Lisa A. Caramico

Distress during the induction of anesthesia and Postoperative behavioral outcomes

UNLABELLED We determined whether children who are extremely anxious during the induction of anesthesia are more at risk of developing postoperative negative behavioral changes compared with children who appear calm during the induction process. Children (n = 91) aged 1-7 yr scheduled for general anesthesia and elective outpatient surgery were recruited. Using validated measures of preoperative anxiety and postoperative behaviors, children were evaluated during the induction of general anesthesia and on Postoperative Days 1, 2, 3, 7, and 14. Using a multivariate logistic regression model, in which the dependent variable was the presence or absence of postoperative negative behavioral changes and the independent variables included several potential predictors, we demonstrated that anxiety of the child, time after surgery, and type of surgical procedure were predictors for postoperative maladaptive behavior. The frequency of negative postoperative behavioral changes decreased with time after surgery, and the frequency of negative postoperative behavioral changes increased when the child exhibited increased anxiety during the induction of anesthesia. Finally, we found a significant correlation (r) of 0.42 (P = 0.004) between the anxiety of the child during induction and the excitement score on arrival to the postanesthesia care unit. We conclude that children who are anxious during the induction of anesthesia have an increased likelihood of developing postoperative negative behavioral changes. We recommend that anesthesiologists advise parents of children who are anxious during the induction of anesthesia of the increased likelihood that their children will develop postoperative negative behavioral changes such as nightmares, separation anxiety, and aggression toward authority. IMPLICATIONS Anesthesiologists who care for children who are anxious during the induction of anesthesia should inform parents that these children have an increased likelihood of developing postoperative negative behavioral changes.

Parental presence and a sedative premedicant for children undergoing surgery : a hierarchical study

Background: Although some anesthesiologists use oral sedatives or parental presence during induction of anesthesia (PPIA) to treat preoperative anxiety in children, others may use these interventions simultaneously (e.g., sedatives and PPIA). The purpose of this investigation was to determine whether this approach has advantages over treating children with sedatives alone. Methods: The child’s and the parental anxiety throughout the perioperative period was the primary endpoint of the study. Parental satisfaction was the secondary endpoint. Subjects (n = 103) were assigned randomly to one of two groups: a sedative group (0.5 mg/kg oral midazolam) or a sedative and PPIA group. Using standardized measures of anxiety and satisfaction, the effects of the interventions on the children and parents were assessed. Statistical analysis (varimax rotation) of the satisfaction questionnaire items resulted in two factors that described satisfaction of the separation process and satisfaction of the overall care provided. Results: Anxiety in the holding area, at entrance to the operating room, and at introduction of the anesthesia mask did not differ significantly between the two groups (F[2,192] = 1.26, P = 0.28). Parental anxiety after separation, however, was significantly lower in the sedative and PPIA group (F[2,93] = 4.46, P = 0.037). Parental satisfaction with the overall care provided (−0.28 ± 1.2 vs. 0.43 ± 0.26, P = 0.046) and with the separation process (−0.30 ± 1.2 vs. 0.47 ± 0.20, P = 0.03) was significantly higher among the sedative and PPIA group compared with the sedative group. Conclusions: PPIA in addition to 0.5 mg/kg oral midazolam has no additive effects in terms of reducing a child’s anxiety. Parents who accompanied their children to the operating room, however, were less anxious and more satisfied.

Parental presence during induction of anesthesia. A randomized controlled trial

Background To determine whether parental presence during induction of anesthesia is an effective preoperative behavioral intervention, a randomized controlled trial with children undergoing outpatient surgery was conducted. Methods Eighty-four children were randomly assigned to a parent-present or parent-absent group. Using multiple behavioral and physiologic measures of anxiety, the effect of the intervention on the children and their parents was assessed. Predictors for the response to the intervention were examined using multivariate linear regression analysis. Results When the intervention group (parent-present) was compared to the control group (parent-absent), overall there were no significant differences in any of the behavioral or physiologic measures of anxiety tested during induction of anesthesia. Using the childs serum cortisol concentration as the outcome, parental presence, the childs age and baseline temperament, and trait anxiety of the parent, were identified as predictors of the childs anxiety during induction. Analysis of variance demonstrated that three groups showed diminished cortisol concentrations with parental presence: children older than 4 yr (P = 0.001), children whose parent had a low trait anxiety (P = 0.02), and children who had a low baseline level of activity as assessed by temperament (P = 0.05). Conclusions Children who were older than 4 yr or those with a parent with a low trait anxiety or who had a low baseline level of activity/temperament benefited from parental presence during induction.

Preoperative preparation programs in children : A comparative examination

We sought to determine whether an extensive behavioral preparation program for children undergoing surgery is more effective than a limited behavioral program.The primary end point was child and parent anxiety during the preoperative period. Secondary end points included behavior of the child during the induction of anesthesia and the postoperative recovery period. Several days before surgery, children (n = 75) aged 2-12 yr randomly received either an information-based program (OR tour), an information + modeling-based program (OR tour + videotape), or an information + modeling + coping-based program (OR tour + videotape + child-life preparation). Using behavioral and physiological measures of anxiety, we found that children who received the extensive program exhibited less anxiety immediately after the intervention, in the holding area on the day of surgery, and on separation to the operating room. These findings, however, achieved statistical significance only in the holding area on the day of surgery (44[10-72] vs 32[8-50] vs 9[6-33]; P = 0.02). Similarly, parents in the extensive program were significantly less anxious on the day of surgery in the preoperative holding area, as assessed by behavioral (P = 0.015) and physiological measures (P = 0.01). In contrast, no differences were found among the groups during the induction of anesthesia, recovery room period, or 2 wk postoperatively. We conclude that children and parents who received the extensive preoperative preparation program exhibited lower levels of anxiety during the preoperative period, but not during the intraoperative or postoperative periods. Implications: The extensive behavioral preoperative program that we undertook had limited anxiolytic effects. These effects were localized to the preoperative period and did not extended to the induction of anesthesia or the postoperative recovery period. (Anesth Analg 1998;87:1249-55)

Preoperative preparation in children: A cross-sectional study

STUDY OBJECTIVE To evaluate the effectiveness of a behavioral preparation program on reducing anxiety in children and their parents prior to elective surgery. DESIGN Cross-sectional study. SETTING A childrens hospital. PATIENTS 143 children undergoing outpatient surgery, and their parents. INTERVENTIONS A behavioral preoperative preparation program. MEASUREMENTS AND RESULTS Overall anxiety in children and their parents did not differ significantly between the group that received the preoperative program and the group that did not (p = NS). Children older than 6 years were least anxious on separation from their parents if they participated in the preparation program more than 5 to 7 days prior to surgery, moderately anxious if they did not receive preparation, and most anxious if they received the preparation 1 day prior to surgery (P = 0.04). Multivariable regression analysis (for overall model, F = 2.14, p = 0.02) revealed that although the preparation program itself was not a predictor of a childs behavior on separation to the operating room, the interaction between childs age and timing of the program (p = 0.003), and childs previous hospitalization were predictors of childrens anxiety response. Similarly, in the preoperative holding area, independent predictors of anxiety included timing of the preparation program, age of child, and the childs baseline temperament characteristics. CONCLUSIONS The results highlight the complexities in assuming that a behavior-based preoperative preparation program is effective for all pediatric outpatients. The effects of such an intervention vary with the childs age, the timing of the intervention, and a history of previous hospitalization.

Parental Desire for Perioperative Information and Informed Consent: A Two-phase Study

The purpose of this investigation was to identify the perioperative anesthetic information parents want from the anesthesiologist, and to determine whether the provision of detailed anesthetic risk information is associated with increased parental anxiety.The investigation consisted of a cross-sectional study followed by a randomized controlled trial. In Phase 1, baseline and situational anxiety, coping strategy, and temperament were obtained from parents of children undergoing surgery (n = 334). A questionnaire examining the desire for perioperative information was administered to all parents. In Phase 2, 47 parents were randomly assigned to receive either routine anesthetic risk information (control) or detailed anesthetic risk information (intervention). The effect of the intervention on parental anxiety was assessed over four time points: prior to the intervention, immediately after the intervention, day of surgery in the holding area, and at separation to the operating room. For Phase 1, the majority of parents (>95%) preferred to have comprehensive information concerning their childs perioperative period, including information about all possible complications. For selected items, increased parental educational level was associated with increased desire for information (P < 0.05). For Phase 2, when the intervention group was compared with the control group, there were no significant differences in parental anxiety over the four time points [F(1,45) = 0.6, P = 0.4]. Also, the interaction between time and group assignment was not significant [F(3,135) = 1.66, P = 0.18]. We conclude that parents of children undergoing surgery desire comprehensive perioperative information. Moreover, when provided with highly detailed anesthetic risk information, the parental anxiety level did not increase. (Anesth Analg 1997;84:299-306)

Environmental Exposure to Toxocara as a Possible Risk Factor for Asthma: A Clinic-Based Case-Control Study

The zoonotic ascarid Toxocara has been suggested as a possible etiologic agent of asthma. We conducted a clinic-based case-control study to examine whether the zoonotic infection acquired by ingesting Toxocara eggs is associated with asthma in children. Blood samples were collected from children aged 2-15 years, 95 of whom had asthma and 229 of whom did not have asthma. Risk factors for asthma and Toxocara infection were assessed by a questionnaire given to each childs parent or legal guardian. Blood samples were tested for the presence of Toxocara antibodies, using an enzyme-linked immunosorbent assay. No significant association was found between Toxocara infection and asthma. Significant associations were found between asthma and risk factors and between Toxocara infection and risk factors. High prevalence of Toxocara infection was noted among Hispanic children of Puerto Rican descent.

Measurement tool for preoperative anxiety in young children: The yale preoperative anxiety scale

Abstract To develop a preoperative anxiety scale (YPAS) for children undergoing surgery, 21 specific behaviors indicating anxiety were defined within five domains (activity, emotional expressivity, state of arousal, vocalization, and use of adults). A reliability Kappa analysis revealed that inter-observer agreement ranged from .66 to .94, while intra-observer Kappa ranged from .66 to .91. Validity analysis between a Visual Analog Scale and the YPAS revealed an r of .59 for entering the operating room. Multiserial analysis comparing the YPAS to the Vernon Anxiety Scale ranged from .61 to .64. Showing good to excellent observer reliability and validity, the YPAS proves to be an appropriate tool for studying childrens responses in preoperative settings. As such, the new assessment instrument should be of interest to clinical and research neuropsychologists who need to assess a childs anxiety level prior to the undertaking of a given surgical procedure.