Répercussions psychocomportementales en périopératoire chez l’enfant

The relevant literature since the 1940s has been collected from the Medline database, using the keywords: child, operation, anxiety, distress, postoperative complications, preparation, premedication, parental presence, prevention. Preoperative anxiety, emergence delirium, and postoperative behavior changes are all manifestations of psychological distress in children undergoing surgery. Preoperative anxiety is most prominent during anaesthesia induction. Emergence delirium is frequent and somewhat independent of pain levels. Postoperative behavior changes most often include separation anxiety, tantrums, fear of strangers, eating problems, nightmares, night terrors and bedwetting. These difficulties tend to resolve themselves with time but can last up to one year in some children. The major risk factors for postoperative behavior problems are young age, prior negative experience with hospitals or medical care, certain kinds of hospitalization, postoperative pain, parental anxiety, and certain personality traits of the child. Currently, tools exist for quantifying anxiety (m-YPAS) and postoperative behavior (PHBQ). It is possible to identify those children who are at risk for postoperative complications during the preanaesthesia consultation by paying close attention to children under six years with higher levels of emotionality and impulsivity and poorer socialization skills with anxious parents. Suggested strategies for reducing child distress include preoperative preparation, premedication, parental presence during anaesthesia induction, and interventions affecting the child's environment, such as hypnosis. There are numerous ways to provide preoperative preparation (information, modeling, role playing, encouraging effective coping) and their effectiveness is proven in the preoperative setting but not during anaesthesia induction or in the operating room. Midazolam has been shown to be an effective preoperative sedative for reducing anxiety. Parental presence during induction has been shown to effectively reduce preoperative anxiety in children in certain contexts (when the parent is calm and the child is anxious). It is worthwhile if it is integrated into a family-centered anxiety management program and remains one of several options offered to families. Overall, taking into account the child's psychological needs should be considered an essential part of paediatric anaesthesia. Tools and techniques are available for assessing and managing the perioperative distress experienced by children.     

Preparation,premedication and parental presence

40% to 60% of children undergoing surgery under general anaesthesia develop anxiety in the preoperative period. Multiple factors contribute to the genesis of this disorder. Preoperative anxiety may complicate the induction of anaesthesia and can cause behavioural modifications in children even long after surgical procedures have been completed. It is important to focus on prevention of such problems. A preparation program, premedication and parental presence during induction of anaesthesia are valid tools for achieving this goal. We are herewith presenting a play preparation program carried out by play specialists and offered to all children prior to surgery. This approach proved effective in reducing preoperative anxiety in children and their mothers.     

An Audit of Preoperative Behaviour and Premedication Practise at Great Ormond Street Hospital

Introduction Despite advances in anaesthesia many children are distressed at induction of anaesthesia (1). The use of paediatric premedication has declined considerably over the last ten years ( 2 ). The aim of our audit was to look at preoperative behaviour and premedication practice at our institute. Method One hundred and seventy seven patients undergoing elective procedures in the main theatre suite at the hospital were audited. This therefore excluded cardiac and neuroanaesthesia. Behaviour scores in the anaesthetic room prior to and at induction were assessed by the operating department assistants. We looked at frequency, type, dose and timing of premedication. The induction method, age and previous anaesthesia were noted. Parents routinely accompany children at induction of anaesthesia. Results Overall 75% of children had satisfactory behaviour scores in the anaesthetic room dropping to 47% at induction. The graph shows the age distribution and associated behaviour scores. Of the patients with satisfactory behaviour scores all received their premedication between 20 and 60 min prior to induction. Three patients in the unsatisfactory behaviour group received their premedication outside this optimal time. Children who had had previous anaesthetics (76%) had worse behaviour scores than those with none both in the anaesthetic room and at induction with satisfactory scores of 71% vs. 84% and 44% vs. 51 % respectively. Those having gas inductions (63%) had worse behaviour scores at induction compared with children having intravenous induction with satisfactory scores of 42% vs. 52% respectively. 12% of all children audited received a sedative premedication. 16 received Midazolam 0.5 mg/kg, 3 Temazepam 10 or 20 mg and 1 Triclofos 50 mg·kg^?1 all given orally. The premedication rate for children with previous anaesthetic experience was 14% vs. 5% in those with none. Only 5% of children received an atropine premedication 20–40 mcg·kg^?1 orally. Only 1 of the 14 children age 6 months and 2 of the 14 children age 6 months?1 year were premedicated with atropine. Discussion As a paediatric tertiary referral centre, many of the patients have previous experience of anaesthetics and have ongoing medical problems Our audit found that many of these children, especially age 1–3, are distressed at induction of anaesthesia despite methods shown to reduce peri‐operative anxiety, including play specialists. It also confirms the perceived trend for decreasing use of sedative and anticholinergic premedication. However several papers report decrease in distress at induction ( 1 ) especially in high‐risk groups ( 2 ) without undue delays in awakening and discharge using midazolain premedication. Conclusion It was decided that a more child friendly anaesthetic room with pictures, toys and other distractions would be helpful. There may also be a need to increase the use of sedative premedication in high‐risk groups especially preschool children.     

Anaesthesia induction in children: a psychological evaluation of the efficiency of parents' presence

BACKGROUND: The induction of anaesthesia for surgery is a stressful time for both child and parents. To treat preoperative anxiety in children, pharmacological methods (premedication) and behavioural methods (the presence of parents during the induction of anaesthesia) have been used, both independently and in combination. The purpose of this investigation was to study the effect of both premedication and parental presence on preoperative anxiety in a homogeneous population. METHODS: In this study conducted between January and April 2001 in the Meyer Hospital in Florence (Anaesthesia Department and Surgical Department), we studied 39 Italian speaking children aged 2-14 years who were undergoing minor surgery. Before the surgical intervention the State Trait Anxiety Inventory (STAI) questionnaire and a questionnaire for the social-demographic characteristics were given to the parents. The stress of the children was evaluated during induction of anaesthesia. We also studied behavioural areas of both children and parents with two specific questionnaires administered after the surgery. RESULTS: The STAI scores showed that the mothers had a higher level of anxiety compared with the fathers. The induction of anaesthesia for surgery was a stressful time for 23% of children of our sample. The correlation between stress of the child at induction and state (P = 0.034) and trait (P = 0.049) anxiety of parents was statistically significant. The child's loss of consciousness was for the majority of parents (56%) the moment of greatest stress and 97% of parents did feel useful during the induction of anaesthesia. There was a significant difference, P = 0.032, in the presence or absence of stress depending on whether the mother or father accompanied the child to the operating room. There was no significant difference in the presence of stress between children who did and did not receive premedication. CONCLUSIONS: Maternal presence, compared with the father's presence, is fundamental in helping to overcome anxiety in a child receiving anaesthesia. If the parents are present during the induction, the addition of premedication does not offer further benefit. Parents themselves judged their presence during the induction of anaesthesia in their child as a positive event. We also found a statistical significant correlation between anxiety of the parents with the level of the stress of the child during induction of anaesthesia.     

The anxiety process under various high doses of thalamonal for premedication

In this study special attention was paid to the individual anxiety--and coping process. 101 patients in a general hospital were premedicated with Innovar in different high dosages with and without Atropine. The four Innovar-groups were referred to a Dolantin/Atosilgroup. The results show that during the preoperative period the intensity of anxiety did not depend on premedication alone. Premedication was effective in reducing anxiety only in those patients who were aware of their somatic excitation at least to a certain degree. The preoperative anxiety process was also influenced by factors, like negative experience with anaesthesia and premedication, a negative attitude towards any kind of sedative and specific intrapsychic coping styles.     

Diclofenac and flurbiprofen with or without clonidine for postoperative analgesia in children undergoing elective ophthalmological surgery

We conducted a prospective, randomized study to compare the efficacy of preoperative diclofenac, flurbiprofen, and clonidine, given alone, as well as the combination of diclofenac and clonidine, and flurbiprofen and clonidine in controlling postoperative pain in 125 children. The patients (ASA I, 2-12 years) undergoing elective ophthalmological surgery were allocated to one of five groups: rectal diclofenac 2 mg.kg(-1) following oral placebo premedication, i. v. flurbiprofen 1 mg.kg(-1) following placebo premedication, oral clonidine premedication, rectal diclofenac 2 mg.kg(-1) following clonidine, and i.v. flurbiprofen 1 mg.kg(-1) following clonidine. The children received clonidine (4 microg.kg(-1)) or placebo 105 min before anaesthesia. Diclofenac or flurbiprofen was given immediately after induction of anaesthesia. Anaesthesia was induced and maintained with sevoflurane and nitrous oxide in oxygen. Postoperative pain was assessed by a blinded observer using a modified objective pain scale (OPS). No opioids were administered throughout the study. Rectal diclofenac 2 mg.kg(-1) i.v. flurbiprofen 1 mg.kg(-1), oral clonidine 4 microg.kg(-1) provided similar OPS scores and requirement for supplementary analgesics during 12 h after surgery. Combination of oral clonidine and one of these nonsteroidal analgesics minimized postoperative pain. Our findings suggest that this combined regimen may be a promising prophylactic approach to postoperative pain control in children undergoing ophthalmological surgery.     

Modulation der Streßantwort bei Kindern während der präoperativen Vorbereitung

Anxiolysis with drugs and psychoprophylaxis are both recognised methods of preoperative preparation. The beneficial effects of anxiolytics, however, appear to be difficult to prove. In this study a comparison was made of heart rate (HR), blood pressure (BP), and norepinephrine, epinephrine, and cortisol levels. In group I 19 children recieved only psychological treatment, while in group II 21 children received 0.2?mg/kg midazolam orally. Measuring points were directly before medication, 30?min afterward, and at induction of anaesthesia. During the observation period the patients (5–10 years old) remained calm. At the beginning of the study the parameters of all patients were within a normal range; 30?min after premedication the HR and BP were significantly higher in group I than in group II. In contrast to group I, epinephrine levels in group II were lower at the beginning of anaesthesia than before premedication. In both groups, norepinephrine levels were the same at induction of anaesthesia as before premedication. Cortisol decreased only in patients who received midazolam. HR, BP, as well as humoral stress parameters indicate that midazolam in a dose of 0.2?mg/kg orally is sufficient to reduce preoperative stress in children.     

Giving toys to children reduces their anxiety about receiving premedication for surgery

Children have increased anxiety during the preoperative period. The administration of oral premedication to children is often met with apprehension, reluctance, or refusal. We sought to determine whether giving a small toy to the children would decrease the anxiety associated with taking oral premedication. This was a prospective study involving 100 children 3-6 yr of age randomized into two equal groups. The anxiety of each child was assessed using the Modified Yale Preoperative Anxiety Scale. The results showed significantly less anxiety in children who received a toy before oral administration of midazolam.     

Efficacy and safety of premedication with oral ketamine for day-case adenoidectomy compared with rectal diazepam/diclofenac and EMLA

BACKGROUND: Because of its pain-attenuating and sedative properties oral ketamine has been used as premedication in children and adults. We wanted to compare in children scheduled for adenoidectomy safety and efficacy of oral ketamine with a premedication that causes similar preoperative sedation and relief of pain at the venepuncture site. We also evaluated the effect of i.v. glycopyrrolate added to these combinations. METHODS: One hundred children between 10 and 15 kg of body weight scheduled for day-case adenoidectomy were randomly assigned to one of four groups: groups DG and DS received diclofenac 12.5 mg and diazepam 0.5 mg/kg rectally, EMLA cream at the venepuncture site, and placebo orally; groups KG and KS received ketamine 6.0 mg/kg orally, placebo cream at the puncture site, and placebo rectally; additionally, groups DG and KG received glycopyrrolate 5 microg/kg, and groups DS and KS received placebo intravenously. We recorded perioperatively scores (open scale 1-9) for stridor, sedation, bleeding, nausea, pain, heart rate, the need for analgesics and registered psychotomimesis and well-being at home. RESULTS: The children of the K-groups became more tearful during separation from their parents (P=0.0072). No other differences were found between the ketamine and diazepam/diclofenac groups before and after premedication until induction of anaesthesia. Oral ketamine produced unpleasant psychotomimesis in four out of 59 children. During the first 10 min postoperatively, the score for stridor was significantly higher in group KS than in the D-groups; stridor scores > or = 6 were seen in one child of the D-groups (DS) and in six children of the K-groups (n.s.), of whom three developed laryngospasm (one reintubation). Glycopyrrolate diminished salivation in all groups, but had no effect on stridor scores. Additionally, glycopyrrolate delayed the onset of eating at home. CONCLUSION: Premedication with racemic oral ketamine 6 mg/kg does not seem to be suitable for upper airway procedures. Addition of i.v. glycopyrrolate before the induction of anaesthesia significantly reduced the scores for salivation.     

ATROPINE INCREASES INSPIRATORY FLOW DURING ENFLURANE ANAESTHESIA AFTER PETHIDINE PREMEDICATION

The effects of atropine i.v. on inspired volume and occlusionpressure were measured in three groups of patients. Group PEreceived premedication with pethidine 50 mg and promethazine12.5 mgi.m., and anaesthesia was provided by 2% enflurane in67% nitrous oxide. Group TE received temazepam 20 mg orallyfor premedication and similar anaesthesia. Group TH receivedtemazepam premedication and 1% halothane in 67% nitrous oxide.Atropine 0.02 mg kg^–1 i.v. increased significantly theinspiratory flow in the first 1 s of inspiration, and this effectwas greater in the group that received pethidine (9% increasein flow). However, occlusion pressure did not change, and minutevolume was not altered. The results suggest that atropine increasesinspiratory flow after pethidine premedication without increasingthe force developed during inspiration, possibly by bronchodilatation.     

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.     

Preoperative parental information and parents' presence at induction of anaesthesia

Preoperative preparation of paediatric patients and their environment in order to prevent anxiety is an important issue in paediatric anaesthesia. Anxiety in paediatric patients may lead to immediate negative postoperative responses. When a child undergoes surgery, information about the child's anaesthesia must be provided to parents who are responsible for making informed choices about healthcare on their child's behalf. A combination of written, pictorial, and verbal information would improve the process of informed consent. The issue of parental presence during induction of anaesthesia has been a controversial topic for many years. Potential benefits from parental presence at induction include reducing or avoiding the fear and anxiety that might occur in both the child and its parents, reducing the need for preoperative sedatives, and improving the child's compliance even if other studies showed no effects on the anxiety and satisfaction level. The presence of other figures such as clowns in the operating room, together with one of the child's parents, is an effective intervention for managing child and parent anxiety during the preoperative period.     

A survey of current usage of anticholinergic drugs in paediatric anaesthesia in Finland

BACKGROUND: The aim of this survey was to obtain information about the current use of anticholinergic preanaesthetic medication in children. It was carried out as a follow-up study of the previous survey amongst Finnish anaesthesiologists in 1990. METHODS: A questionnaire was send to all members of the Finnish Society of Anaesthesiologists. Data from anaesthesiologists taking care of at least three paediatric anaesthesias/week (n= 183) were analyzed. RESULTS: In 1998 only one-third of the Finnish anaesthesiologists routinely used anticholinergics before paediatric anaesthesia. The main indications for routine anticholinergic premedication were ENT surgery (66%), eye surgery (71%) and endoscopic procedures (67%). Anticholinergic drugs were administered principally via the intravenous route (90%) briefly before induction of anaesthesia, and glycopyrrolate was the most frequently used (66%). CONCLUSION: During the last eight years in Finland the routine use of anticholinergic premedication has decreased. As in 1990 the anticholinergic prophylaxis is directed to ENT and eye surgery, endoscopic procedures and to children younger than 1 year. Use of glycopyrrolate has gained popularity at the expense of atropine and scopolamine.     

Oral midazolam premedication for paediatric day case patients

Forty-nine children having day-stay surgical procedures were randomly assigned to receive oral midazolam 0.75 mg·kg^?1 or placebo in a double blind fashion. The child's level of anxiety was assessed before premedication using parental, child and observer scales. The child and observer anxiety scores were repeated in the anaesthetic room. Most children presented for anaesthesia in a calm state, irrespective of whether they had received midazolam. Parents tended to overestimate their child's level of anxiety. Observer anxiety scores reliably predicted behaviour during induction of anaesthesia in the absence of a sedative. Observer scores decreased in the midazolam group (P<0.02), but not in the placebo group, children below six years having the greatest decrease with midazolam. The median time to discharge from hospital was delayed by 30 min in the midazolam group (P<0.01). Children do not require routine sedative premedication for day case procedures, but oral midazolam is useful in producing calm behaviour in those children with high observer anxiety scores.     

Providing parents with information before anaesthesia: what do they really want to know?

BACKGROUND: Videotapes presenting information concerning children's anaesthesia are often based on what the makers of the videotape believe the parents want to know rather than what parents actually want to know. They frequently do not take into account the parent's coping style. Two common parental coping styles are information-seeking (monitoring) and information-avoiding (blunting). METHODS: We wished to take parent needs into account when making our local videotape and accordingly constructed a questionnaire designed to elicit these needs. RESULTS: Of the parents questioned, 55% wanted more extensive preoperative information and 41% of parents wanted a videotape as part of this preparation. Information about premedication, induction of anaesthesia, side-effects of anaesthesia and postoperative pain management were sought by more than 70% of parents. Parents had concerns about induction of anaesthesia, emergence from anaesthesia and postoperative pain and nausea. When asked a question concerning preference about being present at the induction of anaesthesia, 90% of parents wanted to be present at the induction and 75% of parents thought that their child should receive a premedicant. The number of parents requesting to be present at the induction decreased to 72% after an explanation about the purpose and effects of premedication. There was no correlation between the coping style of the parent and the responses given to the questions. There was no correlation between the level of education and the coping style of the parent. CONCLUSIONS: The use of a questionnaire of parental attitudes towards information and anaesthesia provided a useful tool in the production of a video as part of our preoperative preparation. Our videotape has proved a success with staff and parents and children and enhances the quality of our service. Its popularity stems from the fact that it addresses what the parents want to know and also conveys what the staff of this hospital would like the parents to know.     

Comparison of oral pentazocine, oral diazepam and intramuscular pentazocine for paediatric premedication

Oral pentazocine-atropine, oral diazepam-atropine and IM pentazocine-atropine were compared as preoperative medication in children. Observations in 300 children ages 1-14 years included the emotional state at time of induction of anaesthesia, smoothness of induction, dryness of oral mucosa and tongue, incidence of vomiting, and emotional state and length of stay in the recovery room. The incidence of a calm state at the time of induction and smoothness of induction of anaesthesia was the same following oral and IM premedication. There was satisfactory drying of salivary secretions. The incidence of vomiting in the recovery room was the same following oral and IM premedication. However, children in age groups 1-4 and 5-9 years who received diazepam-atropine were more restless in the recovery room than those who received oral or IM pentazocine-atropine. More children in groups 1-4 and 5-9 years who received IM pentazocine-atropine stayed longer in the recovery room. We conclude that oral diazepam-atropine and oral pentazocine-atropine are comparable as to preoperative medication IM pentazocine-atropine and that they can be given as an alternate to intramuscular injection.     

Prolonged elimination of midazolam after i. m. administration

The elimination pharmacokinetics of midazolam after i.m. administration was compared with combined i.m. and i.v. administration in a randomized study of 55 gynaecological patients in outpatient general anaesthesia. Group 1 (n = 40) received midazolam 0.1 mg/kg i.m. as premedication 45 min before induction of general anaesthesia with midazolam 0.3 mg/kg i.v. Group 2 (n = 15) received midazolam 0.1 mg/kg i.m. as premedication 45 min before induction of general anaesthesia with thiopentone 4 mg/kg. Serum midazolam concentration measurements were performed regularly post-induction for 7 h in each patient. The elimination half-life of midazolam after i.m. administration (Group 2) was 6.6 +/- 1.2 h (mean +/- s.e. mean), which was significantly longer (P less than 0.05) than the 3.9 +/- 0.3 h observed after the combined i.m. and i.v. administration of midazolam (Group 1), and significantly longer than 2.9 h obtained from a calculated i.v. administration curve. We postulate a slow i.m. depot release of midazolam, representing the rate-limiting step in the elimination of midazolam after i.m. administration.     

Perioperative effects of melatonin and midazolam premedication on sedation, orientation, anxiety scores and psychomotor performance

BACKGROUND AND OBJECTIVE: To compare the perioperative effects of melatonin and midazolam given in premedication, on sedation, orientation, anxiety scores and psychomotor performance. METHODS: Exogenous administration of melatonin not only facilitates the onset of sleep but also improves its quality. A prospective, randomized, double-blind, placebo-controlled study was performed in 66 patients undergoing laparoscopic cholecystectomy. Patients were given melatonin 5 mg, midazolam 15 mg or placebo, 90 min before anaesthesia, sublingually. Sedation, orientation and anxiety were quantified before; 10, 30, 60 and 90 min after premedication; and 15, 30, 60 and 90 min after admission to the recovery room. Neurocognitive performance was evaluated at these times, using the Trail Making A and B and Word Fluency tests. The differences between the groups were analysed by ANOVA. Two-way comparisons were performed by Scheffé analysis. Sedation and amnesia were analysed by the chi2 test. RESULTS: Patients who received premedication with either melatonin or midazolam had a significant increase in sedation and decrease in anxiety before operation compared with controls. After operation, there was no difference in sedation scores of all groups. Whereas, 30, 60 and 90 min after premedication the melatonin and midazolam groups exhibited a significantly poorer performance in Trail Making A and B tests compared with placebo, there were no significant differences among the groups in terms of neuropsychological performance after the operation. Amnesia was notable only in the midazolam group for one preoperative event. CONCLUSION: Melatonin premedication was associated with preoperative anxiolysis and sedation without postoperative impairment of psychomotor performance.     

Preoperative assessment and preparation for anaesthesia in children

Providing anaesthesia for children presents many challenges, but careful preoperative assessment and preparation can enable the experience to be positive for the child, parents and anaesthetist. The aims of the preoperative assessment are to gather information from the notes, child and family, plan an appropriate anaesthetic technique, allow assessment of risk, deliver information to the child and family and enable a degree of psychological preparation for the anaesthetic experience. This article discusses aspects of paediatric preoperative assessment and preparation which are designed to facilitate the patient journey with maximum efficiency and minimum upheaval.     

Parents and paediatric anaesthesia: a prospective survey of parental attitudes to their presence at induction.

Parental presence at induction of anaesthesia is controversial and of disputed value. Ninety out of 117 parents replied to a preoperative questionnaire designed to identify their preference and motivation with regard to accompanying their children to the anaesthetic room. Half the parents wished to be present at induction, irrespective of the child's age or previous surgical experience and the most commonly cited reasons for this were the child's anxiety or the parents' sense of duty; 32% of these parents changed their preference if their child were to be adequately sedated preoperatively. In addition, 18% of all parents felt that they would prefer not to be present at induction. The results suggest that in circumstances where parents are to be excluded from induction, adequate preoperative explanation and sedative premedication would contribute to allaying parental anxiety, but that a flexible policy may be most appropriate.