia/intensive care is not a separate specialty, an ‘informal accreditation’ for a specialist position is obtained after training. The pleasure of working in a relatively small group of devoted colleagues and staff has persisted from the pioneering years. It is still one of the most inspiring and pleasant gifts for those working in this demanding specialty.     

Effects of low dose ketamine before induction on propofol anesthesia for pediatric magnetic resonance imaging

BACKGROUND: We aimed to investigate effects of low dose ketamine before induction on propofol anesthesia for children undergoing magnetic resonance imaging (MRI). METHODS: Forty-three children aged 9 days to 7 years, undergoing elective MRI were randomly assigned to receive intravenously either a 2.5 mg x kg(-1) bolus of propofol followed by an infusion of 100 microg x g(-1) x min(-1) or a 1.5 mg x kg(-1) bolus of propofol immediately after a 0.5 mg x kg(-1) bolus of ketamine followed by an infusion of 75 microg x kg(-1) x min(-1). If a child moved during the imaging sequence, a 0.5-1 mg x kg(-1) bolus of propofol was given. Systolic and diastolic blood pressures, heart rate, peripheral oxygen saturation and respiratory rates were monitored. Apnea, the requirement for airway opening maneuvers, secretions, nausea, vomiting and movement during the imaging sequence were noted. Recovery times were also recorded. RESULTS: Systolic blood pressure and heart rate decreased significantly in the propofol group, while blood pressure did not change and heart rate decreased less in the propofol-ketamine group. Apnea associated with desaturation was observed in three patients of the propofol group. The two groups were similar with respect to requirements for airway opening maneuvers, secretions, nausea-vomiting, movement during the imaging sequence and recovery time. CONCLUSIONS: Intravenous administration of low dose ketamine before induction and maintenance with propofol preserves hemodynamic stability without changing the duration and the quality of recovery compared with propofol alone.     

Physically restraining children for induction of general anesthesia: survey of consultant pediatric anesthetists

Objectives: To discover whether any consensus exists among the Association of Paediatric Anaesthetists of Great Britain and Ireland (APA) members regarding the use and acceptability (or otherwise) of physical restraint. Background: Despite growing recognition of children’s right to be consulted regarding their healthcare, the issue of how to proceed when faced with a child unwilling to undergo induction of general anesthesia remains relatively unaddressed. Methods: APA members were surveyed regarding their use or avoidance of physical restraint and alternate techniques to facilitate induction; factors affecting choice of technique; and extent of preoperative discussion. The anonymous online survey used both structured and free text responses. Results: Of 596 surveys, 310 were returned, a 52% response rate. Use of physical restraint and extent of restraint employed declines with increasing child age. Distraction techniques are frequently employed for children under 6 years, with the use of sedative premedication increasing as child age increases. Urgency of procedure, developmental delay, and preoperative discussion all have an effect. Comments demonstrated a wide range of views and lack of consensus on what constitutes physical restraint, and what degree of restraint, if any, is acceptable. Conclusion: Our results are similar to the US Society of Pediatric Anesthesia members, suggesting this remains an issue internationally. Consideration of practices in other specialties gives some guidance. Our survey shows a range of views as to what physical restraint is or involves, and what constitutes acceptable practice regarding the use or avoidance of physical restraint. We were unable to demonstrate consensus.     

The introduction of a paediatric anaesthesia information leaflet: an audit of its impact on parental anxiety and satisfaction

BACKGROUND: A paediatric anaesthesia information leaflet was produced to address preoperative parental anxiety and to facilitate informed parental consent. METHODS: An audit was undertaken to assess the impact of introducing the leaflet. This addressed the information needs and expectations of parents of children undergoing anaesthesia, parental satisfaction with information provision and parental preoperative anxiety. RESULTS: The audit revealed that parents expect to be provided with information, although not necessarily in written form. However, the majority who received the information leaflet concluded that verbal information alone would not have been sufficient. The information leaflet was found to be accessible, informative and useful and those who received it reported greater satisfaction with information provision than a control group. Many parents perceived that it resulted in lower levels of preoperative anxiety CONCLUSIONS: A decision was therefore undertaken that routine use of the leaflet would continue on all of the paediatric surgical wards. However, the study also indicated that leaflets should not replace verbal communication with nursing and medical staff, who remain important sources of information.