Brenda C. McClain

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.

Effects of age and emotionality on the effectiveness of midazolam administered preoperatively to children.

Background:Multiple studies document the beneficial effect of midazolam on preoperative anxiety in children. Many clinicians report, however, that some children may in fact not benefit from the administration of this drug. Methods:After screening for relevant exclusion criteria, children undergoing surgery were enrolled in the study (n = 262) and received 0.5 mg/kg oral midazolam at 20–40 min before induction of anesthesia. Personality instruments were administered to all children, and anxiety levels were evaluated before and after administration of midazolam as well as during induction of anesthesia. Blood was drawn during the induction process and later analyzed for midazolam levels. A priori definitions of responders and nonresponders to midazolam were established using a multidisciplinary task force, videotapes of induction, and a validated and reliable anxiety scale, the modified Yale Preoperative Anxiety Scale. Results:While 57% of all children scored at the minimum of the modified Yale Preoperative anxiety scale, 14.1% of children fell in the a priori defined group of midazolam nonresponders. Midazolam blood levels (94 ± 41 vs. 109 ± 40 ng/ml) and timing between administration of midazolam and induction (28 ± 9 vs. 29 ± 8 min) did not differ between midazolam responders and nonresponders. In contrast, midazolam nonresponders were younger (4.2 ± 2.3 vs. 5.9 ± 2.0 yr), more anxious preoperatively (49.7 ± 22.9 vs. 38.3 ± 19.1), and higher in emotionality (13.6 ± 3.6 vs. 11.3 ± 3.8) as compared with responders (P < 0.05). Conclusions:Although midazolam is an effective anxiolytic for most children, 14.1% of children still exhibit extreme distress. This subgroup is younger, more emotional, and more anxious at baseline. Future studies are needed to determine the best strategy to treat these children.

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.

Procedural pain in neonates: the new millennium.

For decades, pain management for infants and neonates was, in essence, nonexistent, and various procedures including surgery were performed in this vulnerable patient population with paralytics and minimal analgesics. This commonly practiced approach was justified by the belief that infants do not feel pain because of immaturity of the central nervous system and that because were no long-term outcomes to infant suffering. Today we know that the neurotransmitters and structures required for pain sensation as well as structures needed for long-term memory are developed adequately in the neonate and thus have the potential to affect long-term outcomes.1 One should note that neonates admitted to an intensive care unit are subjected daily to multiple painful procedures. These critically ill neonates experience procedures such as numerous heel sticks, arterial and venous punctures, endotracheal intubations, and gastric suctioning. Indeed, a recent study conducted in a tertiary neonatal intensive care unit confirmed the need for improved pain relief in neonates.2 The investigators indicated that the number of procedures to which each infant was exposed ranged from 0 to 53 per day. On a scale of 0 to 10, the average pain score in these infants ranged from 1.7 for a diaper change to 8.9 for endotracheal intubation. The investigators indicated … Address correspondence to Zeev N. Kain, MD, MBA, Department of Anesthesiology, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510. E-mail: zeev.kain{at}yale.edu

Pediatric palliative care: a novel approach to children with sickle cell disease.

Palliative care is both a philosophy of care and an organized system for delivering care. The goals of palliative care are to prevent and relieve suffering and support the best possible quality of life for patients and their families.1 Contrarily to common belief, palliative care is not synonymous with hospice care and should be introduced early in the disease process, possibly even at the time of diagnosis. Indeed, palliative care, with its emphasis on symptom management and quality of life, nurtures a sense of well-being and is an important coping principle in the care of children with life-threatening illnesses.2 Although many strides have been made in the management of children with sickle cell disease (SCD), the life expectancy of these patients is still significantly decreased compared with the general population. Indeed, a recent study reported that half of all patients with sickle cell anemia only survive into their 40s.3 The chronicity of illness in SCD is punctuated by painful episodes, end-organ disease with the development of chronic sequelae, and fear of sudden death. Infection, acute chest syndrome, stroke, and multiorgan failure continue to be the main causes of death.4,5 As such, one can assume that the principles of palliative care are relevant and should be applied to patients with SCD. Current literature on pediatric palliative care, however, does not consistently list SCD as an illness that is appropriate for palliative care, and children with SCD are only occasionally included in palliative care programs once the onset of complicating sequelae has occurred. In … Address correspondence to Brenda McClain, MD, FAAP, Yale University School of Medicine, Director of Pediatric Pain Management Services, Yale New Haven Childrens Hospital, 333 Cedar St, TMP-3, New Haven, CT 06520-8051. E-mail: brenda.mcclain{at}yale.edu

Intravenous Clonidine Use in a Neonate Experiencing Opioid-induced Myoclonus

USE of clonidine in the management of pain and opioid taper is well-established for adults. Various treatment modalities have been described, ranging from abrupt opioid cessation with clonidine substitution to gradual taper with clonidine as an adjunct. Oral administration of clonidine in neonatal abstinence syndrome has been cited as safe and effective. Short-term use of intravenous clonidine for sedation in children has been recently reported in the literature. This report describes prolonged and continuous use of intravenous clonidine in the management of opioid-induced myoclonus and opioid taper in a neonate.

Hospital-Based Pain Care for Infants and Children

Some view acute, in-hospital pain management as within the purview of a said specialty. However, hospital-based pain care for children is more than associated symptom management of a given disease. This chapter demonstrates the complexity of pediatric in-hospital pain management and indicates acute pain syndromes as major components of the specialty of pain medicine. The practice of hospital-based pediatric pain care requires a vast knowledge base that also encompasses the philosophies and skills of chronic pain medicine. The essentials of neurobiology, pharmacology, and practice principles of hospital-based pain care for children are the focus of this chapter.

Handbook of pediatric chronic pain

Handbook of pediatric chronic pain : , Handbook of pediatric chronic pain : , کتابخانه دیجیتال جندی شاپور اهواز

Applied pharmacology in pediatric pain management

The pharmacokinetics and pharmacodynamics of opioid and nonopioid analgesics and adjuvants are discussed in a framework applicable to daily clinical practice. In this paper we elicit the impact of physiology of the developing child on drug dosing and drug choice. Conversely, the pharmacologic effect of various analgesics on the physiologic function of key organ systems is presented as well. This review offers the scientific justification for pain intervention philosophies, and thus broadens the armamentarium of the physician who manages pain in children. Research efforts and clinical findings to date of frequently employed analgesics and adjuvants are discussed.