Perioperative approach to children

Magnetic Resonance Imaging in Children under Anesthesia: The Relationship between the Degree of Information Provided to Parents and Parents’ Anxiety Scores

Background. We aimed to investigate the correlation between the anxiety scores of parents whose children are administered anesthesia for magnetic resonance imaging (MRI) and the level of information provided to them before the MRI. The study included 146 children and their parents. The demographic information of the children and their parents was recorded. The parents were divided into two groups. In Group I, the patient's medical history and physical exam findings were recorded on a standard consultation form by an anesthesiologist. In Group II, the parents were additionally provided with more detailed information on how the anesthesia would be administered and the drugs to be used and their side effects and complications. The anxiety scores of the parents were found to be lower in Group II. A higher level of education was associated with higher anxiety scores. Intergroup comparison detected lower anxiety scores for Group II parents whose education levels were up to high school. However, no change upon receiving detailed information was detected in the anxiety scores of parents with higher education levels. In conclusion, this may lower the anxiety scores in parents informed about details of anesthesia administration and may raise parents' sense of confidence in the doctor.

The perioperative dialogue reduces postoperative stress in children undergoing day surgery as confirmed by salivary cortisol

AIM

To evaluate the efficacy of 'the perioperative dialogue (PD)' by analyzing salivary cortisol, in 5- to 11-year-old children undergoing day surgery.

BACKGROUND

  To deal with anxiety prior to investigations and/or procedures, children need to be confident and informed about what is going to happen. Therefore, intervention strategies should be initiated before admission to hospital.

METHODS AND MATERIALS

  Children (n = 93), 79 boys and 14 girls, scheduled for elective day surgery requiring general anesthesia were randomly recruited into three groups: (i) standard perioperative care (n = 31), (ii) standard perioperative care including preoperative information (n = 31), and (iii) the PD (n = 31). Saliva was sampled for cortisol analysis at specific time points during the pre- and perioperative procedures.

RESULTS

  The children who received the PD had significantly lower (P = 0.003) salivary cortisol concentrations postoperatively. Moreover, it continuously decreased during the day of surgery compared with the other two groups (P < 0.01). Among the children who received analgesics, the PD group received significantly less morphine (P = 0.014) related to bodyweight: the mean dose was 0.1 mg·kg(-1) (n = 9) in the control group vs 0.04 mg·kg(-1) (n = 6) in the PD group. Irrespective of group, there was a positive correlation between the children's morphine consumption and salivary cortisol concentration (r = 0.56; P = 0.038). The W-B scale score was higher in the group that received morphine (median = 3 vs median=1; P = 0.001).

CONCLUSIONS

  The PD's caring, continuity, and on-going dialogues were associated with low concentrations of salivary cortisol postoperatively and reduced morphine consumption and thus appears to be a valuable complement to standard perioperative care in children undergoing day surgery.

Psychosocial considerations of perioperative care in children, with a focus on effective management strategies

Children are not just 'small adults'. They have specific physical, psychological and social requirements that must be identified and addressed to optimise their well-being in the perioperative period. The healthcare practitioner should be trained to understand the needs of the paediatric patient in hospital, including the ever increasing need to take into account cultural differences. Hospital policy should include a preoperative preparation programme, specially aimed at the paediatric population, where parental involvement is encouraged throughout.

Parental stress in paediatric day-case surgery

Day-case surgery involves a considerable amount of stress not only for the children who undergo surgery but also for their parents. In a prospective survey analysis performed in 1995/1996, we identified the following main factors influencing the amount of stress experienced by parents: feelings of insufficient preparation and problems with postoperative pain at home. As a consequence, measures were taken regarding information and pain management, including the creation of an interactive CD-ROM. We then analysed the consequences of our interventions regarding parental stress. In this study we collected the data of all patients who underwent day-case surgery during two additional 13-month periods in 1997/1998 and 1999/2000. The methods of data collection remained unchanged for all three periods and included a questionnaire for the parents. In total, 1,490 questionnaires were analysed. Comparing the three time periods, parents' feelings of being well-informed improved significantly (91% vs. 98% vs. 97%, P < 0.0001). However, the percentage of those experiencing moderate to severe stress did not change substantially (16% vs. 9% vs. 19%, not significant). Analgaesics were given more frequently over the years in a general as well as a prophylactic manner (20% vs. 35% vs. 43%, P < 0.0001). Nevertheless, problems with pain control at home remained unchanged (33% vs. 23% vs. 29%, not significant). Despite considerable efforts to improve information, parental stress did not significantly decrease. It cannot be assessed yet whether wrong information was given or whether a certain degree of stress cannot be prevented. There is some evidence that improvements in coping with pain-related problems might be a promising next step.

Anaesthesia induction in children: a psychological evaluation of the efficiency of parents' presence

BACKGROUND

The induction of anaesthesia for surgery is a stressful time for both child and parents. To treat preoperative anxiety in children, pharmacological methods (premedication) and behavioural methods (the presence of parents during the induction of anaesthesia) have been used, both independently and in combination. The purpose of this investigation was to study the effect of both premedication and parental presence on preoperative anxiety in a homogeneous population.

METHODS

In this study conducted between January and April 2001 in the Meyer Hospital in Florence (Anaesthesia Department and Surgical Department), we studied 39 Italian speaking children aged 2-14 years who were undergoing minor surgery. Before the surgical intervention the State Trait Anxiety Inventory (STAI) questionnaire and a questionnaire for the social-demographic characteristics were given to the parents. The stress of the children was evaluated during induction of anaesthesia. We also studied behavioural areas of both children and parents with two specific questionnaires administered after the surgery.

RESULTS

The STAI scores showed that the mothers had a higher level of anxiety compared with the fathers. The induction of anaesthesia for surgery was a stressful time for 23% of children of our sample. The correlation between stress of the child at induction and state (P = 0.034) and trait (P = 0.049) anxiety of parents was statistically significant. The child's loss of consciousness was for the majority of parents (56%) the moment of greatest stress and 97% of parents did feel useful during the induction of anaesthesia. There was a significant difference, P = 0.032, in the presence or absence of stress depending on whether the mother or father accompanied the child to the operating room. There was no significant difference in the presence of stress between children who did and did not receive premedication.

CONCLUSIONS

Maternal presence, compared with the father's presence, is fundamental in helping to overcome anxiety in a child receiving anaesthesia. If the parents are present during the induction, the addition of premedication does not offer further benefit. Parents themselves judged their presence during the induction of anaesthesia in their child as a positive event. We also found a statistical significant correlation between anxiety of the parents with the level of the stress of the child during induction of anaesthesia.

A survey of parental satisfaction during parent present induction of anaesthesia for children undergoing cardiovascular surgery

METHODS

To assess parental reaction and possible complications of parent present induction (PPI) for children undergoing cardiovascular surgery, the parents of 183 patients were provided with a questionnaire to complete after they had participated in PPI. Questions included: prior experience with PPI, which member of the staff initiated the plan for PPI, parental role in the process, how prepared parents felt, and overall satisfaction.

RESULTS

PPI was successfully performed in the 183 patients surveyed. No parent was asked to leave the operating room because of respiratory or haemodynamic complications; 77.6% of the parents had no prior experience with PPI; however, 91.8% were aware of their role in the operating room, 94.5% were aware how their child would be anaesthetized and 96.7% felt prepared for their role and believed that this was a positive experience for themselves and their child.

CONCLUSIONS

This prospective survey demonstrated a high level of parental acceptance and satisfaction for PPI in children undergoing cardiovascular surgery, with a low incidence of untoward events, despite the underlying congenital heart disease. Further work is necessary to objectively characterize anxiety levels associated with induction of anaesthesia in this group of patients and parents.

Preparing children for surgery--an integrative research review

The purpose of this integrative research review was to determine the methodological and substantive characteristics of the research pertaining to preparation of children for surgery, examine pertinent research issues, and suggest recommendations for future research and practice. A total of 400 articles were reviewed using inclusion and exclusion criteria. Twenty-two studies, published between 1974 and 1995, met the criteria and, therefore, constituted the study corpus. The total sample comprised 1,263 subjects. Findings indicate that further research is needed to examine the efficacy of preparation strategies, address diverse populations, and include patient and parent involvement in the preparation process.

Distress during the induction of anesthesia and postoperative behavioral outcomes

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.

[Relations between anesthetists and general practitioners or pediatricians. Results of a cross sectional study among 2281 physicians with private practice]

OBJECTIVE

To assess the relationship of anaesthetiologists (Anaes) with general practitioners (GP) and paediatricians (Paed), possessors of the medical files of children scheduled to undergo ambulatory anaesthesia and participating in postoperative surveillance.

STUDY DESIGN

Cross-sectional prospective survey.

PERSONS

GP and Paed treating children admitted in September 1994 at the paediatric clinic of the University hospital of Tours for ambulatory surgery.

METHOD

Questionnaire including 11 items circulated to 2,181 GP and 100 Paed of the centre of France.

RESULTS AND DISCUSSION

Replies were obtained from 1,053 GP (48%) and 64 Paed (64%). The experience of Anaesth in paediatric anaesthesia was the least important criterion for the choice of the clinic (for 67% of Paed and 44% of GP). The rate of contacts of Anaesth with GP and Paed was low (23% of GP and 38% of Paed). Informations concerning anaesthesia (26% of GP and 42% of Paed), or its complications (8% of GP and 8% of Paed) were scarce. The rules of ambulatory anaesthesia were better known by Paed (56%) than by GP (34%), unlike those for autotransfusion (45% of GP and 23% of Paed). A majority of GP (82%) and Paed (73%) would appreciate an anaesthetic report. Most of GP (86%) and Paed (83%) were in favour of more informations, mainly through continuing medical education, on these problems.

Midazolam as a pediatric premedicant in the ambulatory setting

In the preoperative setting, the nurse is responsible for the comprehensive evaluation and preparation of the patient. Among these activities, the administration of various premedications to achieve a physiological (eg, raise gastric fluid pH) or psychological (eg, reduce apprehension) effect is commonplace. Midazolam, a benzodiazepine, is one of the more popular medications used preoperatively for its anxiolytic properties. Several studies have evaluated the variety of routes by which midazolam can effectively be administered to the pediatric patient. A review of midazolam as a premedication specific to the pediatric population in the ambulatory setting is presented.

Day-case tonsillectomy--is it appropriate?

There is continued encouragement to increase the use of day surgery. Recent publications have suggested that day-case tonsillectomy is a safe procedure due to the low primary haemorrhage rates (0.14-3.5%). One of the suggested benefits of day surgery is that patients want it. They prefer to recover at home after an operation. With tonsillectomy, personal experience suggested that this was not the case. A review of 117 patients having tonsillectomy was undertaken. All patients stayed in for at least one post-operative night. No patients or parents thought that the post-operative stay was too long (80% 'just right', 20% 'too short') and only 7% would have been happy to go home on the day of operation. 'Safety' does not automatically make an operation suitable for day-case surgery. Pain, nausea, vomiting, drowsiness and anxiety about the operation and post-operative course were all reasons given for not wanting to go home on the day of surgery. The justification for the increased use of day surgery is that it increases efficiency by reducing costs per case while maintaining the quality of care. One aspect of quality of care is patient acceptability and before day-case tonsillectomy is acceptable to patients the factors responsible for the post-operative morbidity need to be addressed.

The behavior of preschoolers during and after brief surgical hospitalizations

This qualitative study describes the behavior of preschool children during and after very brief hospitalizations for tonsillectomies and/or adenoidectomies. Structured, open-ended home interviews were conducted with 23 parents 5 to 7 days after their children's hospital discharge. Parents were asked to describe their children's behaviors during hospitalization and the first week at home. Approximately half of the parents and children had attended an optional surgical preadmission teaching program. The remaining parents had prepared their children for hospitalization using toy doctor kits and library books. Preoperatively, children who had attended the program behaved similarly to those who had not: They either cooperated fully, resisted initially, or completely refused to cooperate with admission procedures. Most children separated easily from their parents to enter the operating room, whereas some (n = 5) demonstrated great anxiety. However, immediately after surgery, most children who had not attended the program appeared more distressed than those who had attended. Finally, despite their relatively minor surgeries and brief hospitalizations, after discharge the majority of children (83%), regardless of whether they had attended the program, exhibited signs of distress. In comparison with their prehospitalization behavior, parents reported that their children were more irritable, had more nightmares, had appetite changes, and experienced more separation anxiety. Implications for nursing practice and research are discussed.