Distress during the induction of anesthesia and postoperative behavioral outcomes

An Intelligent Customer-Driven Digital Solution to Improve Perioperative Health Outcomes Among Children Undergoing Circumcision and Their Parents: Development and Evaluation

BACKGROUND

Circumcision as a common elective pediatric surgery worldwide is a stressful and anxiety-inducing experience for parents and children. Although current perioperative interventions proved effective, such as reducing preoperative anxiety, there are limited holistic solutions using mobile apps.

OBJECTIVE

This paper aims to describe the development and primary evaluation of an intelligent customer-driven smartphone-based app program (ICory-Circumcision) to enhance health outcomes among children undergoing circumcision and their family caregivers.

METHODS

Based on the review of the literature and previous studies, Bandura's self-efficacy theory was adopted as the conceptual framework. A multidisciplinary team was built to identify the content and develop the apps. Semistructured interviews were conducted to evaluate the ICory-Circumcision.

RESULTS

The ICory-Circumcision study was carried out from March 2019 to January 2020 and comprised 2 mobile apps, BuddyCare app and Triumf Health mobile game app. The former provides a day-by-day perioperative guide for parents whose children are undergoing circumcision, while the latter provides emotional support and distraction to children. In total, 6 participants were recruited to use the apps and interviewed to evaluate the program. In total, 4 main categories and 10 subcategories were generated from content analysis.

CONCLUSIONS

ICory-Circumcision seemed to lean toward being useful. Revisions to ICory-Circumcision are necessary to enhance its contents and features before advancing to the randomized controlled trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04174404; https://clinicaltrials.gov/ct2/show/NCT04174404.

Individual cartoon video for alleviating perioperative anxiety and reducing emergence delirium in children: a prospective randomised trial

BACKGROUND

Perioperative anxiety and emergence delirium (ED) in young children may cause a series of adverse events, which are worth investigating. Pharmacological treatments of anxiety and delirium remain uncertain, while non-pharmacological treatments lack personalization and pertinence.

AIMS

The aim of study was to determine whether an individual cartoon video can alleviate perioperative anxiety and reduce ED in young children undergoing adenoidectomy and tonsillectomy.

METHODS

Children between 3 and 7 years old undergoing adenoidectomy and tonsillectomy were randomly assigned to an individual cartoon video group (group V) or a control group (group C). In group V, an individual cartoon video of the child' s own choice was played throughout the whole waiting, anaesthesia induction and recovery periods. The children in group C were contacted through verbal conversation. The primary outcomes were anxiety measured by the Modified Yale Preoperative Anxiety Scale and ED assessed by the Paediatric Anaesthesia Emergence Delirium (PAED) scale. The secondary outcomes included cooperation during induction, postoperative pain and adverse events.

RESULTS

The incidence of anxiety were comparable in group V and group C at the holding area (T0) (26% vs 22%, p=0.323), but the incidence of anxiety of group V were significantly lower than those of group C at the time of entering the operating room (T1), during the induction of anaesthesia (T2) and leaving the post anaesthesia care unit (T6) (p<0.001, p<0.001, p<0.001) after intervention. The peak PAED score in group V was significantly lower than that in group C (12.00 (9.00-13.00) vs 13.50 (10.00-15.00), p=0.016). We found no significant differences in cooperation during induction, postoperative pain or the incidence of adverse events between the groups (2.00 (0.00-4.00) vs 3.00 (1.25-4.00), p=0.110; F=0.059, Pgroup=0.808; 3 (7.5%) vs 4 (10), p=0.692).

CONCLUSIONS

The individual cartoon video is an effective method of reducing perioperative anxiety and alleviating ED in children.

TRIAL REGISTRATION NUMBER

ChiCTR2200062300 (https://www.chictr.org.cn/index.aspx).

Virtual Reality during Intrathecal Pump Refills in Children: A Case Series

Virtual reality has proven to be an effective approach to decrease pain in acute settings, both in adults and children. The aim of this study is to evaluate whether virtual reality (VR) could reduce pain during an intrathecal pump refill procedure in children receiving intrathecal drug delivery, compared to a standard refill procedure. This is a three-arm crossover randomized controlled trial, evaluating the effect of VR on pain in children with cerebral palsy undergoing an intrathecal pump refill compared to a standard refill and a refill with distraction (watching a video). Pain was evaluated using the Wong–Baker Faces Scale. Secondary outcomes were procedural pain, fear, state anxiety, the incidence of adverse events and satisfaction. Six children participated in this study, whereby all children underwent the three conditions. Five children indicated an equal of lower pain score during VR, compared to a standard refill. This finding of an equal or lower pain intensity score for the VR condition compared to the control condition was also revealed by the ratings of the parents, physician and the researcher. The influence of VR on anxiety and fear seem to be in line with the influence of watching a video. In terms of satisfaction, all children and parents agreed with the statement that they would like to use VR again for a next refill. Due to the lack of adverse events, the high degree of satisfaction of children with VR and the decreased pain levels after a refill with VR, physicians may aim to explore the implementation of VR during intrathecal pump refill procedures in children in a daily clinical routine care setting.

Research Progress on Risk Factors of Preoperative Anxiety in Children: A Scoping Review

Preoperative anxiety has adverse effects on children and negative impacts on postoperative rehabilitation. Anesthesiologists can accurately identify children with preoperative anxiety, and individualized intervention can effectively improve their psychological state and clinical prognosis. However, a comprehensive summary of the current available evidence has yet to be conducted. Searches were conducted in Medline databases from inception to March 2022. Primary studies that reported preoperative anxiety in children and its attendant effects on postoperative recovery and prognosis were screened and included. Among the 309 publications identified, 12 related studies (n = 3540 patients) met the eligibility criteria. The incidence of preoperative anxiety in children in the included studies ranged from 41.7% to 75.44%. While 16 influencing factors were identified, only 5 factors had a significant impact on preoperative anxiety in children: younger age (n = 8), parental anxiety (n = 7), negative previous hospitalizations (n = 3), less sociableness (n = 2), and surgical setting (n = 1). The current scoping review identified risk factors for preoperative anxiety in children. Healthcare workers should identify and manage preoperatively anxious children. There are still some factors that are controversial, and large-scale clinical studies are needed.

Minimally invasive anesthesia for laparoscopic hysterectomy: a case series

PURPOSE

Regional anesthesia (RA) is considered as a "minimally invasive technique" to achieve anesthesia. To assess the feasibility and the perioperative outcomes of laparoscopic hysterectomy in regional anesthesia from the point of view of the surgeon, anesthesiologist and patient.

METHODS

A retrospective search was performed to identify patients who underwent laparoscopic hysterectomy under RA from April 2020 to September 2021. Five patients affected by benign gynecological disease (atypical endometrial hyperplasia or uterine leiomyomas) were included.

RESULTS

The postoperative pain, nausea, and vomiting (PONV) and the antiemetic/analgesic intake were evaluated. Postoperative surgical and anesthesiological variables were recorded. Duration of surgery was 84 ± 4.18 and no conversion to GA was required. According to VAS score, the postoperative pain during the whole observation time was less than 4 (median). A faster resumption of bowel motility (≤ 9 h) and patient's mobilization (≤ 4 h) were observed as well as a low incidence of post-operative nausea and vomit. Early discharge and greater patient's satisfaction were recorded. Intraoperatively pain score was assessed on Likert scale during all the stages of laparoscopy in RA, with only 2 patients complaining scarce pain (= 2) at pneumoperitoneum.

CONCLUSION

RA showed to have a great impact on surgical stress and to guarantee a quicker recovery without compromising surgical results. RA technique could be a viable option for patients undergoing laparoscopic hysterectomy.

Pediatric surgery and self-reported anxiety in children and their parents: A psychometric analysis of the state-trait operation anxiety (STOA) questionnaire

OBJECTIVE

The preoperative experience in pediatric surgery can cause significant anxiety for both, children and their parents. To date there is no questionnaire available that assesses the child's self-report or both, the child's and parent's self-reported anxiety. The aim of this study was to perform a psychometric analysis of the State-Trait Operation Anxiety (STOA) which provides this option.

METHODS

The data based on a randomized controlled study conducted with n = 90 child-parent dyads. The psychometric analyses were performed using classical test theory, including item statistics, Cronbach's α, factor analysis, and test-retest reliability.

RESULTS

The statistics of the anxiety items were good overall for both ratings following common guidelines. The item means indicated that the items tended to be rather difficult which reduces the reliability for lower anxiety levels. The given scale structure was confirmed overall for both informants. However, a one-factor structure instead of two factors was found for state anxiety. The internal consistencies and retest reliabilities were good to very good. Follow-up analyses confirmed the sensitivity to change for state anxiety. Child anxiety was hardly correlated with parental anxiety, and age and gender effects were rather small.

CONCLUSIONS

The STOA questionnaire is the first psychometrically tested questionnaire specifically for fears of surgery that can be used for self-report among children, adolescents, and their parents. Future studies should collect further evidence of its validity as well as comparative scores for specific patient groups and norm values to increase the utility of the instrument.

Comparison of the Effects of Oral Midazolam and Intranasal Dexmedetomidine on Preoperative Sedation and Anesthesia Induction in Children Undergoing Surgeries

Background and Purpose: Premedication with either oral midazolam or intranasal dexmedetomidine prior to surgery remains less than ideal. The aim of this study was to investigate whether the combination of those two drug regimens would have any beneficial effects on the preoperative sedation and the children’s compliance during anesthesia inhalation induction.

Experimental Approach: One hundred thirty-eight children aged 2–6 years were randomly allocated into three groups: Group M with oral midazolam 0.5 mg kg⁻¹, Group D with intranasal dexmedetomidine 2 μg kg⁻¹, and Group M + D with intranasal dexmedetomidine 1 μg kg⁻¹ plus oral midazolam 0.5 mg kg⁻¹. The primary outcome was the children’s compliance during inhalation induction with sevoflurane. The secondary outcomes included the preoperative sedative effects, behavior scores, parental separation anxiety scores, and the postoperative incidence of emergence agitation and recovery time.

Results: Subjects in Group M + D showed higher satisfaction scores of compliance (p = 0.0049) and mask acceptance (MAS) (p = 0.0049) during anesthesia inhalation induction. Subjects in Group M + D had a significantly shorter time than those in Groups M and D to achieve the desired sedation level (p < 0.001) and remained at a higher sedation score in the holding area and up to the anesthesia induction after drug administration (p < 0.001).

Conclusion and Implications: We conclude that pediatric patients premedicated with intranasal dexmedetomidine 1 μg kg⁻¹ plus oral midazolam 0.5 mg kg⁻¹ had significantly improved anesthesia induction compliance, and quicker onset to achieve and maintain a satisfactory level of sedation than those premedicated separately with two drugs. Therefore, the combined premed regimen is a greater choice when we are expecting a higher quality of sedation and a smoother anesthesia induction in children undergoing the surgeries.

Interventions for Parental Anxiety in Preparation for Pediatric Surgery: A Narrative Review

The preoperative experience can cause significant anxiety for both pediatric patients and their parents in the lead up to a surgical procedure. Pediatric anxiety in a preoperative setting has been shown to have significant negative downstream effects on the clinical outcomes of children and the healthcare system as a whole. Studies have found that preoperative parental anxiety has significant negative effects on children, regarding anxiety and emotional response. Therefore, interventions for parental preoperative anxiety are important to reduce the child’s anxiety. This review provides a brief overview of a broad range of strategies used to alleviate parental anxiety in a preoperative setting. Preoperative education, play-based interventions, music therapy, the presence of parents at induction of anesthesia, and integrative preoperative preparation programs have all demonstrated some evidence for reducing parental preoperative anxiety. The ultimate goal of using interventions for parental preoperative anxiety is to equip healthcare systems to better support families and optimize the perioperative outcomes of children.

Predictors for COVID-19-related new-onset maladaptive behaviours in children presenting to a paediatric emergency department

BACKGROUND AND OBJECTIVE

The goal of the present study was to determine the incidence of new onset maladaptive behaviours in paediatric emergency department (PED) patients during the COVID-19 pandemic and to examine whether child and parent anxiety and parental health status were predictors for the new-onset of maladaptive behaviours.

METHODS

Participants included child-parent dyads seen in a PED following the state's issuance of mandatory stay-at-home orders on 19 March 2020. A total of 351 children age 0-25 years and 335 parents enrolled in the study. Parents provided baseline demographic data and completed standardised surveys that assessed aspects of parental and child anxiety and parental health, as well as child new-onset maladaptive behaviours. Children ≥8 years of age completed surveys that assessed child anxiety.

FINDINGS

Parents reported the new onset of maladaptive behaviours in children during the pandemic with frequencies up to 43%. Bivariate analysis identified predictors such as child anxiety (t(96) = -2.04, P = 0.044) as well as parental variables such as state anxiety (t(190) = -4.91, P < 0.001) and parental sensitivity to anxiety (t(243) = -3.19, P = 0.002). A logistic regression model identified parent mental health and COVID-19 anxiety as predictors of new onset maladaptive behaviours in children (X² (6) = 42.514, P < 0.001). Specifically, every unit change in parental anxiety of COVID-19 was associated with a unit increase in maladaptive behaviours in children.

CONCLUSIONS

We identified distinct parent and child-related factors that predicted new onset child maladaptive behaviours during the COVID-19 pandemic. The identification of such predictors may help clinicians to prevent maladaptive responses to the pandemic quarantine.

Postoperative Maladaptive Behavior, Preoperative Anxiety and Emergence Delirium in Children Undergone General Anesthesia: A Narrative Review

Over the years, the number of pediatric patients undergoing surgeries are increasing steadily. The types of surgery vary between elective to emergency with involvement of multidisciplinary teams. The development of day care surgery unit is expanding where the patients will only come to the hospital on the day of surgery and discharge home after such as satisfactory parameters achieved, minimal to no pain, minimal to no bleeding from surgical site and able to tolerate fluids. Hospitalization and surgery could contribute to significant psychological disturbance to the children. These issues are not being addressed as children have difficulty in conveying their problems and fear. They do however express it through negative behavioral changes.

Self-produced audio-visual animation introduction alleviates preoperative anxiety in pediatric strabismus surgery: a randomized controlled study

Background

Hospital anxiety caused by strabismus surgery has an unpleasant and disturbing feeling for both children and their parents. This study aimed to determine the effect of viewing a self-produced audio-visual animation introduction on preoperative anxiety and emergence agitation of pediatric patients undergoing strabismus surgery.

Methods

In this prospective randomized study, 1 hundred children scheduled for strabismus surgery with aged 3 ~ 6 years. The children were randomly divided into 2 groups (n = 50 for each), Group A: using a self-produced audio-visual animation introduction; Group C: controlled group without audio-visual animation introduction. Children’s preoperative anxiety was determined by the modified Yale Preoperative Anxiety Scale (mYPAS) at different time points: the night before surgery(T1), at pre-anesthetic holding room(T2), and just before anesthesia induction(T3). The Spielberger State-Trait Anxiety Inventory (STAI) was used to record the anxiety of parents at T1,T2 and T3. The incidence and the degree of emergence agitation were recorded.

Results

The mYPAS scores at T2 and T3 were higher than T1(p < 0.05) in both groups. The average score of mYPAS in Group A was significantly lower than in Group C at T2 and T3(p < 0.05). The STAI scores in Group A at T2 and T3 were significantly lower than in Group C(p < 0.05). The incidence of agitation in Group A was lower than that in Group C(p < 0.05).

Conclusions

Based on the findings, viewing a self-produced audio-visual animation can effectively alleviate the preoperative anxiety for both children and their parents in pediatric strabismus surgery, and it was effective for reducing emergence agitation as well.

Trial registration

The trial was prospectively registered before patient enrollment at Chinese Clinical Trial Registry (Clinical Trial Number: ChiCTR1900025116, Date: 08/12/2019).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-021-01922-6.

Application of a non-pharmacological technique in addition to the pharmacological protocol for the management of children's preoperative anxiety: A 10 years' experience

The aim of the study was to investigate how Non- Pharmacological Techniques (NPT), in addition to standard pharmacological techniques, can help to manage and reduce the preoperative anxiety of children waiting for Day Surgery procedures (DS). Isola Serena activity started in 2008 to manage the preoperative time of children waiting for surgery in the playing room. The latter is run by a pedagogist. NPT includes use of games and toys, readings and drawings. A descriptive and comparative study was conducted on 50 children, aged 4 to 12 years, randomly assigned to Isola Serena group ISG and control group CG. All children received standard pharmacological techniques, while those of the ISG also received the NPT. The evaluation of the preoperative anxiety level (modified Yale Preoperative Anxiety Scale) and parent's coping style (Coping Inventory for Stressful Situation) compared the two groups. The ISG showed a significantly lower level of preoperative anxiety than the CG. Parents' coping style was not related to the preoperative anxiety. The activity performed in the Isola Serena Project resulted to be effective for the reduction of preoperative anxiety in children undergoing DS procedures.

Comparing health-related quality of life and burden of care between early-onset scoliosis patients treated with magnetically controlled growing rods and traditional growing rods: a multicenter study

STUDY DESIGN

Multicenter retrospective cohort study.

OBJECTIVES

To compare pre-operative and post-operative EOSQ-24 scores in magnetically controlled growing rods (MCGR) and traditional growing rod (TGR) patients. Since the introduction of MCGR, early-onset scoliosis patients have been afforded a reduction in the number of surgeries compared to the TGR technique. However, little is known about (health-related quality of life) and burden of care outcomes between these surgical techniques.

METHODS

This is a retrospective cohort study using a multicenter registry on patients with EOS undergoing MCGR or TGR between 2008 and 2017. The EOSQ-24 was administered at preoperative and postoperative 2-year assessments. The EOSQ-24 scores were compared between MCGR and TGR as well as preoperatively and postoperatively within each procedure.

RESULTS

110 patients were analyzed in this study (TGR, N = 32; MCGR, N = 78). There were no significant differences in preoperative age, gender, etiology, main coronal curve or maximum kyphosis between TGR and MCGR groups. Patients with TGR had averaged 3.9 surgical lengthenings and MCGR had averaged 7.7 non-invasive lengthenings by the 2-year follow-up. When changes in preoperative to postoperative scores were compared, MCGR had more improvements in pain, emotion, child satisfaction and parent satisfaction than TGR although there were no statistical significance. When analyzed separately, MCGR cohort had improvement in scores for all four domains and four sub-domains; while, TGR cohort only had improvement in financial burden domain and pulmonary function sub-domain.

CONCLUSION

Although there was no statistical significance, the improvement in pain, emotion and satisfaction scores was larger in MCGR than TGR. Since these areas can be influenced more by mental well-being than other sub-domains, the results may prove our hypothesis that compared to TGR, MCGR with reduced number of surgeries have better psychosocial effects.

LEVEL OF EVIDENCE

III.

The role of anxiety and related states in pediatric postsurgical pain

Background: Nearly 20% of children and adolescents have pain with disability 1 year after surgery, and they experience poor sleep, school absence, and decreased activities. Negative clinical, psychological, and developmental effects include greater pain medication use, longer recovery, and fear of future medical care. Research has found psychological and family influences (i.e., child and parental anxiety) on pediatric chronic postsurgical pain (CPSP), but a better understanding of the role of perioperative anxiety and its related states in predicting pediatric postsurgical pain is needed. The poor understanding of the causes of child CPSP can lead to misdiagnosis and inadequate treatment, with significant short- and long-term effects. Objectives: The aim of this review was to summarize the literature on children's perioperative anxiety and parental anxiety in relation to acute postsurgical pain, CPSP, and pain trajectories. We also examined other related psychological factors (i.e., anxiety sensitivity, catastrophizing, pain anxiety, and fear of pain) in relation to pediatric acute and chronic postsurgical pain. Lastly, we discuss the interventions that may be effective in reducing children's and parents' preoperative anxiety. Conclusions: Our findings may improve the understanding of the causes of CPSP and highlight the gaps in research and need for further study.

Emergence Agitation and Delirium: Considerations for Epidemiology and Routine Monitoring in Pediatric Patients

Emergence from anesthesia can be associated with a wide spectrum of cognitive and behavioral dysregulation in children, including delirium or acute brain dysfunction. This period of neurobehavioral recovery can be further confounded by pain, anxiety, and fear. The implementation of monitoring for level of consciousness, pain, and delirium using valid pediatric tools is necessary to avoid misdiagnosis due to overlapping symptomatology and support appropriate management. Understanding the epidemiology of delirium in the postoperative setting will require consistent use of accurate terminology in the medical literature. The current interchangeable use of the terms “emergence agitation” and “emergence delirium” needs to be highlighted and awareness of differences in patient conditions and assessment tools is essential. We discuss epidemiology of emergence agitation and delirium in the pediatric population, and the challenges for future delineation of monitoring and management. Furthermore, we describe the possible impact of long-term consequences of emergence delirium among infants and children, and the necessary areas of future research.

A Comparative Evaluation of Oral Clonidine, Dexmedetomidine, and Melatonin As Premedicants in Pediatric Patients Undergoing Subumbilical Surgeries

INTRODUCTION

Sedative premedication is the mainstay of pharmacological therapy in children undergoing surgeries. This study compares preoperative melatonin, clonidine, and dexmedetomidine on sedation, ease of anesthesia induction, emergence delirium, and analgesia.

MATERIALS AND METHODS

One hundred and five children, 3-8 years, either sex, ASA I/II, posted for infraumbilical surgery, randomized to receive clonidine 5 mcg/kg (Group C), dexmedetomidine 3 mcg/kg (Group D), and melatonin 0.2 mg/kg (Group M) 45 minutes before surgery. Preoperative Sedation/Anxiety and Child-Parent Separation Score (CPSS) were assessed. Identical anesthesia technique was utilized. Emergence delirium (Watcha score) and postoperative pain (Objective Pain Scale score) were monitored postoperatively.

RESULTS

Patients were demographically comparable. Sedation score >Grade 3 was absent. Grades 1/2/3 were present in 10/19/6 (Group C), 2/26/7 (Group D), and 7/26/2 (Group M). Grade 1 CPSS was present in 42.6% (Group C), 37.1% (Group D), and 28.6% (Group M). Pediatric Anesthesia Behavior Score (PABS) was comparable between Groups C and D (p = 0.224; 95% CI -0.090 to 0.604) and Groups C and M (p = 0.144; 95% CI -0.633 to 0.061) while PABS was better in Group D compared to Group M (p = 0.0007; 95% CI -0.890 to -0.195). Watcha scores were 33/2/0/0 (Group C), 34/1/0/0 (Group D), and 32/2/1/0 (Group M) immediately after extubation. Scores were 31/4/0/0 (Group C), 33/2/0/0 (Group D), and 31/4/0/0 (Group M) at 30 minutes and 28/7/0/0 (Group C), 29/6/0/0 (Group D), and 24/11/0/0 (Group M) at 1 hour. The scores were comparable (p > 0.05). Objective Pain Scale scores were comparable between Groups C and D and Groups C and M (p > 0.05). Lower scores were present in Group D compared to M (p = 0.023).

CONCLUSION

Melatonin, clonidine, and dexmedetomidine are efficacious for producing preoperative sedation, reducing anxiety, postoperative pain, and emergence delirium.

A comparative evaluation of dexmedetomidine and midazolam in pediatric sedation: A meta-analysis of randomized controlled trials with trial sequential analysis

Background

The present study with trial sequential analysis (TSA) was conducted to evaluate comprehensively the efficacy and safety of dexmedetomidine and midazolam in pediatric sedation, and to investigate whether the outcomes achieved the required information size to draw the conclusions.

Methods

PubMed, Embase, and Cochrane Library were searched from inception to October 2019. All randomized controlled trials used dexmedetomidine and midazolam in pediatric sedation were enrolled. Sedative efficacy, postoperative analgesic effect, and incidence of emergence agitation were considered as the co‐primary outcomes. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was applied to rate the quality of evidences.

Results

We acquired data from 34 studies involving 2281 pediatric patients. The results indicated that administration of dexmedetomidine was associated with less incidence of emergence agitation (RR = 0.78, with 95% CI [0.65, 0.92]) and more satisfactory sedation at parental separation (RR = 0.31, with 95% CI [0.24, 0.41]) compared to midazolam, and the current sample sizes were sufficient with unnecessary further trials. Two groups did not differ significantly in sedation level at mask induction (RR = 0.86, with 95% CI [0.74, 1.00]). And using of dexmedetomidine was associated with less incidence of postoperative analgesic rescue (RR = 0.57, with 95% CI [0.35, 0.93]), but the number of patients was too few to achieve the required information size and to draw reliable conclusions. Premedication of dexmedetomidine was associated with significant less value of SBP, heart rate, increased incidence of bradycardia, and a lower rate of shivering. And there were no differences about onset of sedation and recovery time between two groups.

Conclusions

Given that more satisfactory sedation at separation from parents and less incidence of emergence agitation, dexmedetomidine is preferred for pediatric sedation. However, compared with midazolam, the superiority of dexmedetomidine in providing adequate sedation at mask induction and postoperative analgesic effects has not yet been defined.

The prevalence of emergence delirium and its associated factors among children at a postoperative unit: A retrospective cohort at a Middle Eastern hospital

BACKGROUND

Emergence delirium (ED) has been reported among children at a postoperative setting, which delays their recovery and exposes them to traumas. The aim of this study was to determine the prevalence of ED and its associated factors among children who underwent surgeries at a major tertiary healthcare facility in Saudi Arabia.

MATERIALS AND METHODS

Between March and August 2018, a retrospective cohort study was conducted based on a review of 413 medical charts of children (<14 years) who underwent an elective/nonemergency surgery and then were admitted to a Post Anesthesia Care Unit. Patient and surgery-related characteristics were analyzed as potential factors associated with ED. The anxiety level was assessed preoperatively using the Modified Yale Preoperative Anxiety Scale (four domains), while the ED was detected after surgery using the Watcha scale (child is agitated and thrashing around).

RESULTS

The leading surgery category was ear, nose, and throat surgeries [184 (44.6%)] and dental surgeries [109 (26.4%)]. Almost one-third received only general anesthesia (31.2%), while 271 (68.8%) received an additional regional block/skin infiltrate. The anxiety domains preop showed that the percentage mean score ± standard deviation of expression of emotions was 37.1 ± 21.6, apparent arousal 33.7 ± 20.4, activeness 30.1 ± 13.5, and vocalization 26.9 ± 20.3. The prevalence of ED among children who underwent surgeries during the 6-month period was 23 (6.6%). Almost 18.8% of those who received opioid analgesics (fentanyl alone) developed ED, while 12% of those who received both opioid and nonopioid analgesics (fentanyl/paracetamol) developed ED. ED was significantly associated with longer recovery duration 69.5 + 27.1 min, P = 0.007. Binary logistics regression analysis showed that participants who did not receive Precedex were adj. odds ratio = 10.3 (2.4-48.9) times more likely to develop ED, compared with those who received it, adj. P = 0.003. Lower preoperative scores of expression of emotions and higher scores of apparent arousal were significantly associated with ED, adj. P = 0.035 and adj. P = 0.023, respectively.

CONCLUSION

ED appears to be inevitable in postoperative settings. It is crucial to address any preoperative anxiety assessment as it is associated with ED. Anxiety remains a modifiable factor that can be managed, as well as to the administration of Precedex and adjunct analgesic treatments.

Patients' concerns and perceptions of anesthesia-associated risks at University Hospital: A cross-sectional study

Background/Aim:

The expectation of undergoing general anesthesia triggers fear in many individuals, and such anxiety can even exceed anxiety about surgery. The only opportunity patients usually have to express their concerns and ask questions is during a preoperative visits to their anesthesiologist. Therefore, a good anesthesiologist-patient relationship is important to reduce patients' anxiety. Achieving this end requires information on patients' attitudes and concerns regarding anesthesia. This study aimed to assess patients' knowledge, attitudes, and concerns about preoperative assessment and fear associated with anesthesia at University Hospital, Jeddah, Saudi Arabia.

Methods:

This cross-sectional study used a self-administered questionnaire distributed to 399 outpatients. Data were collected on patient's characteristics, perceptions about anesthesiologists, preferences for anesthetic management, and preoperative concerns regarding anesthesia.

Results:

Most patients thought that anesthesiologists spent only 3 years in medical school and 2 years in a residency program. Survey participants had several misconceptions about anesthesiologists' role, but it did not affect ratings of their importance. Although, the confidence of patients in anesthesiologists was high, it was significantly lower than their confidence in surgeons. The most common concern expressed by the patients was based on whether anesthesiologists had sufficient experience and qualifications.

Conclusions:

Discussing anesthetic forms preoperatively can help decrease patients' anxiety. More efforts should be made preoperatively to address patients' high level of fear about rare side effects and discuss common side effects they tend to ignore. Preoperative preparation must allow the anesthesiologists enough time to reassure patients about their concerns, as they obtain patients' informed consent.

Pediatric Anesthesia Concerns and Management for Orthopedic Procedures

Anesthetic management of pediatric orthopedic patients is uniquely challenging. Approach to the pediatric patient must consider heightened preoperative anxiety and its postoperative behavioral and pain effects. Frequent respiratory infections can complicate timing of surgery and anesthetic care. Perioperative pain management usually involves a multimodal pharmacologic approach with the goal of minimizing opioid requirements. Regional anesthesia is valuable for postoperative pain control. Safety of its use in the pediatric population has been confirmed in recent studies. Included for discussion are fractures, slipped capital femoral epiphysis, club foot, and scoliosis.

Children's own perspectives demonstrate the need to improve paediatric perioperative care

AIM

To explore children's perspectives when facing anaesthesia and surgery.

DESIGN

Interpretative qualitative design.

METHODS

Children undergoing outpatient surgery were interviewed in three different phases, before and after anaesthesia and surgery (phase 1 and 2) and 1 month after the hospitalization (phase 3). Twenty-two children (4-15 years) were interviewed in phase 1 and 2 and six children (5-13 years) in phase 3. Data were analysed using manifest and latent qualitative content analysis.

RESULTS

Two contrasting themes were identified: Fearful in association with anaesthesia and surgery and Confident in association with anaesthesia and surgery. Comprehension of the perioperative procedures, continuous information and interaction with the healthcare providers were decisive factors for children's expressions of confidence or fearfulness. Events considered as major from a healthcare perspective may be of no importance to the child, while events considered as less important by healthcare providers may be significant to the child. Understanding children's perspectives and awareness of their need to process the information provided are significant factors for establishment of trust and confidence in a highly technological perioperative environment.

The comparison of dexmedetomidine and midazolam premedication on postoperative anxiety in children for hernia repair surgery: A randomized controlled trial

BACKGROUND

Perioperative anxiety is common in pediatric patients undergoing surgery.

AIMS

The aim of this study was to determine whether an infusion of dexmedetomidine prior to hernia repair in children provides better postoperative anxiety outcomes that a preoperative infusion of midazolam.

METHODS

Ninety 6-11-year-old children, who were scheduled to undergo elective hernia repair, were enrolled for this double-blind, randomized controlled trial. Group D (n = 45) received an intravenous infusion of dexmedetomidine (0.5 μg/kg) and Group M (n = 45) received an intravenous infusion of midazolam (0.08 mg/kg) in 20 mL of normal saline for 10 minutes before the induction of anesthesia. Pre- and postoperative scores on the modified Yale Preoperative Anxiety Scale were the main outcomes. Secondary outcomes included systolic blood pressure, diastolic blood pressure, heart rate, and postoperative pain measured on a visual analogue scale and patient satisfaction using a numerical rating scale.

RESULTS

Postoperative anxiety in Group D was significantly lower than preoperative anxiety (2 hours postoperatively mean difference [95% CI]: 2.83 [0.87-4.79], P = 0.036, 4 hours postoperatively mean difference [95% CI]: 3.29 [1.39-5.20], P = 0.005). Preoperative and postoperative anxiety in Group M was similar. Anxiety scores in Group D were also significantly lower than anxiety in Group M 2 hours (mean difference [95% CI]: 1.89 [0.52-3.26], P = 0.01) and 4 hours (mean difference [95% CI]: 3.32 [1.98-4.66], P < 0.001) postoperatively. Systolic blood pressure, diastolic blood pressure and heart rate were lower in Group D than in Group M after administration of sedative drugs until children left PACU (SBP mean difference [95% CI]: 13.87 [10.30-17.43], P < 0.001, DBP mean difference [95% CI]: 5.96[3.80-8.11], P < 0.001, HR mean difference [95% CI]: 10.36 [7.58-13.13], P < 0.001). Pain was also significantly lower in Group D than in Group M at 2 hours (median difference [95% CI]: 1 [0.26-1.34], P = 0.004), 4 hours (median difference [95% CI]: 1 [0.31-1.02], P = 0.003), and 1 day (median difference [95% CI]: 0 [0.22-0.76], P = 0.003) postoperatively. Patient satisfaction scores were significantly higher in Group D than in Group M 1 day (median difference [95% CI]: 0 [-0.83 to -0.24], P = 0.006) and somewhat higher 1 week (median difference [95% CI]: 0 [-0.67 to -0.04], P = 0.06) postoperatively.

CONCLUSION

Compared with midazolam, a single preoperative intravenous dose of dexmedetomidine appears to provide better postoperative anxiolytic effects for children undergoing same-day surgery.

Association of Temperament With Preoperative Anxiety in Pediatric Patients Undergoing Surgery: A Systematic Review and Meta-analysis

IMPORTANCE

Preoperative anxiety is associated with poor behavioral adherence during anesthetic induction and adverse postoperative outcomes. Research suggests that temperament can affect preoperative anxiety and influence its short- and long-term effects, but these associations have not been systematically examined.

OBJECTIVE

To examine the associations of temperament with preoperative anxiety in young patients undergoing surgery.

DATA SOURCES

Studies from MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and the Cochrane Central Register of Controlled Trials databases were searched from database inception to June 2018.

STUDY SELECTION

All prospective studies reporting associations of temperament with preoperative anxiety were included. Overall, 43 of 5451 identified studies met selection criteria.

DATA EXTRACTION AND SYNTHESIS

Using the PRISMA guidelines, reviewers independently read 43 full-text articles, extracted data on eligible studies, and assessed the quality of each study. Data were pooled using the Lipsey and Wilson random-effects model.

MAIN OUTCOMES AND MEASURES

Primary outcome was the association of temperament with preoperative anxiety in patients undergoing surgery.

RESULTS

A total of 23 studies, with 4527 participants aged 1 to 18 years, were included in this review. Meta-analysis of 12 studies including 1064 participants revealed that emotionality (r = 0.11; 95% CI, 0.04 to 0.19), intensity of reaction (r = 0.29; 95% CI, 0.11 to 0.46), and withdrawal (r = 0.40; 95% CI, 0.23 to 0.55) were positively associated with preoperative anxiety, whereas activity level (r = -0.23; 95% CI, -0.31 to -0.16) was negatively correlated with preoperative anxiety. Impulsivity was not significantly associated with preoperative anxiety.

CONCLUSIONS AND RELEVANCE

This systematic review and meta-analysis provided evidence suggesting that temperament may help identify pediatric patients at risk of preoperative anxiety and guide the design of prevention and intervention strategies. Future studies should continue to explore temperament and other factors influencing preoperative anxiety and their transactional effects to guide the development of precision treatment approaches and to optimize perioperative care.

Postoperative behavioral changes in Chinese children undergoing hypospadias repair surgery: A prospective cohort study

BACKGROUND

The perioperative period can be psychologically challenging, and children may exhibit behavioral changes following surgical anesthesia. It is unknown whether children in China have additional risk factors associated with negative behavioral changes.

OBJECTIVES

The aim of this study was to investigate the incidence of behavioral changes in children after hypospadias repair surgery and to identify potential risk factors associated with negative behavioral changes.

METHODS

A prospective cohort of 177 children aged 2-12 years scheduled for hypospadias repair surgery from 2016 to 2017 was studied. The primary outcome was the incidence of behavioral changes on postoperative days 14 and 30 evaluated with the Post-Hospitalization Behavioral Questionnaire. Data collected included demographic data, anesthesia details, procedure details, admission details, child anxiety, child temperament, pain, and emergence delirium. Multivariable logistic regression was used to identify risk factors associated with postoperative negative behavioral changes.

RESULTS

A total of 60.5% (107/177) of children exhibited negative postoperative behavioral changes on day 14 and 46.5% (79/170) exhibited changes on day 30 after the surgery. Approximately 2.3% (4/177) and 2.4% (4/170) of children showed improved behavior on postoperative days 14 and 30, respectively. The frequency of temper tantrums changed the most. The logistic regression results suggested that a younger age (odds ratio: 0.86; 95% confidence interval 0.76-0.96), emotional temperament (odds ratio: 1.1; 95% confidence interval 1.0-1.2) and maternal education (odds ratio: 2.2; 95% confidence interval 1.1-4.5) were associated with negative postoperative behavioral changes on day 14. On day 30, a younger age (odds ratio: 0.87; 95% confidence interval 0.77 to 0.98) was the only factor associated with negative postoperative behavioral changes.

CONCLUSION

For children undergoing hypospadias repair surgery in our institution, approximately three in five showed postoperative behavioral changes. In addition to a younger age and a higher maternal education, an emotional temperament is associated with a high incidence of negative postoperative behavioral changes.

What are the validity and reliability of the modified Yale Preoperative Anxiety Scale-Short Form in children less than 2 years old?

BACKGROUND

Accurate measurement of preoperative anxiety is important for pediatric surgical patients' care as well as for monitoring anxiety-reducing interventions. The modified Yale Preoperative Anxiety Scale-short form is well validated for this purpose in children aged 2 years and above, but not in younger children.

AIMS

We aimed to validate the Dutch version of the modified Yale Preoperative Anxiety Scale-short form for measuring preoperative anxiety in children less than 2 years old.

METHODS

Two investigators independently assessed infants' anxiety at the holding area and during induction of anesthesia with the modified Yale Preoperative Anxiety Scale-short form and the COMFORT-Behavior scale-live and from video observations. Construct validity and responsiveness of both scales were tested with Pearson correlation coefficient. Internal consistency of the modified Yale Preoperative Anxiety Scale-short form was assessed using Cronbach's α, and inter-rater reliability and intra-rater reliability were tested using the intraclass correlation coefficient and Cohen's linearly weighted kappa. Hypotheses for sufficient inter-rater reliability (r > 0.60) and validity (r > 0.65) had been formulated a priori in line with the COSMIN guidelines.

RESULTS

Behavior of 129 infants (89.1% male) with a median age of 6.5 months (range 0.9-16.5 months) was observed. The correlations between the modified Yale Preoperative Anxiety Scale-short form and COMFORT-Behavioral scale were strong at the holding area and at induction of anesthesia, as were the correlation of change scores between the holding area and induction. Internal consistency of the modified Yale Preoperative Anxiety Scale-short form was excellent at both the holding area and at induction of anesthesia. Inter-rater reliability was good to excellent on scale level and moderate to good on item level.

CONCLUSION

These findings support the validity and reliability of the Dutch version of the modified Yale Preoperative Anxiety Scale-short form in children less than 2-years-old.

Comparison of Oral Triclofos and Oral Midazolam as Premedication in Children undergoing Elective Surgery

Background:

Children who have experienced previous hospital admission, operation, procedures, and needle pricks are more reactive to subsequent anesthetic procedures. Many sedative agents have been used for the purpose of premedication, but few of them can be given orally, thus avoiding the pricks. Midazolam, being one such choices, can be given orally, intranasally, and parenterally but has unpredictable response. Triclofos, available as sweet syrup, is a phosphorylated derivative of chloral hydrate, has been proven to be effective within 30 min in doses of 25–75 mg/kg. Hence, this study compares triclofos hydrochloride with midazolam oral to know the efficacy of both the drugs as premedication.

Aim:

This study aims to assess sedation score, level of anxiety/resistance, and behavior of the child in the preoperative period.

Settings and Design:

After parental and institutional approval, a total of 70 children were studied based on computer-generated randomization and divided into groups M and T of 35 each.

Materials and Methods:

Group M patients received oral midazolam 0.5 mg/kg. Group T patients received commercially available triclofos syrup containing 100 mg/ml of drug in dose of 75 mg/kg. The response of children to taste of premedication was noted, whether completely ingested or not. In case of vomiting, the child was excluded from further study.

Statistical Analysis:

Numerical variables were analyzed using Student's paired t-test and other variables using Mann–Whitney U-test, Fisher exact test, and Friedman ANOVA.

Results:

Sedation score at 5 min interval from 0 to 30 min showed P = 0.54, 0.71, 0.65, 0.92, 0.29, 0.42, and 0.15; none were statistically significant. Anxiety score during parental separation, intravenous cannulation, and mask application were also similar in both the groups.

Conclusion:

From data obtained, it can be concluded that parenteral formulation of either midazolam or triclofos can be safely used as premedicant in children.

Web-Based Learning for Children in Pediatric Care: Qualitative Study Assessing Educational Challenges

Background

Hospitalization is a significant and stressful experience for children, which may have both short-term and long-term negative consequences. Anaesthesia-Web is a Web-based preparation program that has been well received and is being used worldwide to reduce stressful experiences, increase understanding, and exchange information in pediatric care. A deeper theoretical and educational understanding encompassing children’s learning processes on Anaesthesia-Web may optimize and support the development and design of similar websites for children in pediatric care.

Objective

The objective of this study was to elucidate key educational principles in the development and design of websites for children in pediatric care.

Methods

A directed qualitative content analysis was applied to analyze the content and design of Anaesthesia-Web from a theoretical and educational perspective. preunderstanding, motivation, learning processes, and learning outcome were used to analyze the learning possibilities of Anaesthesia-Web for children prior to contact with pediatric care.

Results

We found 4 themes characterizing children’s learning opportunities on Anaesthesia-Web in the analysis: “In charge of my learning”; “Discover and play”; “Recognize and identify“; and “Getting feedback”. The analysis showed that Anaesthesia-Web offers children control and enables the use of the website based on interest and ability. This is important in terms of motivation and each child’s individual preunderstanding. Through discovery and play, children can receive, process, and apply the information on Anaesthesia-Web cognitively, emotionally, and by active participation. Play stimulates motivation and is very important in a child’s learning process. When facing pediatric care, children need to develop trust and feel safe so that they can focus on learning. On Anaesthesia-Web, children can recognize situations and feelings and can find someone with whom to identify. Several features on the website promote feedback, which is necessary to judge learning achievements, confirm understanding, and embody the need for repetition.

Conclusions

Web-based preparation programs are important learning resources in pediatric care. Content and design needs to change from simply providing information to embracing the importance of a child’s need to process information to learn and fully understand. By developing Web-based preparation programs that include educational principles, Web-based technology can be used to its fullest advantage as a learning resource for children. The 4 educational themes described in this study should help future similar website developments within pediatric care.

Effect of Two Techniques of Parental Interaction on Children's Anxiety at Induction of General Anaesthesia-A Randomized Trial

Objective

Several non-pharmacological techniques, such as parental presence and behavioral preparation, are used to decrease children's anxiety at anaesthesia induction. We compared the mean anxiety score in children at the time of anaesthesia induction with two different physical techniques of parental interaction and a control group with no parent present. The secondary objective was to determine the face mask acceptance during induction.

Methods

This study recruited 123 ASA I & II children, aged 1 to 8 years, undergoing day care surgery, who were randomly allocated to three groups. Children either went to the operating room (OR) alone (Gp C), or one parent sat next to the child at induction (Gp PS), or the child sat in parent's lap (Gp PH). The anxiety score on the modified Yale Preoperative Anxiety Scale (mYPAS) was recorded in the preinduction area of OR and at the induction of anaesthesia before the face mask application. A cut-off value of less than 30 indicated low anxiety. The face mask acceptance was also rated.

Results

All patients had the mYPAS scores higher than 30 in the preinduction area with no significant difference between groups. Prior to induction, the Gp C score was significantly high as compared to Gp PS (p=0.016) and Gp PH (p=0.001), but it was not different between the Gp PS and PH (p=1.00). The face mask acceptance was easy in 4.9 % patients in Gp C, 26.8% in Gp PS, and 56% in Gp PH.

Conclusion

Parental presence during induction did not prevent children's anxiety, but it reduced it, irrespective of the physical technique used. The face mask acceptance was better in Gp PH.

Is surgery a risk factor for separation anxiety in children?

OBJECTIVE

Postoperative anxiety symptoms are distressing for both family and child. The aim of this study was to examine the prevalence of postoperative anxiety symptoms in children.

METHODS

60 children aged 6-12 undergoing surgery were included in the study group. The study group was assessed three times in terms of separation anxiety disorder (SAD), at the time of presentation, 1 and 3 months postoperatively. A personal information form and the SAD section of the K-SADS-PL on the basis of DSM-IV diagnostic criteria for screening SAD symptoms were used.

RESULTS

Study group consisted of 19 girls (31.7%) and 41 boys (68.3%) (mean age 8.9 ± 2.3). Four (6.6%) of the cases at the time of presentation and 13 (21.6%) in the study group met SAD diagnostic criteria in 1 month and 21 (35.0%) in 3 months. Anxiety disorder symptoms were significantly higher in the study group at 3 months postoperatively (p < 0.05). There is significant correlation between both SAD symptoms and duration of hospitalization. There was also a positive correlation between duration of hospitalization and parental education and SAD symptoms.

CONCLUSION

Greater SAD was observed in children undergoing surgical procedures. It will be useful to physicians to consider SAD after surgery in pediatric patients especially when the level of parental education and duration of hospitalization increase. Since SAD may persist long after surgery, it may cause constant fear in personality disorders and lead to psychological problems by significantly lowering quality of life.

A Retrospective Review of a Bed-mounted Projection System for Managing Pediatric Preoperative Anxiety

Introduction:

Most children undergoing anesthesia experience significant preoperative anxiety. We developed a bedside entertainment and relaxation theater (BERT) as an alternative to midazolam for appropriate patients undergoing anesthesia. The primary aim of this study was to determine if BERT was as effective as midazolam in producing cooperative patients at anesthesia induction. Secondary aims reviewed patient emotion and timeliness of BERT utilization.

Methods:

We conducted a retrospective cohort study of pediatric patients undergoing anesthesia at Lucile Packard Children’s Hospital Stanford between February 1, 2016, and October 1, 2016. Logistic regression compared induction cooperation between groups. Multinomial logistic regression compared patients’ emotion at induction. Ordinary least squares regression compared preoperative time.

Results:

Of the 686 eligible patients, 163 were in the BERT group and 150 in the midazolam. Ninety-three percentage of study patients (290/313) were cooperative at induction, and the BERT group were less likely to be cooperative (P = 0.04). The BERT group was more likely to be “playful” compared with “sedated” (P < 0.001). There was a reduction of 14.7 minutes in preoperative patient readiness associated with BERT (P = 0.001).

Conclusions:

Although most patients were cooperative for induction in both groups, the midazolam group was more cooperative. The BERT reduced the preinduction time and was associated with an increase in patients feeling “playful.”

Does dexmedetomidine given as a premedication or intraoperatively reduce post-hospitalisation behaviour change in children? A study protocol for a randomised controlled trial in a tertiary paediatric hospital

INTRODUCTION

It has been reported that post-hospitalisation behaviour change (PHBC) occurs in over 50% of children undergoing a general anaesthetic and manifests as behaviours such as sleep and eating disorders, defiance of authority, nightmares, enuresis and temper tantrums. The effect is usually short-lived (2-4 weeks); however, in 5-10% of children, these behaviours can last up to 12 months. The risk factors for developing PHBC include underlying anxiety in the child or parent, a previous bad hospital experience, emergence delirium and preschool age. A recent meta-analysis of alpha-2 agonists (including dexmedetomidine) found that they effectively reduce the incidence of emergence delirium but none of the studies looked at longer term outcomes, such as PHBC.

METHODS AND ANALYSIS

Two-year-old to seven-year-old children requiring general anaesthesia for common day-case procedures will be randomly assigned to one of three groups: a dexmedetomidine pre medication group, an intraoperative dexmedetomidine group and a control group. Baseline anxiety levels of the parent will be recorded and the anxiety of the child during induction of anaesthesia will also be recorded using validated tools. The primary outcome will be negative behaviours after hospitalisation and these will be measured using the Post Hospitalisation Behaviour Questionnaire for Ambulatory Surgery and the Strengths and Difficulties Questionnaire. These questionnaires will be administered by a blinded researcher at days 3, 14 and 28 post surgery.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the Children's Health Queensland human research ethics committee (HREC/15/QRCH/248) and the University of Queensland human research ethics office (#2016001715). Any amendments to this protocol will be submitted to the ethics committees for approval.

TRIAL REGISTRATION NUMBER

ANZCTR:12616000096459; Pre-results.

Behavioral Changes in Children After Emergency Department Procedural Sedation

OBJECTIVE

The purpose of this study was to determine the proportion of children undergoing procedural sedation for fracture reduction in the emergency department (ED) observed to experience negative postdischarge behaviors. Predictors of negative behaviors were evaluated, including anxiety.

METHODS

This was a prospective cohort study of children receiving intravenous ketamine sedation for ED fracture reduction. The child's anxiety prior to sedation was measured with the Modified Yale Preoperative Anxiety Scale. Negative behavioral changes were measured with the Post-Hospitalization Behavior Questionnaire 1 to 2 weeks after discharge. Descriptive statistics and odds ratios (ORs) were calculated. Chi-square test was used for comparisons between groups. Multivariable logistic regression models evaluated predictors of negative behavioral change after discharge.

RESULTS

Ninety-seven patients were enrolled; 82 (85%) completed follow-up. Overall, 33 (40%) children were observed to be highly anxious presedation and 18 (22%) had significant negative behavior changes after ED discharge. Independent predictors for negative behaviors were high anxiety (OR = 9.0, 95% confidence interval [CI] = 2.3-35.7) and nonwhite race (OR = 6.5, 95% CI = 1.7-25.0).

CONCLUSION

For children undergoing procedural sedation in the ED, two in five children have high preprocedure anxiety and almost one in four have significant negative behaviors 1 to 2 weeks after discharge. Highly anxious and nonwhite children have increased risk of negative behavioral changes that have not been previously recognized in the ED setting.

The Role of Ethnicity and Acculturation in Preoperative Distress in Parents of Children Undergoing Surgery

This study examined the effects of acculturation on anxiety and stress in Latino and non-Latino white parents of children undergoing outpatient surgery. Participants included 686 parent-child dyads from four major children's hospitals in the United States. Latino parents who grew up in the U.S. reported higher levels of anxiety (p = 0.009) and stress (p < 0.001) compared to parents who grew up in a Latin American country. Additionally, English-speaking Latino parents reported higher anxiety and stress compared to both Spanish-speaking Latino and non-Latino white parents (p's < 0.05), whereas Spanish-speaking Latino and non-Latino white parents reported similar levels of stress and anxiety. Results of the current study were consistent with the immigrant health paradox in that more acculturated Latino parents reported higher levels of anxiety and stress than less acculturated Latino and non-Latino white parents, supporting the need for culturally tailored interventions in the perioperative environment.

Experiences During a Psychoeducational Intervention Program Run in a Pediatric Ward: A Qualitative Study

Hospitalization, despite its duration, is likely to result in emotional, social, and academic costs to school-age children and adolescents. Developing adequate psychoeducational activities and assuring inpatients' own class teachers' collaboration, allows for the enhancement of their personal and emotional competences and the maintenance of a connection with school and academic life. These educational programs have been mainly designed for patients with long stays and/or chronic conditions, in the format of Hospital Schools, and typically in pediatric Hospitals. However, the negative effects of hospitalization can be felt in internments of any duration, and children hospitalized in smaller regional hospitals should have access to actions to maintain the connection with their daily life. Thus, this investigation aims to present a psychoeducational intervention program theoretically grounded within the self-regulated learning (SRL) framework, implemented along 1 year in a pediatric ward of a regional hospital to all its school-aged inpatients, regardless of the duration of their stay. The program counts with two facets: the psychoeducational accompaniment and the linkage to school. All the 798 school-aged inpatients (M_age = 11.7; SD_age = 3.71; M_{hospital stay} = 4 days) participated in pedagogical, leisure nature, and SRL activities designed to train transversal skills (e.g., goal-setting). Moreover, inpatients completed assigned study tasks resulting from the linkage between the students' own class teachers and the hospital teacher. The experiences reported by parents/caregivers and class teachers of the inpatients enrolling in the intervention allowed the researchers to reflect on the potential advantages of implementing a psychoeducational intervention to hospitalized children and adolescents that is: individually tailored, focused on leisure playful theoretically grounded activities that allow learning to naturally occur, and designed to facilitate school re-entry after hospital discharge. Parents/caregivers highlighted that the program helped in the preparation for surgery and facilitated the hospitalization process, aided in the distraction from the health condition, promoted SRL competences, and facilitated the communication and linkage with school life. Class teachers emphasized the relevance of the program, particularly in the liaison between hospital and school, in the academic and psycho-emotional and leisure-educational support provided, and in smoothing the school re-entry.

Helping Children Cope with Medical Tests and Interventions

Medical procedures and tests become a challenge when anxiety and pain make it difficult for the patient to cooperate or remain still when needed. Fortunately a short intervention with hypnoidal language at the onset of a procedure induces a positive and sustained change in the way pain and anxiety are processed. While anesthesia may appear to be a simple solution to eliminate pain, the adverse effects of pre-anesthesia anxiety on postoperative behavior and recovery are often not fully appreciated. This paper discusses options for self-hypnotic relaxation that are applicable to interactions with children. The high suggestibility of children makes it relatively easy to engage them in make-believe scenarios. Avoidance of negative suggestions is key in avoiding nocebo effects that may be difficult to overcome later. Once a child is immersed in his or her preferred scenario or hobby/activity of choice, environmental and procedural stimuli can be easily integrated in the imagery. Ego-strengthening metaphors that tie in features of strength, confidence, or resilience are particularly empowering. Even when children are fully under general anesthesia they may still have recall of what is said in the room and therefore caution in word choice should be maintained.

Childhood preoperative anxiolysis: Is sedation and distraction better than either alone? A prospective randomized study

BACKGROUND

Preoperative anxiety management receives special attention in pediatric anesthesia. Different pharmacological and nonpharmacological techniques can be employed. This study was designed to assess three different strategies for childhood preoperative anxiolysis: midazolam premedication, midazolam in combination with portable Digital Video-Disk player, or video distraction strategy alone.

METHODS

In this prospective randomized study, children aged 2-12 years were assigned to one of the three study groups. The primary outcome was a change in preoperative children's anxiety, from baseline (before transfer to the preanesthetic holding area) to separation from parents, assessed by the Modified Yale Preoperative Anxiety Scale (mYPAS) and the Visual Analog Anxiety Scale (VAS-Anxiety). Delirium emergence, postoperative pain, and parental satisfaction were also collected.

RESULTS

One hundred and thirty-five patients were enrolled. The three preventive strategies allowed control of preoperative distress. Within the three study groups, no significant change was objectified in the anxiety level from baseline to separation from parents (mean change in mYPAS midazolam group: 2.4 95% CI [-1.7 to 6.3]; midazolam+Digital Video-Disk group: -1.0 95% CI [-5.9 to 3]; and Digital Video-Disk group: 1.4 95% CI [-4 to 6.7]). Comparison of change in preoperative children's anxiety between the groups did not show any difference. Emergence delirium, postoperative pain scores, and analgesic consumption were similar between the groups and parents' satisfaction was excellent.

CONCLUSION

Both pharmacological premedication and video distraction are effective strategies for controlling preoperative childhood anxiety. The combination of midazolam and Digital Video-Disk player was not better than either alone.

Fears and Perceptions Associated with Regional Anesthesia: A Study from a Tertiary Care Hospital in South India

AIMS

To assess the patients' fears and their perception about regional anesthesia and to study the correlation between fears and perception and demographic profile.

DESIGN

A prospective cross-sectional survey on 150 patients scheduled for surgery under regional anesthesia (RA).

MATERIALS AND METHODS

The structured questionnaires composed of patients' demographic data and questions regarding patients' fears about RA. Questionnaires along with consent forms were sequentially distributed to patients. American Society of Anesthesiologists physical status Classes I and II patients aged between 18 and 80 years scheduled for surgery under RA at the preanesthesia clinics were included in the study.

STATISTICAL ANALYSIS

Statistical analysis was done by calculating percentages using Chi-square test.

RESULTS

One hundred and fifty participants were studied, and their responses were analyzed. Overall, 75.3% (n = 113) patients had preoperative fear. Fear of pain during surgery, i.e., 49.3% (n = 56) and fear of needles 48.7% (n = 55) were the most common fears that were observed in the study population. Patients had less fear regarding nausea, vomiting, and headache. Patients' demographic details did not have a significant correlation with their fears except for gender, with women being more afraid (86.3% vs. 67.7% of men, P = 0.01). Six patients (4%) revealed dissatisfaction and 10 patients were neutral with RA. Ten patients (6.7%) opted for GA in the future and one patient opted for RA with sedation.

CONCLUSION

There is a significant prevalence of fear for RA and its procedures which can affect the patients' decision and postoperative anxiety. The study replicated the high prevalence of anxiety and fear and has clinical implication of improving the education and specifically targeting the fears and anxiety to help the patients' better cope during and after the surgical procedure.

Fear of going under general anesthesia: A cross-sectional study

Objectives:

Fears related to anesthesia have affected a considerable number of patients going for surgery. The purpose of this survey was to identify the most common concerns about general anesthesia during the preoperative anesthetic clinic in different healthcare settings, and whether they are affected by patients’ sex, age, education, or previous experience of anesthesia or not.

Materials and Methods:

Structured questionnaires with consent forms were distributed to patients in their preanesthesia clinic visit in three tertiary hospitals (King Abdul-Aziz Medical City, King Faisal Specialist Hospital, and King Khalid University Hospital) in Riyadh, Saudi Arabia. Patients’ demographics and questions related to their fears regarding general anesthesia were included in the questionnaires. All categorical and interval variables were compared statically using a Chi-square test for independence and a t-test, respectively. All statistical tests were declared significant at α level of 0.05 or less.

Results:

Among 450 questionnaires that were disturbed, 400 questionnaires were collected and analyzed. Eighty-eight percent experienced preoperative fear. The top three causes of their fears were fear of postoperative pain (77.3%), fear of intraoperative awareness (73.7%), and fear of being sleepy postoperatively (69.5%). Patients are less fearful of drains and needles in the operative theater (48%), of revealing personal issues under general anesthesia (55.2%), and of not waking up after surgery (56.4%). Age and gender were significant predictors of the overall fear among preanesthetic patients. Females are 5 times more likely to experience fear before surgery (P = 0.0009). Patients aged more than 40 years old are also at 75% higher risk of being afraid (P = 0.008).

Conclusion:

The majority of the patients going for surgery experienced a fear of anesthesia. Mostly females, especially those over 40, were at a higher risk of being afraid. Fear can bring anxiety which, in turn, might affect the patient's surgery.

[Medical and psychological aspects of the treatment of connatal dacryostenosis : Parental evaluation of their own and their child's stress]

BACKGROUND

Lacrimal probing and syringing for connatal dacryostenosis can be performed under local (LA) and general anesthesia (GA). In cases of invasive medical procedures, pain and anxiety can be distressing for children and their parents.

MATERIALS AND METHODS

Using questionnaires (n = 65), parents were asked to evaluate their own stress and that of their child during lacrimal probing and syringing. Analyzing different subgroups, the impact of the kind of anesthesia (LA vs. GA), trust in medical treatment, therapeutic success, prior experiences with GA, parental educational level, age of parents and children, number of children, and time between the intervention and the interview on the stress was examined. Stress level was evaluated on a scale from 1 (no stress) to 10 (maximal stress).

RESULTS

Mean children's age was 8.5 ± 7.42 months. Mean age of the parents was 30.8 ± 6.17 years. Treating children under LA, parents reported moderate to severe stress levels for themselves (mean, M = 7.15) and for their children (M = 7.82). Children's stress levels were significantly higher when the treatment was performed under LA (n = 47; M = 7.34) in comparison to GA (n = 18; M = 6.06; p < 0.05). Parents having two or more children reported significantly lower stress levels than those with only one child. Furthermore, prior experiences with GA led to significantly higher parental stress levels when their children were treated under GA. Other factors did not show any impact on parent's and children's stress levels.

CONCLUSIONS

Parents might have been influenced by hearing the children's reaction (e. g., crying) during the intervention under LA. Nevertheless, parents had a higher acceptance of this type of intervention (LA) in comparison to GA. This effect was even stronger among parents with prior experience of GA.

Comparison of intranasal dexmedetomidine and dexmedetomidine-ketamine for premedication in pediatrics patients: A randomized double-blind study

BACKGROUND

Goal of premedication in pediatric anesthesia are relieving pre and postoperative anxiety, good parental separation, and smooth induction of anesthesia. Anxiety can produce aggressive reactions, increased distress, increased postoperative pain and postoperative agitation. The benzodiazepine, midazolam, is the most frequently used premedication in pediatric anesthesia. Midazolam has a number of beneficial effects when used as premedication in children: Sedation, fast onset, and limited duration of action. Though midazolam has a number of beneficial effects, it is far from an ideal premedicant having untoward side effects such as paradoxical reaction, respiratory depression, cognitive impairment, amnesia, and restlessness. Dexmedetomidine is a newer α-2-agonist, which can be used as premedicant.

AIMS

To compare the level of sedation, parental separation, mask acceptance, postoperative recovery of intranasal premedication with dexmedetomidine and dexmedetomidine-ketamine combination in pediatric patients.

SETTINGS AND DESIGN

Prospective randomized double-blind study.

SUBJECTS AND METHODS

After written informed consent from the patient's parents or legal guardian, 54 children of American Society of Anesthesiologists physical status I or II, aged between 1 and 6 years, scheduled to undergo elective minor surgery were enrolled. In group D patient received 1 μg/kg dexmedetomidine intranasally and in group DK received 1 μg/kg dexmedetomidine and 2 mg/kg ketamine intranasally. Patients were assessed every 10 min for the level of sedation, parenteral separation, heart rate, and oxygen saturation by an independent observer. Mask acceptance and postoperative agitation were noted using an appropriate scale.

STATISTICAL ANALYSIS USED

Pearson Chi-square analysis to determine differences between two groups with respect to separation anxiety and acceptance of the anesthesia mask. Percentages used to represent frequencies. The level of significance was set at P< 0.05.

RESULTS

Acceptable parenteral separation was achieved in 90% of patients 30 min after premedication. Sedation was acceptable in 80% of patients at induction. Good mask acceptance was seen in 60% of patients. The incidence of emergence agitation (EA) was 2%. None of the above parameters was statistically significant between the two groups.

CONCLUSIONS

Dexmedetomidine, as premedicant in children provides acceptable parenteral separation. However, mask acceptance in operation room is poor. Combination of dexmedetomidine and ketamine does not increase the success of premedication. Use of dexmedetomidine is associated with decreased EA.

Memory effects of sedative drugs in children and adolescents--protocol for a systematic review

BACKGROUND

Some sedatives used in children and adolescents can affect memory function. Memory impairment of traumatic experience can minimize the chance of future psychological trauma. Knowledge about the potential of different sedatives to produce amnesia can help in the decision-making process of choosing a sedative regimen. The aim of this systematic review is to evaluate the effect of different sedatives on memory of perioperative events in children and adolescents.

METHODS/DESIGN

Electronic databases and other sources, such as trial registers, gray literature, and conference abstracts will be searched. Randomized controlled trials will be included that assess memory of perioperative events in children and adolescents 2-19 years old receiving sedative drugs as premedication or as agents for procedural sedation in a medical or dental settings. The outcomes will be loss of memory after and before sedative administration (anterograde and retrograde amnesia). Two independent reviewers will perform screening, study selection, and data extraction. Disagreement at all levels will be resolved by consensus or by involving a third reviewer. Assessment of the risk of bias of included studies will be performed according to "Cochrane Collaboration's Tool for Assessing Risk of Bias in Randomized Trials." Clinical and methodological heterogeneity across studies will be evaluated to determine if it is possible to combine or not combine study results in a meta-analysis.

DISCUSSION

To the best of our knowledge, there is no systematic review that specifically addresses this question. Findings from the review will be useful in the decision-making process about the best sedative for minimizing recall of the medical/dental event and possible psychological trauma.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015017559.

Systematic Review: Audiovisual Interventions for Reducing Preoperative Anxiety in Children Undergoing Elective Surgery

OBJECTIVE

To examine the effectiveness of Audiovisual (AV) interventions at reducing preoperative anxiety and its associated outcomes in children undergoing elective surgery.

METHODS

A systematic review of randomized controlled trials (RCTs) and nonrandomized studies where the primary outcome was children's preoperative anxiety was conducted. Secondary outcomes included postoperative pain, behavioral changes, recovery, induction compliance, satisfaction, and cost-effectiveness. The risk of bias of each study was assessed.

RESULTS

In all, 18 studies were identified. A meta-analytic approach and narrative synthesis of findings were used to summarize the results of the studies.

CONCLUSIONS

This systematic review suggests that AV interventions can be effective in reducing children's preoperative anxiety. Videos, multi-faceted programs, and interactive games appear to be most effective, whereas music therapy and Internet programs are less effective. While AV interventions appear potentially useful, adequately powered RCTs are required to conclusively pinpoint the components and mechanisms of the most effective AV interventions and guide practice.

Predictive Factors of Postoperative Pain and Postoperative Anxiety in Children Undergoing Elective Circumcision: A Prospective Cohort Study

BACKGROUND

Although circumcision for phimosis in children is a minor surgical procedure, it is followed by pain and carries the risk of increased postoperative anxiety. This study examined predictive factors of postoperative pain and anxiety in children undergoing circumcision.

METHODS

We conducted a prospective cohort study of children scheduled for elective circumcision. Circumcision was performed applying one of the following surgical techniques: sutureless prepuceplasty (SP), preputial plasty technique (PP), and conventional circumcision (CC). Demographics and base-line clinical characteristics were collected, and assessment of the level of preoperative anxiety was performed. Subsequently, a statistical model was designed in order to examine predictive factors of postoperative pain and postoperative anxiety. Assessment of postoperative pain was performed using the Faces Pain Scale (FPS). The Post Hospitalization Behavior Questionnaire study was used to assess negative behavioral manifestations.

RESULTS

A total of 301 children with a mean age of 7.56 ± 2.61 years were included in the study. Predictive factors of postoperative pain measured with the FPS included a) the type of surgical technique, b) the absence of siblings, and c) the presence of postoperative complications. Predictive factors of postoperative anxiety included a) the type of surgical technique, b) the level of education of mothers, c) the presence of preoperative anxiety, and d) a history of previous surgery.

CONCLUSIONS

Although our study was not without its limitations, it expands current knowledge by adding new predictive factors of postoperative pain and postoperative anxiety. Clearly, further randomized controlled studies are needed to confirm its results.

Preoperative Psychological Preparation of Children

Surgery and anaesthesia are significant sources of anxiety for children. In the preoperative period, reducing anxiety helps in preventing the negative consequences that may occur after surgery. The predetermined high-risk children in terms of the development of anxiety play an important role in reducing the negative consequences. Recently featured approaches are modelling and coping techniques, although many techniques are used in the preoperative psychological preparation. The use of computer programs in this area may facilitate important achievements, and it needs to support new studies to be performed.

Effect of preoperative oral midazolam sedation on separation anxiety and emergence delirium among children undergoing dental treatment under general anesthesia

Aim:

To investigate the possible effects of preoperative oral Midazolam on parental separation anxiety, emergence delirium, and post-anesthesia care unit time on children undergoing dental rehabilitation under general anesthesia.

Methods:

Randomized, prospective, double-blind study. Seventy-eight American Society of Anesthesiology (ASA) I children were divided into two groups of 39 each. Children of the first group were premedicated with oral Midazolam 0.5 mg/kg, while children of the control group were premedicated with a placebo. Scores for parental separation, mask acceptance, postoperative emergence delirium, and time spent in the post-anesthesia care unit were compared statistically.

Results:

The test group showed significantly lower parental separation scores and high acceptance rate for anesthetic mask. There was no significant difference between the two groups regarding emergence delirium and time spent in post-anesthesia care unit.

Conclusions:

Preoperative oral Midazolam could be a useful adjunct in anxiety management for children suffering dental anxiety. The drug may not reduce the incidence of postoperative emergence delirium. The suggested dose does not seem to affect the post-anesthesia care unit time.

Effectiveness of gaseous and intravenous inductions on children's anxiety and distress during extraction of teeth under general anesthesia

Context:

Anxiety and distress regarding dental treatment is a major issue for dental patients and can be exaggerated in pediatric dental patients.

Aims:

The aim was to investigate how different methods of induction for general anesthesia affect children's distress for dental procedures such as extraction of teeth.

Subjects and Methods:

This was an observational clinical study conducted at Manchester University Dental Hospital. The induction of anesthesia in children was achieved with either intravenous (I.V.) or a gaseous induction. The Modified Child Smiley Faces Scales were completed for children at various times intervals.

Statistical Analysis Used:

There were statistically significant differences between the mean distress scores for the I.V. and inhalation groups (P values from independent t-test: P < 0.001) was applied.

Results:

In gaseous induction group, the number of children who scored severe and very severe distress was greater than those who were in I.V. group. Gaseous induction was used for 23 children. Preoperatively, 56.5% children were in very severe distress, 17.4% in severe distress, 13% in moderate distress, 8.7% in mild distress and only one (4.3%) showed no distress. For I.V. induction, 11.2% children were in very severe distress, 9% in severe distress, and 9.6% in moderate distress, 24.2% in mild distress and 46.1% showed no distress.

Conclusions:

Gaseous induction anesthesia for extractions of teeth does produce high levels of distress than I.V. induction in children for dental extractions. There was no significant difference between both induction methods in terms of distress levels at the time of recovery and 15 min postoperatively.

Treating perioperative anxiety and pain in children: a tailored and innovative approach

Millions of children undergo outpatient surgery in the United States each year; the overwhelming majority will experience significant perioperative anxiety and pain. Behavioral preparation programs focused on skills acquisition and modeling, considered essential for effective preparation, are no longer offered to most children and families in the outpatient surgery setting. Moreover, what little preparation does occur is typically generic in nature, rather than tailored to unique characteristics of the child and family. Untreated anxiety and pain have significant implications for children's short- and long-term recovery and future interactions in the medical environment. The rapid growth of the World Wide Web and increasing access to Internet by families across the country provide an opportunity to develop tailored, Web-based behavioral preparation programs that can be accessed repeatedly at times convenient to the child and family, that include coping skills training and modeling, and that can provide unique output based upon child and parent characteristics known to impact perioperative pain and anxiety. In this review article, we present a conceptual framework for a computer-based intervention that may transform the way we manage children and parents before and after surgery.

Premedication with dexmedetomidine in pediatric patients: a systematic review and meta-analysis

Premedication is important in pediatric anesthesia. This meta-analysis aimed to investigate the role of dexmedetomidine as a premedicant for pediatric patients. A systematic literature search was conducted to identify randomized controlled trials comparing dexmedetomidine premedication with midazolam or ketamine premedication or placebo in children. Two reviewers independently performed the study selection, quality assessment and data extraction. The original data were pooled for the meta-analysis with Review Manager 5. The main parameters investigated included satisfactory separation from parents, satisfactory mask induction, postoperative rescue analgesia, emergence agitation and postoperative nausea and vomiting. Thirteen randomized controlled trials involving 1190 patients were included. When compared with midazolam, premedication with dexmedetomidine resulted in an increase in satisfactory separation from parents (RD = 0.18, 95% CI: 0.06 to 0.30, p = 0.003) and a decrease in the use of postoperative rescue analgesia (RD = -0.19, 95% CI: -0.29 to -0.09, p = 0.0003). Children treated with dexmedetomidine had a lower heart rate before induction. The incidence of satisfactory mask induction, emergence agitation and PONV did not differ between the groups. Dexmedetomidine was superior in providing satisfactory intravenous cannulation compared to placebo. This meta-analysis suggests that dexmedetomidine is superior to midazolam premedication because it resulted in enhanced preoperative sedation and decreased postoperative pain. Additional studies are needed to evaluate the dosing schemes and long-term outcomes of dexmedetomidine premedication in pediatric anesthesia.

Postsurgical behaviors in children with and without symptoms of sleep-disordered breathing

BACKGROUND

Although some children undergo formal preoperative testing for obstructive sleep apnea, it is likely that many children present for surgery with undetected sleep-related disorders. Given that these children may be at increased risk during the perioperative period, this study was designed to compare postoperative behaviors between those with and without symptoms of sleep-disordered breathing (SDB).

METHODS

This study represents a secondary analysis of data from a study examining the effect of SDB on perioperative respiratory adverse events in children. Parents of children aged 2-14 years completed the Sleep-Related Breathing Disorder (SRBD) subscale of the Pediatric Sleep Questionnaire prior to surgery. Children were classified as having SDB if they had a positive score (≥0.33) on the SRBD subscale. Seven to ten days following surgery, the SRBD subscale was re-administered to the parents who also completed the Children's Post Hospitalization Behavior Questionnaire. Children were classified as exhibiting increased problematic behaviors if their postoperative behaviors were considered to be "more/much more" relative to normal.

RESULTS

Three hundred thirty-seven children were included in this study. Children with SDB were significantly more likely to exhibit problematic behaviors following surgery compared with children without SDB. Logistic regression identified adenotonsillectomy (OR 9.89 [3.2-30.9], P < 0.01) and posthospital daytime sleepiness (OR 2.8 [1.3-5.9], P < 0.01) as risk factors for postoperative problematic behaviors.

CONCLUSIONS

Children presenting for surgery with symptoms of SDB have an increased risk for problematic behaviors following surgery. These results are potentially important in questioning whether the observed increase in problematic behaviors is biologically grounded in SDB or simply a response to poor sleep habits/hygiene.