Alison A. Caldwell-Andrews

Preoperative anxiety and emergence delirium and postoperative maladaptive behaviors.

Based on previous studies, we hypothesized that the clinical phenomena of preoperative anxiety, emergence delirium, and postoperative maladaptive behavioral changes were closely related. We examined this issue using data obtained by our laboratory over the past 6 years. Only children who underwent surgery and general anesthesia using sevoflurane/O2/N2O and who did not receive midazolam were recruited. Children’s anxiety was assessed preoperatively with the modified Yale Preoperative Anxiety Scale (mYPAS), emergence delirium was assessed in the postanesthesia care unit, and behavioral changes were assessed with the Post Hospital Behavior Questionnaire (PHBQ) on postoperative days 1, 2, 3, 7, and 14. Regression analysis showed that the odds of having marked symptoms of emergence delirium increased by 10% for each increment of 10 points in the child’s state anxiety score (mYPAS). The odds ratio of having new-onset postoperative maladaptive behavior changes was 1.43 for children with marked emergence status as compared with children with no symptoms of emergence delirium. A 10-point increase in state anxiety scores led to a 12.5% increase in the odds that the child would have a new-onset maladaptive behavioral change after the surgery. This finding is highly significant to practicing clinicians, who can now predict the development of adverse postoperative phenomena, such as emergence delirium and postoperative behavioral changes, based on levels of preoperative anxiety.

Preoperative anxiety, postoperative pain, and behavioral recovery in young children undergoing surgery

OBJECTIVE. Findings from published studies suggest that the postoperative recovery process is more painful, slower, and more complicated in adult patients who had high levels of preoperative anxiety. To date, no similar investigation has ever been conducted in young children. METHODS. We recruited 241 children aged 5 to 12 years scheduled to undergo elective outpatient tonsillectomy and adenoidectomy. Before surgery, we assessed child and parental situational anxiety and temperament. After surgery, all subjects were admitted to a research unit in which postoperative pain and analgesic consumption were assessed every 3 hours. After 24 hours in the hospital, children were discharged and followed up at home for the next 14 days. Pain management at home was standardized. RESULTS. Parental assessment of pain in their child showed that anxious children experienced significantly more pain both during the hospital stay and over the first 3 days at home. During home recovery, anxious children also consumed, on average, significantly more codeine and acetaminophen compared with the children who were not anxious. Anxious children also had a higher incidence of emergence delirium compared with the children who were not anxious (9.7% vs 1.5%) and had a higher incidence of postoperative anxiety and sleep problems. CONCLUSIONS. Preoperative anxiety in young children undergoing surgery is associated with a more painful postoperative recovery and a higher incidence of sleep and other problems.

Family-centered preparation for surgery improves perioperative outcomes in children: a randomized controlled trial.

Background:Children and parents experience significant anxiety and distress during the preoperative period. Currently available interventions are having limited efficacy. Based on an integration of the literature in both the anesthesia and psychological milieus, the authors developed a behaviorally oriented perioperative preparation program for children undergoing surgery that targets the family as a whole. Methods:Children and their parents (n = 408) were randomly assigned to one of four groups: (1) control: received standard of care; (2) parental presence: received standard parental presence during induction of anesthesia; (3) ADVANCE: received family-centered behavioral preparation; and (4) oral midazolam. The authors assessed the effect of group assignment on preoperative anxiety levels and postoperative outcomes such as analgesic consumption and emergence delirium. Results:Parents and children in the ADVANCE group exhibited significantly lower anxiety in the holding area as compared with all three other groups (34.4 ± 16 vs. 39.7 ± 15; P = 0.007) and were less anxious during induction of anesthesia as compared with the control and parental presence groups (44.9 ± 22 vs. 51.6 ± 25 and 53.6 ± 25, respectively; P = 0.006). Anxiety and compliance during induction of anesthesia was similar for children in both the ADVANCE and midazolam groups (44.9 ± 22 vs. 42.9 ± 24; P = 0.904). Children in the ADVANCE group exhibited a lower incidence of emergence delirium after surgery (P = 0.038), required significantly less analgesia in the recovery room (P = 0.016), and were discharged from the recovery room earlier (P = 0.04) as compared with children in the three other groups. Conclusion:The family-centered preoperative ADVANCE preparation program is effective in the reduction of preoperative anxiety and improvement in postoperative outcomes.

Low back pain during pregnancy: prevalence, risk factors, and outcomes.

OBJECTIVE: To estimate the severity of the low back pain (LBP) during pregnancy, including prevalence, risk factors, impact on daily living, and health provider management. METHODS: An anonymous survey consisting of 36 questions was distributed to pregnant women participating in various prenatal care clinics and educational classes in New Haven County, Connecticut. A total of 950 surveys was returned from May 2002 through October 2003. At each site, a researcher was available each week to answer questions and gather surveys. RESULTS: Six hundred forty-five (68.5%; 95% confidence interval [CI] 65–72%) respondents reported experiencing LBP during their current pregnancy. The prevalence was not affected by gestational age (P = .56). Low back pain during the current pregnancy was predicted by age (younger women were more likely to develop it; P = .004), history of LBP without pregnancy (P = .002), during menstruation (P = .01), and during a previous pregnancy (P = .002). The majority of respondents reported that LBP during pregnancy caused sleep disturbances (58%; 95% CI 54–62%) and impaired daily living (57%; 95% CI 53–62%). Average pain was moderate in severity. Nearly 30% of respondents stopped performing at least one daily activity because of pain and reported that pain also impaired the performance of other routine tasks. Only 32% (95% CI 28–36%) of the respondents with LBP during pregnancy informed their prenatal care providers of this problem, and only 25% (95% CI 21–28%) of prenatal care providers recommended a treatment. CONCLUSION: Low back pain during pregnancy is a common problem that causes hardship in this population. Further studies are indicated in the areas of prevention and treatment. LEVEL OF EVIDENCE: III

Trends in the Practice of Parental Presence During Induction of Anesthesia and the Use of Preoperative Sedative Premedication in the United States, 1995-2002: Results of a Follow-Up National Survey

Both parental presence during induction of anesthesia and sedative premedication are currently used to treat preoperative anxiety in children. A survey study conducted in 1995 demonstrated that most children are taken into the operating room without the benefit of either of these two interventions. In 2002 we conducted a follow-up survey study. Five thousand questionnaires were mailed to randomly selected physician members of the American Society of Anesthesiologists. Mailings were followed by a nonresponse bias assessment. Twenty-seven percent (n = 1362) returned the questionnaire after 3 mailings. We found that a significantly larger proportion of young children undergoing surgery in the United States were reported to receive sedative premedication in 2002 as compared with 1995 (50% vs 30%, P = 0.001). We also found that in 2002 there was significantly less geographical variability in the use of sedative premedication as compared with the 1995 survey (F = 8.31, P = 0.006). Similarly, we found that in 2002 parents of children undergoing surgery in the United States were allowed to be present more often during induction of anesthesia as compared with 1995 (χ2 = 26.3, P = 0.0001). Finally, similar to our findings in the 1995 survey, midazolam was uniformly selected most often to premedicate patients before surgery.

Predicting Which Child-parent Pair Will Benefit from Parental Presence During Induction of Anesthesia: A Decision-making Approach

Using a multiply matched, concurrent cohort analysis, with 568 subjects matched from data obtained by our laboratory over the past 7 yr, we examined whether parental presence during induction of anesthesia (PPIA) reduces children’s anxiety depending on the interaction between child and parent’s baseline anxiety. Children’s and parents’ baseline anxiety was assessed preoperatively; children’s anxiety was again assessed during induction of anesthesia. We found that anxious children who received PPIA from a calm parent were significantly less anxious during induction of anesthesia as compared with anxious children who did not receive PPIA (P = 0.03). In contrast, calm children who received PPIA from an overly anxious parent were significantly more anxious as compared with calm children who were not accompanied by a parent (P = 0.002). We found no effect of PPIA on children’s anxiety during induction of anesthesia when calm parents accompanied calm children into the operating room (P = 0.15) or when overly anxious parents accompanied anxious children (P = 0.49). We conclude that the presence of a calm parent does benefit an anxious child during induction of anesthesia and the presence of an overly anxious parent has no benefit.

Parental presence during induction of anesthesia: physiological effects on parents.

Background The authors conducted a randomized controlled trial to determine whether parental presence during induction of anesthesia (PPIA) is associated with parental physiologic and behavioral manifestations of stress. Methods Children and their parents (N = 80) were randomly assigned to one of three groups: (1) PPIA; (2) PPIA plus 0.5 mg/kg oral midazolam; and (3) control (no PPIA or midazolam). The effect of the group assignment on parental heart rate (HR), parental blood pressure, and parental skin conductance level (SCL) were assessed. Both parental HR and parental SCL were monitored continually. Anxiety of the parent and child was also assessed. Results Parental HR increased from baseline until the induction of anesthesia (P = 0.001). A group-by-time effect (P = 0.005) was also found. That is, throughout the induction period there were several time points at which parents in the two PPIA groups had a significantly higher HR than did parents in the control group (P < 0.05). Similarly, SCL was found to increase in all parents from baseline until induction of anesthesia (P = 0.001). Significant group differences in SCL changes over time were found as well (P = 0.009). State anxiety and blood pressure following induction of anesthesia did not differ significantly between groups (P = nonsignificant). Examination of parental Holter data revealed no rhythm abnormalities and no electrocardiogram changes indicating ischemia. Conclusions The authors found that PPIA is associated with increased parental HR and SCL. However, no increased incidence of electrocardiogram abnormalities were found in parents present during induction of anesthesia.

Parental Auricular acupuncture as an adjunct for parental presence during induction of anesthesia

Background: The purpose of this study was to determine whether parental auricular acupuncture reduces parental preoperative anxiety and thus allows children to benefit from parental presence during induction of anesthesia. Methods: Mothers of children who were scheduled to undergo surgery were randomly assigned to an acupuncture intervention group (auricular press needles at relaxation, tranquilizer point, and master cerebral point) or a sham acupuncture control group (auricular press needles at the shoulder, wrist, and extraneous auricular point). The intervention was performed at least 30 min before the childs induction of anesthesia. All mothers were present during induction of anesthesia. The behavioral and physiologic anxiety of mothers and children were rated during the perioperative process. Results: Multivariable analysis examining maternal anxiety as a function of group found a group-by-time interaction (F1,65 = 4.1, P = 0.04). That is, after induction, maternal anxiety in the acupuncture group was significantly lower (42.9 ± 10 vs. 49.5 ± 11; P = 0.014). A multivariate model (F1,65 = 4.8, P =0.031) also showed that children whose mothers received the acupuncture intervention were significantly less anxious on entrance to the operating room (34.9 ± 20 vs. 47.4 ± 26; P = 0.03) and during introduction of the anesthesia mask (38.6 ± 25 vs. 55.6 ± 31; P = 0.016). There were no significant differences in maternal blood pressure and heart rate between the two groups. Conclusions: Auricular acupuncture significantly decreased maternal anxiety during the preoperative period. Children of mothers who underwent acupuncture intervention benefitted from the reduction of maternal anxiety during the induction of anesthesia.

Acupressure and Preoperative Parental Anxiety: A Pilot Study

In this randomized sham-controlled study we examined the anxiolytic and sedative effects of acupressure on parents in the preoperative holding area before their children’s surgery. Sixty-one parents received acupressure either at the Yintang point (midpoint between the two eyebrows) or at a sham point. Anxiety (as measured by the Stait-Trait Anxiety Inventory), arterial blood pressure, and heart rate were assessed before and after the intervention and a Bispectral Index monitor was used to continuously monitor hypnotic sedation levels. Repeated-measures analysis of variance showed that parents in the acupressure group reported significantly less anxiety at 20 min postintervention as compared with parents in the sham group (37 ± 10 versus 45 ± 13, P = 0.03). Bispectral Index values, heart rate, and arterial blood pressure, however, did not differ between the two study groups (P = not significant). We conclude that acupressure at the Yintang point may be used as a treatment for parental preoperative anxiety. Future studies are needed to quantify the magnitude and duration of the anxiolytic effect.

Sevoflurane versus halothane: Postoperative maladaptive behavioral changes : A randomized, controlled trial

Background: The authors conducted a double-blind, randomized, controlled trial to determine whether the use of sevoflurane in children undergoing anesthesia and surgery results in a higher incidence of postoperative maladaptive behavioral changes as compared with halothane. Methods: Children and their parents (n = 102) were randomly assigned to either a halothane group (n = 50) or a sevoflurane group (n = 52). The intraoperative anesthetic protocol was strictly controlled, and the postoperative analgesic consumption and pain levels were recorded. The effect of the group assignment on emergence status and maladaptive postoperative behavioral changes was assessed both by validated psychological measures and physiologic instruments (actigraphy) on postoperative days 1–7. Anxiety of the parent and child was also assessed, as was the child’s postoperative recovery (Recovery Inventory). Results: There were no group differences in preoperative state anxiety, postoperative analgesic requirements, postoperative pain, or the incidence of emergence delirium (P = not significant). Two-way repeated-measures analysis of variance showed no group differences in the incidence of postoperative maladaptive behaviors (F4,72 = 0.60, P = 0.701) or actigraphic variables such as percent sleep, number of night awakenings, and night awakenings that lasted for more than 5 min (P = not significant). Conclusion: The authors found no increased incidence of emergence delirium, maladaptive postoperative behavior changes, or sleep disturbances in children undergoing anesthesia with sevoflurane as compared with halothane.