Anxiety and Salivary Cortisol Levels in Children Undergoing Esophago-Gastro-Duodenoscopy Under Sedation

Oxidative stress responses of virtual reality use in refugee children undergoing elective surgery: A randomized controlled trial

BACKGROUND

With the Virtual Reality (VR) technique, 3D movies can be made for refugee children for pre-operative stress. The study aims to reveal the oxidative responses of the VR technique in pre-operative anxiety in elective surgery in children aged 5-12 years.

METHODS

The Study was designed according to the CONSORT checklist with a randomized controlled parallel design. The whole sample (n = 23), VR experimental group (n = 12), and control group (n = 11) were determined according to the total count method prospectively in 6 months. Oxidative stress parameters (Cortisol, Malondialdehyde, Nitric oxide, Glutathione) were measured in blood samples from the first hospitalization (beginning) and before the intervention (pre-operative) in the experimental and control groups.

FINDINGS

MDA, NO, and cortisol levels (p < 0.05), which indicate the stress level, are high in all groups. In pre-operative measurements, oxidative parameters were lower in the VR experimental group than in the control group. At the same time, the anti-stress antioxidant factor Glutathione was higher in the VR experimental group in pre-operative measurements.

DISCUSSION

The application of 3D film as a VR technique reduces stress parameters in pre-operative stress, and its antioxidant system activating effect has been determined.

APPLICATION TO PRACTICE

It can be applied to refugee child groups for pre-operative stress by shooting 3D movies in different languages.

Salivary cortisol as a biomarker of stress in surgical patients

Background

Surgical stress and pain result in activation of hypothalamus-pituitary-adrenal axis. The aim of this study was to establish the effects of postoperative pain and various modalities of analgesic administration on salivary and serum cortisol levels, as well as to establish the validity of salivary cortisol as a stress indicator in surgical patients.

Methods

A randomized controlled trial involved 60 patients scheduled for elective abdominal aortic aneurysm surgery. Patients were randomly divided into two groups depending on the model of postoperative analgesia. The first group (MI - morphine intermittently) included patients given morphine doses 0.1 mg/kg/6h s.c. intermittently. The second group (MPCA - morphine patient-controlled analgesia) included patients who received morphine via the PCA system - intravenous administration of morphine adjusted to a dose of 1 mg per shot and a lockout interval of 6 minutes.

Measuring Children's Stress via Saliva in Surgical and Endoscopic Procedures and Its Measurement Intention in the Community: Reality-Future Prospects

(1) Background: Children who undergo surgical or endoscopic procedures display high levels of stress, and various means are applied to reduce their anxiety. Salivary cortisol (S Cortisol) and salivary alpha-amylase (SAA) are often used as a valid biomarker of stress. The primary purpose of the study was the investigation of stress levels through S Cortisol and S amylase after intervention in surgical or endoscopic procedures (gastroscopy-colonoscopy). The secondary outcomes were the investigation of the intention to adopt new methods of saliva sampling. We collected saliva samples from children subjected to invasive medical procedures, with the aim of applying the Theory of Planned Behavior (TPB) as an intervention means to provide information and education to both parents and children undergoing stressful situations, and assess its efficacy in reducing stress levels. We also aimed at acquiring a better understanding of the acceptability of noninvasive biomarker collection in community settings. (2) Methods: The sample of this prospective study comprised 81 children who underwent surgical or endoscopic procedures at the Attikon General University Hospital, Athens, Greece and 90 parents. The sample was divided into two groups. The first, 'Group Unexplained', was not provided any information or education about the procedures, while the second, 'Group Explained', was informed and educated based on TPB. Thereafter, 8-10 weeks after intervention, the Theory of Planned Behavior questions were re-completed by the 'Group Explained'. (3) Results: Significant differences were detected in cortisol and amylase values between the two groups postoperatively after applying the TPB intervention. Saliva cortisol was reduced by 8.09 ng/mL in the 'Group Explained' while in the 'Group Unexplained' it was reduced by 4.45 ng/mL (p < 0.001). Salivary amylase values decreased by 9.69 ng/mL in the 'Group Explained' after the intervention phase of the study, while in the 'Group Unexplained' they increased by 35.04 ng/mL (p < 0.001). The regression explains 40.3% (baseline) and 28.5% (follow-up) of parental intention. The predictive factor of parental intention (baseline) is attitude (p < 0.001) and follow-up is behavioral control (p < 0.028) and attitude (p < 0.001). (4) Conclusions: Providing proper education and information for parents has a positive effect on reducing children's stress levels. Changing parental attitudes towards saliva collection plays the most important role, since a positive attitude can influence intention and ultimately participation in these procedures.

Salivary Cortisol and Sustained Auditory Attention in Children with and without Cleft Lip and Palate

Introduction  Cortisol is a hormone involved in the response to stress. Attention is a function that can change due to exposure to stress. Objectives  To verify the correlation between the level of salivary cortisol and sustained auditory attention in children with cleft lip and palate, as well as to compare the results of the variables analyzed between female and male patients. Methods  In total, 103 children aged 6 to 11 years, were divided into 2 groups: those with cleft lip and palate (experimental group, EG; n  = 69) and the control group (CG; n  = 34). The Sustained Auditory Attention Ability Test (SAAAT) and salivary cortisol levels, measured by an enzyme immunoassay kit (Salimetrics, Stage College, PA, US), were calculated and compared regarding the two groups. The statistical tests used were the Mann-Whitney test and the Spearman correlation. Results  The median level of salivary cortisol was of 0.03615 µl/dL and 0.18000 µl/dL respectively for the EG and CG, with a significant difference between the groups ( p  = 0.000). Absence of statistical significance (total error score = 0.656; vigilance decrement = 0.051) was observed the for SAAAT among the EG (median total error score = 12.00; 25th percentile [25%] = 7.00; 75th percentile [75%] = 21.00; and vigilance decrement = 1.00; 25% = 0.00; 75% = 2.50) and the CG (median total error score = 12.00; 25% = 6.00; 75% = 24.00; and vigilance decrement = 0.00; 25% = -1.00; 75% = 2.00). Conclusion  All children had median levels of salivary cortisol and scores for sustained auditory attention within normal parameters. A significant correlation between the level of salivary cortisol and the ability to sustain auditory attention was observed in children without cleft lip and palate. There were no differences regarding the SAAAT and salivary cortisol between female and male patients.

Less stress, better success: a scoping review on the effects of anxiety on anesthetic and analgesic consumption

Preoperative anxiety has an incidence of 11-80% in patients undergoing surgical or interventional procedures. Understanding the role of preoperative anxiety on intraoperative anesthetic requirements and postoperative analgesic consumption would allow personalized anesthesia care. Over- or under-anesthetizing patients can lead to complications such as postoperative cognitive dysfunction in elderly patients, or procedural discomfort, respectively. Our scoping review focuses on the current evidence regarding the association between preoperative anxiety and intraoperative anesthetic and/or postoperative analgesic consumption in patients undergoing elective surgical or interventional procedures. Based on 44 studies that met the inclusion criteria, we found that preoperative anxiety has a significant positive correlation effect on intraoperative propofol and postoperative opioid consumption. The analysis of the literature is limited by the heterogeneity of preoperative anxiety tools used, study designs, data analyses, and outcomes. The use of shorter, validated preoperative anxiety assessment tools may help optimize the intraoperative anesthetic and postoperative analgesic regimen. Further research to determine the most feasible and clinically relevant preoperative anxiety tool and subsequent implementation has the potential to optimize perioperative care and improve patient outcomes.

Effects of anxiety on sedation among pediatric patients undergoing esophagogastroduodenoscopy

We investigated whether the severity of anxiety among children undergoing endoscopy could affect sedation. We prospectively recruited patients under 18 years of age who were scheduled to undergo esophagogastroduodenoscopy (EGD). Baseline anxiety was evaluated using the Spence Children's Anxiety Scale (SCAS). Our analysis considered the type and dose of sedative drugs, degree of sedation, and complications associated with sedation according to the scale score. The mean total SCAS T-scores and each subscale score were significantly higher in the 6-12-year age group. The mean T-score among patients who exhibited irritability during EGD was higher than that among other patients, with significant differences in the Total, Obsessive Disorder, Panic Agoraphobia and General Anxiety subscales. The midazolam doses of children exhibiting irritability were more likely to need higher (p = 0.006). Other sedation-related complications were not associated with the T-scores in each subscale. Total sleep time was not associated with any T-score subscales. Anxiety levels were significantly higher among 6-12-year-olds and children exhibiting irritability. Anxiety was often associated with irritability, difficulties achieving adequate sedation during EGD, and additional sedative drug administration. We recommend higher doses or more potent drugs to facilitate endoscopy for children with high anxiety levels.

Intestinal Ultrasound in Pediatric Inflammatory Bowel Disease: Promising, but Work in Progress

Intestinal ultrasound (IUS) is increasingly used and promulgated as a noninvasive monitoring tool for children with inflammatory bowel disease because other diagnostic modalities such as colonoscopy and magnetic resonance imaging cause significant stress in the pediatric population. The most important parameters of inflammation that can be assessed using IUS are bowel wall thickness and hyperemia of the bowel wall. Research has shown that IUS has the potential to be a valuable additional point-of-care tool to guide treatment choice and to monitor and predict treatment response, although evidence of its accuracy and value in clinical practice is still limited. This review gives an update and overview of the current evidence on the use and accuracy of IUS in children with inflammatory bowel disease.

Investigation of Whole and Glandular Saliva as a Biomarker for Alzheimer's Disease Diagnosis

Salivary Aβ40, Aβ42, t-tau, and p-tau 181 are commonly employed in Alzheimer's disease (AD) investigations. However, the collection method of these biomarkers can affect their levels. To assess the impact of saliva collection methods on biomarkers in this study, 15 healthy people were employed in the morning with six saliva collection methods. The chosen methods were then applied in 30 AD patients and 30 non-AD controls. The levels of salivary biomarkers were calculated by a specific enzyme-linked immunosorbent assay. The receiver operating characteristic was utilized to assess salivary biomarkers in AD patients. The results demonstrated that the highest levels of salivary Aβ40, Aβ42, t-tau, and p-tau were in different saliva collection methods. The correlations between different saliva biomarkers in the same collection method were different. Salivary Aβ40, Aβ42, t-tau, and p-tau had no significant association. Salivary Aβ42 was higher in AD than in non-AD controls. However, p-tau/t-tau and Aβ42/Aβ40 had some relevance. The area under the curve for four biomarkers combined in AD diagnosis was 92.11%. An alternate saliva collection method (e.g., USS in Aβ40, UPS in Aβ42, t-tau, SSS in p-tau 181) was demonstrated in this study. Moreover, combining numerous biomarkers improves AD diagnosis.

Use of Hypnosis in Paediatric Gastrointestinal Endoscopy: A Pilot Study

Objectives: Experience of hypnosis in gastrointestinal (GI) endoscopy is scarce in children. Our aims were to assess the rate of successful GI endoscopy performed using hypnosis alone or in combination with midazolam, with or without additional equimolar mixture of oxygen and nitrous oxide (EMONO), and to identify predictive factors of successful endoscopy in children. Methods: This prospective single-centre study included children older than 6 years requiring a diagnostic esophagogastroduodenoscopy (EGD) or rectosigmoidoscopy. Ericksonian hypnosis was performed alone or in combination with midazolam, with or without additional EMONO. Successful endoscopy was defined by a complete and well-tolerated procedure. Levels of satisfaction of the endoscopist, nurse, and patient were assessed. Results: One hundred forty children [70 boys, median age: 12 years (Q1-Q3: 9-14)] were included over a 14-month period. They underwent EGD in 51.4% (n = 72) and rectosigmoidoscopy in 48.6% (n = 68) of cases. EMONO and midazolam were combined with hypnosis in 136 cases (97.1%). Successful endoscopy rate reached 82.9%. The procedure was interrupted due to poor tolerance and was rescheduled under general anaesthesia in 11 patients (7.9%). Predictive factors for successful endoscopy were older age (13 vs. 8 years, OR: 1.34, CI 95% [1.10-1.62], p = 0.003) and type of endoscopy (EGD vs. rectosigmoidoscopy, OR: 16.34 [2.14-124.68], p = 0.007). A good cooperation of the patient was reported by the endoscopist and the nurse in 88.4 and 86.9% of cases, respectively. Ninety-two per cent of patients mentioned that the procedure went well. Conclusions: Our study suggests that hypnosis combined with EMONO and/or midazolam is of additional value to perform diagnostic EGD or rectosigmoidoscopy in children older than 6 years without systematic need for general anaesthesia.

Propofol use in newborns and children: is it safe? A systematic review

OBJECTIVES

To determine the main indications and assess the most common adverse events with the administration of hypnotic propofol in most pediatric clinical scenarios.

SOURCES

A systematic review of PubMed, SciELO, Cochrane, and EMBASE was performed, using filters such as a maximum of five years post-publication, and/or references or articles of importance, with emphasis on clinical trials using propofol. All articles of major relevance were blind-reviewed by both authors according to the PRISMA statement, looking for possible bias and limitations or the quality of the articles.

SUMMARY OF THE FINDINGS

Through the search criterion applied, 417 articles were found, and their abstracts evaluated. A total of 69 papers were thoroughly studied. Articles about propofol use in children are increasing, including in neonates, with the majority being cohort studies and clinical trials in two main scenarios: upper digestive endoscopy and magnetic resonance imaging. A huge list of adverse events has been published, but most articles considered them of low risk.

CONCLUSIONS

Propofol is a hypnotic drug with a safe profile of efficacy and adverse events. Indeed, when administered by non-anesthesiologists, quick access to emergency care must be provided, especially in airway events. The use of propofol in other scenarios must be better studied, aiming to reduce the limitations of its administration by general pediatricians.

Oral Lorazepam is not Superior to Placebo for Lowering Stress in Children Before Digestive Endoscopy: A Double-Blind, Randomized, Controlled Trial

BACKGROUND

Digestive endoscopies must be performed within a safe and comfortable environment. We have previously shown that the quality of intravenous sedation is influenced by preoperative stress.

AIM

Our primary objective was to compare the effects of oral lorazepam and placebo on the salivary cortisol response of children undergoing a digestive endoscopy. Secondary objectives were the assessment of procedural pain and comfort as well as the occurrence of adverse events.

METHODS

Participants were randomized and received either lorazepam, placebo, or no premedication. Saliva was collected upon arrival at the hospital and 1 h following randomization. The sedation protocol included midazolam and fentanyl ± ketamine. Procedural pain was evaluated with the Nurse Assessed Patient Comfort Score (NAPCOMS). Patients completed a postoperative questionnaire. The primary outcome was defined as the proportion of children having a cortisol decrease ≥ 15 nmol/L.

RESULTS

101 participants (54 females) were included. The rate of children having a cortisol decrease ≥ 15 nmol/L was 27.3%, 35.3%, and 19.4% for lorazepam, placebo, and no premedication, respectively (p = 0.356). The median (IQR) NAPCOMS pain score was 3.0 (0-6) for lorazepam, 4.4 (0-6) for placebo, and 3.4 (3-4) for no premedication (p = 0.428). With lorazepam, 75.9% of children reported experiencing a comfortable procedure, compared with 41.9% taking placebo and 34.5% with no premedication (p = 0.013). Transient tachycardia was the most frequent intraoperative adverse event, particularly with lorazepam (62.5%, p = 0.029).

CONCLUSIONS

Oral lorazepam had no effect on patients' preoperative stress, as measured by salivary cortisol, but was associated with a higher rate of comfortable procedures.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov, Identifier NCT03180632.