Shu-Ming Wang

Music and Preoperative Anxiety: A Randomized, Controlled Study

Music may decrease the anxiety experienced by patients before surgery. Previous studies of this issue were hindered with multiple methodological problems. In this investigation, we examined this hypothesis while using a rigorous study design and objective outcome measures. Adult patients undergoing

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.

Acupuncture Analgesia: I. The Scientific Basis

Acupuncture has been used in China and other Asian countries for the past 3000 yr. Recently, this technique has been gaining increased popularity among physicians and patients in the United States. Even though acupuncture-induced analgesia is being used in many pain management programs in the United States, the mechanism of action remains unclear. Studies suggest that acupuncture and related techniques trigger a sequence of events that include the release of neurotransmitters, endogenous opioid-like substances, and activation of c-fos within the central nervous system. Recent developments in central nervous system imaging techniques allow scientists to better evaluate the chain of events that occur after acupuncture-induced stimulation. In this review article we examine current biophysiological and imaging studies that explore the mechanisms of acupuncture analgesia.

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.

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

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.

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.

The Use of Auricular Acupuncture to Reduce Preoperative Anxiety

IMPLICATIONS Ear acupuncture can decrease preoperative anxiety in adults undergoing outpatient surgery.

Auricular acupuncture: a potential treatment for anxiety.

Acupuncture can be an effective treatment for chronic anxiety disorders. The purpose of this study was to assess the effectiveness of acupuncture in reducing anxiety in a volunteer population. If found effective, this modality could be introduced as a treatment of anxiety before surgery. Adult volunteers (n = 55), were randomized to three treatment groups: a) Shenmen group—bilateral auricular acupuncture at the “shenmen” point; b) Relaxation group—bilateral auricular acupuncture at a “relaxation” point; and c) Sham group—bilateral auricular acupuncture at a “sham” point. Press-acupuncture needles were inserted at the respective auricular areas for 48 h. State anxiety, blood pressure, heart rate, and electrodermal activity were assessed at 30 min, 24 h, and 48 h after insertion. Analyzing anxiety levels using repeated-measures analysis of variance has demonstrated a significant difference [F (2,51) =8.8, P = 0.001] between the three treatment groups. Post hoc analysis demonstrated that patients in the Relaxation group were significantly less anxious at 30 min (P = 0.007) and 24 h (P = 0.035) as compared with patients in both the Shenmen group and the Sham group, and less anxious at 48 h (P = 0.042) as compared with patients in Shenmen group. Repeated-measures analysis of variance performed for electrodermal activity, blood pressure, and heart rate demonstrated no group differences (P = ns). We conclude that auricular acupuncture at the “relaxation” point can decrease the anxiety level in a population of healthy volunteers. Implications Auricular acupuncture at the “relaxation” point can decrease anxiety in healthy volunteers.