Maura B. Hofstadter

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.

postoperative Behavioral Outcomes in Children : Effects of Sedative Premedication

BACKGROUND Although multiple studies document the effect of sedative premedication on preoperative anxiety in children, there is a paucity of data regarding its effect on postoperative behavioral outcomes. METHODS After screening for recent stressful life events, children undergoing anesthesia and surgery were assigned randomly to receive either 0.5 mg/kg midazolam in 15 mg/kg acetaminophen orally (n = 43) or 15 mg/kg acetaminophen orally (n = 43). Using validated measures of anxiety, children were evaluated before and after administration of the intervention and during induction of anesthesia. On postoperative days 1, 2, 3, 7, and 14, the behavioral recovery of the children was assessed using the Post Hospitalization Behavior Questionnaire. RESULTS The intervention group demonstrated significantly lower anxiety levels compared with the placebo group on separation to the operating room and during induction of anesthesia (F[1,77] = 3.95, P = 0.041). Using a multivariate logistic regression model, the authors found that the presence or absence of postoperative behavioral changes was dependent on the group assignment (R = 0.18, P = 0.0001) and days after operation (R = -0.20, P = 0.0001). Post hoc analysis demonstrated that during postoperative days 1-7, a significantly smaller number of children in the midazolam group manifested negative behavioral changes. At week 2 postoperatively, however, there were no significant differences between the midazolam and placebo groups. CONCLUSIONS Children who are premedicated with midazolam before surgery have fewer negative behavioral changes during the first postoperative week.

Premedication in the United States: a status report.

We undertook a mailing survey study to assess the current practice of sedative premedication in anesthesia.A total of 5396 questionnaires were mailed to randomly selected physician members of the American Society of Anesthesiologists. Forty-six percent (n = 2421) of those sampled returned the questionnaire after two mailings. The reported rate of sedative premedication in the United States varied widely among age groups and geographical locations. Premedicant sedative drugs were least often used with children younger than age 3 years and most often used with adults less than 65 years of age (25% vs 75%, P = 0.001). Midazolam was the most frequently used premedicant both in adults and children (>75%). When analyzed based on geographical locations, use of sedative premedicants among adults was least frequent in the Northeast region and most frequent in the Southeast region (50% vs 90%, P = 0.001). When the frequency of premedication was examined against health maintenance organization (HMO) penetration (i.e., HMO enrollment by total population) in the various geographical regions, correlation coefficients (r) ranged from -0.96 to -0.54. Multivariable analysis revealed that HMO penetration is an independent predictor for the use of premedication in adults and children. The marked variation among geographical areas in premedicant usage patterns under-scores the lack of consensus among anesthesiologists about the need for premedication. The data suggest that HMO participation may affect delivery of this component of anesthetic care. (Anesth Analg 1997;84:427-32)

Midazolam: effects on amnesia and anxiety in children.

BACKGROUND The minimum time interval between administration of oral midazolam and separation of children from their parents that ensures good anterograde amnesia has not been previously determined. This is of particular importance in a busy operating room setting where schedule delays secondary to midazolam administration may not be tolerated. METHODS Children (n = 113) undergoing general anesthesia and surgery completed preoperative baseline memory testing using a validated series of picture cards and were randomly assigned to one of three midazolam groups or a control group. Exactly, 5, 10, or 20 min after receiving oral midazolam (0.5 mg/kg) or 15 min after receiving placebo, children were administered a second memory test that used pictures. Anxiety of children was assessed during induction of anesthesia with use of a validated anxiety measurement tool. Postoperatively, recall and recognition for picture cards seen during baseline testing and postintervention testing were assessed. RESULTS Postoperatively, recall and recognition of pictures presented to patients after drug administration (anterograde amnesia) showed significant group differences (P = 0.0001), with recall impaired in the 10- (P = 0.004) and 20-min groups (P = 0.0001). Similarly, recognition memory was impaired in the 5- (P = 0.0008), 10- (P = 0.0001) and 20-min (P = 0.0001) groups. Significant anxiolytic effects of midazolam were observed as early as 15 +/- 4 min after midazolam administration (P = 0.02). CONCLUSIONS Midazolam administered orally produces significant anterograde amnesia when given as early as 10 min before a surgical procedure.

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)

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)

Social adaptability, cognitive abilities, and other predictors for children’s reactions to surgery

STUDY OBJECTIVE To examine the relationship between social adaptability, cognitive abilities, and other personality characteristics to perioperative anxiety. STUDY DESIGN Prospective cohort investigation. PATIENTS 60 children ASA physical status I and II, age 3 to 10 years. SETTING Tertiary care childrens hospital. MEASUREMENTS Temperament (EASI), cognitive abilities (KABC), and adaptive behavior (Vineland) were evaluated in a group of children undergoing surgery. Parental coping style (MBBS) and parental state (STAI-S) and trait (STAI-T) anxiety were assessed as well. On the day of surgery, anxiety of the child was measured at the preoperative holding area and during induction of anesthesia (m-YPAS). MAIN RESULTS Univariate correlational analysis demonstrated that young age (r = -0.27), poor social adaptability (Vineland) (r = -0.38), shy and inhibited personality (EASI; temperament) (r = -0.33), higher intelligence (KABC) (r = 0.29), increased parental anxiety (r = 0.44), and parental high-monitoring coping style (r = -0.25) are all associated with higher levels of perioperative anxiety. Stepwise multivariate regression analysis has demonstrated that controlling for the variables above, parental anxiety (p = 0.004), childs social adaptive capabilities (p = 0.04), and childs temperament (sociability) (p = 0.04) are independent predictors for increased perioperative anxiety (R(2) = 0.38, F = 5.5, p = 0.003). CONCLUSIONS Anesthesiologists need to pay close attention to the families of pediatric surgical children who are socially maladjusted, shy and inhibited, and have anxious parents.

An alternative method to alleviate postoperative nausea and vomiting in children

STUDY OBJECTIVE To evaluate whether isopropyl alcohol vapor is an effective treatment for postoperative nausea and vomiting. DESIGN Double-blind, randomized, controlled study. SETTING Pediatric surgery center. PATIENTS 91 ASA physical status I and II children age 6-16 years, scheduled to undergo general anesthesia and elective outpatient surgery. INTERVENTIONS Subjects were randomized to inhale isopropyl alcohol or saline. The intervention was repeated up to three times. If postoperative nausea or vomiting persisted after three sequences, intravenous ondansetron was administered as rescue therapy. MEASUREMENTS AND MAIN RESULTS Improvement in nausea was assessed using a visual analog scale, and improvement in vomiting was assessed using categorical analysis. After three treatment sequences, 65% of the children in the treatment group and 26% of the children in the control group had a significant reduction in the severity of either nausea or vomiting (p = 0.03). However, 54% of subjects in the treatment group and 80% of subjects in the control group had recurrent nausea or vomiting within 20 to 60 minutes. CONCLUSIONS Under the conditions of this study, repetitive inhaled isopropyl alcohol only achieved a transient antiemetic effect in children with established postoperative nausea or vomiting following general anesthesia and surgery.