The Effects of Preanesthetic Parental Presence on Preoperative Anxiety of Children and their Parents: A Randomized Clinical Trial Study in Iran

Parental Presence during Induction of Anesthesia and Emergence Delirium Influence the Incidence of Postoperative Maladaptive Behavioral Changes

OBJECTIVE

 Surgical intervention in pediatric patients can cause variable degrees of psychological stress with potential consequences in the perioperative period and even in the long term, after hospital discharge in the form of behavioral changes days and months later. The aim of our study was to determine which preoperative preparation strategy reduces postoperative maladaptive behavioral changes in children undergoing ambulatory pediatric surgery.

MATERIALS AND METHODS

 This prospective observational study included 638 pediatric American Society of Anesthesiologists physical status I or II patients who underwent ambulatory pediatric surgery. They were grouped into four preoperative preparation groups: not premedicated (NADA), premedicated with midazolam (MDZ), parental presence during induction of anesthesia (PPIA), and parental presence during induction of anesthesia and premedicated with midazolam (PPIA + MDZ). All patients included in the study were contacted by telephone during 1 year posthospital discharge to assess the postoperative maladaptive behavioral changes using the Posthospitalization Behavior Questionnaire (PHBQ). We performed a multivariate analysis to evaluate the influence of type of preparation and behavioral changes.

RESULTS

 Patients in the PPIA and PPIA + MDZ preparation groups presented less postoperative maladaptive behavioral changes compared to patients in the NADA and MDZ groups (odds ratio [OR]: 1.8 [1.1-2.8] and OR 2.2 [1.03-4.49]) during the first week and first month. The intensity of emergence delirium measured by the Pediatric Anesthesia Emergence Delirium (PAED) scale increases the probability of postoperative maladaptive behavioral changes (OR: 1.05 [1.006-1.103]).

CONCLUSION

 The presence of parents during induction of anesthesia (PPIA and PPIA + MDZ) is a very effective strategy in reducing postoperative behavioral changes. These benefits are more significant in children under 5 years of age.

Effect of interactive, multimedia-based home-initiated education on preoperative anxiety inchildren and their parents: a single-center randomized controlled trial

BACKGROUND

Anesthesiologists need to appreciate the impact of preoperative anxiety in children. The present study aimed to explore whether interactive multimedia-based home-initiated interventions could effectively relieve preoperative anxiety in pediatric patients.

METHODS

In this prospective study, we compared preoperative anxiety between two groups of children aged 4-9 years. Children in the control group received a question-and-answer (Q&A) introduction, and children in the intervention group received multimedia-based home-initiated preoperative education using comic booklets, videos, and coloring game books. Differences in anxiety between the two groups were evaluated by the modified Yale Preoperative Anxiety Scale-Short Form (mYPAS-SF) at four time points: in the ophthalmology outpatient clinic before intervention as the baseline (T0); in the preoperative waiting area (T1); at the time of separating from their parents and moving to the operating room (T2); and at the time of anesthesia induction (T3). Parental anxiety was assessed by the Self-rating Anxiety Scale (SAS) and Visual Analog Scale (VAS) at T0 and T2. Other related information was collected by questionnaire.

RESULTS

Eighty-four children who underwent pediatric strabismus in our center between November 2020 and July 2021 were included in this study. An intention-to-treat (ITT) analysis was performed on data from 78 enrolled children. Children in the intervention group exhibited lower m-YPAS-SF scores at T1, T2, and T3 than those in the control group (all p < 0.001). By using a mixed-effect model with repeated measurement (MMRM) after adjusting the m-YPAS score at T0 as a covariate, the interventional effect in terms of themYPAS-SF score was also significant over time (p < 0.001). The percentage of children with perfect induction compliance (ICC = 0) in the intervention group was significantly higher than that in the control group [18.4% vs. 7.5%], and poor induction compliance (ICC>4) was lower (2.6% vs. 17.5%, p = 0.048). The mean parental VAS score at T2 in the intervention group was significantly lower than that in the control group (p = 0.021).

CONCLUSIONS

Interactive multimedia-based home-initiated intervention could reduce preoperative anxiety in children and improve the quality of anesthesia induction based on ICC scores, which may in turn impose a positive impact on parental anxiety.

Parental Presence at Induction of Anesthesia to Reduce Anxiety: A Systematic Research and Meta-Analysis

PURPOSE

Perioperative anxiety can significantly alter outcomes for pediatric patients. Parental presence at induction of anesthesia (PPIA) is one method of anxiety reduction, but the efficacy remains unclear. This systematic review and meta-analysis aimed to determine if PPIA affects child and caretaker perioperative anxiety levels.

DESIGN

Systematic Review and Meta-analysis METHODS: This study followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive literature search of PubMed, Scopus, CINAHL, PsycINFO, and Cochrane Library databases was performed on June 29, 2021. Search terms were related to parental presence in the operating room, anesthesia or anesthesia induction, and pediatric patients. The literature search identified English-language studies comparing children receiving PPIA to controls or studies examining attitudes toward PPIA.

FINDINGS

A total of 21 articles (n = 9573) met inclusion criteria. Seven studies (n = 776) quantified child anxiety with validated scales, and seven studies quantified parent anxiety (n = 621). There was no significant difference in preoperative anxiety between PPIA and controls for patients (P = .27) or caretakers (P = .99). PPIA patients had 8.40 [0.16, 16.64] (P = .05) lower Modified Yale Preoperative Anxiety Scale scores compared to control at induction, and parents had 3.41 [0.32, 6.50] (P = .03) lower State-Trait Anxiety Inventory State scores. Three studies concluded that PPIA did not increase operating room time or induction time. Twenty-three studies examined parental attitudes toward PPIA and found that 98.03% [96.09%, 99.32%] of parents present at induction would like to be present at subsequent surgeries. Contention in support for PPIA was seen amongst healthcare providers, but attitudes increasingly favored PPIA after implementation.

CONCLUSIONS

PPIA reduces parental and patient anxiety, may increase parental satisfaction, and may not impede operating room efficiency. PPIA should be considered as a valuable tool to improve surgical outcomes and patient and family satisfaction.

Parental Presence during Induction of Anesthesia Improves Compliance of the Child and Reduces Emergence Delirium

INTRODUCTION

 Preoperative stress and anxiety in pediatric patients are associated with poor compliance during induction of anesthesia and a higher incidence of postoperative maladaptive behaviors. The aim of our study was to determine which preoperative preparation strategy improves compliance of the child during induction and decreases the incidence and intensity of emergence delirium (ED) in children undergoing ambulatory pediatric surgery.

MATERIALS AND METHODS

 This prospective observational study included 638 pediatric American Society of Anesthesiologists I-II patients who underwent ambulatory pediatric surgery, grouped into four preoperative preparation groups: NADA (not premedicated), MDZ (premedicated with midazolam), PPIA (parental presence during induction of anesthesia), and PPIA + MDZ. The results were subsequently analyzed in four age subgroups: Group 1 (0-12 months), Group 2 (13-60 months), Group 3 (61-96 months), and Group 4 (> 96 months). Preoperative anxiety (modified Yale Preoperative Anxiety Scale [m-YPAS]), compliance of the child during induction (Induction Compliance Checklist [: ICC]), and ED (Pediatric Anesthesia Emergence Delirium scale) were analyzed in each group.

RESULTS

 Eighty-one percent of patients in the PPIA + MDZ preparation group presented a perfect compliance during the induction of anesthesia (ICC = 0), less preoperative anxiety (mean score m-YPAS = 26), less probability of ED (odds ratio: 10, 5 [3-37.5]; p < 0.05), and less ED intensity compared with the NADA group (1.2 vs. 5.8; p = 0.001).

CONCLUSION

 PPIA associated with midazolam premedication improves compliance during induction and decreases the incidence and intensity of ED.

Video Glasses Reduce Preoperative Anxiety Compared With Portable Multimedia Player in Children: A Randomized Controlled Trial

PURPOSE

Preoperative anxiety in children is challenging for anesthesia providers and nurses. The use of video glasses (VG), an immersive head mount display, helps conceal the unfamiliar operating room environment from the patient's visual field. The aim of this study was to determine the anxiolytic effect of VG compared with that of a portable multimedia player (PMP) during the preoperative period in children.

DESIGN

Prospective randomized trial.

METHODS

Participants were randomized into VG or PMP groups. Patients watched their favorite animation videos using the allocated device from the time of entering the preanesthetic holding area to the end of anesthetic induction. We evaluated modified Yale Preoperative Anxiety Scale scores during anesthetic induction.

FINDINGS

The modified Yale Preoperative Anxiety Scale score in the VG group was significantly lower than that in the PMP group (P = .001).

CONCLUSIONS

In children, the anxiolytic effect of VG during the preoperative period is larger than that of PMP.