Bommy Hong Mershon MD Assistant Professor Johns Hopkins Department of Anesthesia amp Critical Care Medicine Disclosures No relevant financial relationships Learning Objectives Describe the effects of preoperative anxiety on children ID: 917848
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Slide1
Approaches to Decreasing Preoperative Anxiety in Pediatric Patients
Bommy Hong Mershon, MDAssistant ProfessorJohns Hopkins Department of Anesthesia & Critical Care Medicine
Slide2Disclosures
No relevant financial relationships
Slide3Learning Objectives:
Describe the effects of preoperative anxiety on childrenAssess the risk factors for developing preoperative anxiety in childrenSummarize the effects of parental presence during the induction of anesthesia on childrenIdentify other non-pharmacologic approaches to decrease anxiety in children
Review pharmacologic premedication options and dosing in children
Slide4Effects of Preoperative Anxiety
Negative Post Hospitalization Behavior Changes (PHBC): Nightmares/nighttime cryingSeparation anxietyEating disorders
Enuresis
Temper tantrums
Increased stress
Slide5Duration of Negative PHBC
Occurs in up to 88% of children
Usually lasts less than 4 weeks
30% to 50% at 2 weeks postop
1,2
9% to 32% at 4 weeks postop
3,4
20% exhibit PHBC at 6 months postop
PHBC can last up to 12 months in 5 - 10% of children
Slide6Effects of Preoperative Anxiety
Adverse post operative outcomes with future anesthetics
Increased postoperative pain
Increased analgesic requirements
Prolonged recovery and hospital stay
Slide7Risk Factors for Negative PHBC After Surgery
At 2 weeks post surgery:
1
Mother’s anxiety
Child’s anxiety
At 6 months post surgery:
1
Mother’s anxiety
Slide8Major risk factors:
Underlying anxiety in child or parentPrevious bad hospital experience
Emergence delirium
Preschool age
Longer hospital stay
Risk Factors of Negative PHBC
Slide9Additional risk factors:
Post op pain on day of surgery predictive of PHBC up to 4 weeks later32 or more older siblings
Higher level of parental education
Having discussion with anesthesiologist preoperatively
Risk Factors of Negative PHBC
Slide10Incidence varies due to
Cultural differencesInstitutional differencesStudy design
Differences in how Post Hospitalization Behavior Questionnaire (PHBQ) is used in studies
Negative PHBC
Slide11Post Hospitalization Behavior Questionnaire (PHBQ)
The most commonly used measurement tool
Developed in 1960s by Vernon et al
5
27 behavior items rated by parents
Slide12Questions from the Updated PHBQ for Ambulatory Surgery
6
Does your child need a pacifier?
Does your child seem to be afraid of leaving the house with you?
Does your child seem uninterested in what goes around him/her?
Does your child bite his/her fingernails?
Does your child seem to avoid or be afraid of new things?
Does your child follow you everywhere around the house?
Slide13Reasons for Parental Presence at Induction of Anesthesia (PPIA)
Primary goal is to decrease anxiety Approximately 50% of children show significant anxiety during induction
Factors contributing to anxiety in children
Unfamiliar surroundings
Separation from parents
Fear of needles
Parental anxiety
Slide14Does PPIA help?
It depends!Level of parental anxiety significant predictor of child anxiety
7,8
Maternal anxiety usually higher than paternal anxiety
Greatest moment of stress during induction for parent (56%): Loss of consciousness of child
97% parent satisfaction and feeling useful during induction
Slide15Does PPIA Help Parents?
It depends!Published systematic review9 showed that parental presence during induction does
not
decrease
parental anxiety
compared to:
No parental presence
Midazolam
Parental presence + midazolam
Slide16Does PPIA Help Children?
Published systematic review9 showed that parental presence during induction does not decrease
child’s anxiety
compared to:
No parental presence
Midazolam
Parental presence + midazolam
Parental presence + video game
Slide17Does PPIA Help?
It depends on the parents, the child, and the study
Parental presence alone does not alleviate patients’ or parents’ anxiety
9
Midazolam or distraction techniques can be suitable substitutes
PPIA may reduce preoperative state anxiety of pediatric patients and improve quality of anesthesia induction based on ICC scores and higher parental satisfaction, but it does not impact parental anxiety
10
Slide18PPIA
Biggest factor is the parent and child dynamics
Depends on parental advocacy
Preference of anesthesiologist
Location of procedure/surgery
Type of surgery
Have an assigned person to escort parent(s) out
Slide19Randomized, controlled trial of family-centered preop prep program ADVANCE vs. standard of care, midazolam, parental presence
Anxiety reduction, Distraction, Video modeling,
A
dding parents,
N
o excessive reassurance,
C
oaching of parents,
E
xposure
Certain special populations benefit
Decreasing Preoperative Anxiety:
ADVANCE Program
11
Slide20Preoperative preparation programs
ADVANCE
11
:
Less anxiety, less emergence delirium, less analgesic requirements, faster discharge vs. only PPIA (parental presence during induction of anesthesia)
This is time consuming (starts 5 - 7 days before
surger
) and requires significant resources
PPIA
Preparation study
12
5-minute video for parents vs. standard PPIA
Shown the day of the child’s procedure
Video for parents did not show any reduction in child’s anxiety, but parents were more satisfied because they knew what to expect
Slide21Non-pharmacologic measures:
Distraction Techniques
Clowns
: conflicting viewpoints
Perceived delay in induction time
13
Too many people during induction
13
“Interference” with induction process
13
In the clown group, maternal state anxiety significantly decreased and the tendency to somatization did not increase
14
After clown intervention, older children’s mothers significantly reduced the level of perceived stress
14
Music
Cochrane reviews concluded that music interventions have beneficial effect on preoperative anxiety
15
May provide viable alternative to sedatives or anti-anxiety drugs
Slide22Non-pharmacologic Measures:
Distraction TechniquesVideo game6s or watching videos
RCT
16
comparing PPIA vs Video vs (PPIA + Video) in 117 children 2-7 years old
All 3 techniques had similar effects on preop anxiety and postoperative behavioral outcomes
RCT
17
comparing Midazolam vs Video vs (Midazolam + Video) in 135 children 2-12 years old
All 3 techniques had similar effects on preop anxiety
Slide23Pharmacologic Premedications
Midazolam: Most commonly used premedication in children
Produces anterograde amnesia
Effective in reducing anxiety for separation from parents and during induction of anesthesia
Can by given oral, rectal, intranasal, IV, or IM
Negative side effects: restlessness, paradoxical reactions, postop behavioral changes, and cognitive impairment
Slide24Midazolam (continued)
Oral: most common route
Bitter taste
Bioavailability is approximately 36% (9 - 71%)
Dose: 0.25 - 1 mg/kg (20 mg max)
Onset: 10 - 15 min
Peak effect: 20 - 30 min
Rectal dosing same as oral
Intranasal
Very unpleasant burning sensation
Dose: 0.2 - 0.5mg/kg
Onset: 10 - 20min
IV
Dose: 0.05 - 0.5 mg/kg
Onset: 2 - 30 min
Duration of effect: 45 – 60 min
Slide25Pharmacologic Premedications
Diazepam: Slower onset and prolonged half life compared to midazolamOral/rectal dosing 0.2 - 0.3 mg/kg with peak plasma levels in 60 - 90 minutes
IV/IM dosing 0.04 - 0.2 mg/kg
Slide26Pharmacologic Premedications
KetamineOral dosing 3 – 8 mg/kgIM dosing 4 – 5 mg/kg
Effective sedation in about 5 minutes
45 minutes duration of action
Can combine 2-3 mg/kg + midazolam 0.1mg/kg
IV dosing 1 – 2 mg/kg
Side effects:
excessive salivation, nausea/vomiting, nystagmus, and hallucinations
Slide27Clonidine:
Alpha 2 adrenergic agonistOral dose: 2-4 mcg/kg for sedation/anxiolysisCauses sedation like normal sleepiness but can awakenNo amnestic effectProlonged onset of action (> 90 min)
Frequent need for supplemental oxygen
Pharmacologic
Premedications
Slide28Pharmacologic Premedication
Dexmedetomidine: Highly selective alpha 2 adrenergic agonistIntranasal/sublingual/buccal: 1 to 2 mcg/kg
IV Loading dose: 0.5 - 2 mcg/kg over 5 - 15 min, then infusion 0.2 - 0.7 mcg/kg/
hr
IM: 2.5 mcg/kg
Oral: 3 - 4 mcg/kg but low bioavailability
Slide29Fentanyl
Available routes: oral, intranasal, IV, or IMOral transmucosal (lollipop form) Not as effective for anxiolysisCan cause nausea/vomiting
Pharmacologic
Premedication
Slide30Pearls & Practical Advice
Be creative and flexible with induction techniques
Play music or videos going to and in the OR
Tell stories
Make breathing into the mask into a game
If the child is afraid of the mask, just use your hands to hold the end of the circuit to form a cup around the child’s mouth and nose
Induce without monitors*
Slide31Pearls & Practical Advice:
Vital Capacity Breath Technique
For kids who can follow directions!
Able to take vital capacity breaths
Prime circuit!
Slide32Pearls & Practical advice
Be mindful of the family dynamics and parental anxiety in preop
Think about the age of the child
Think about premedication
Think about negotiating IV placement in older children
Slide33Engage child life specialists (if available) early
Engage preop nurses They can be instrumental in prepping families wellEducate them on when to alert you if a child will need a premed
Pearls & Practical advice
Slide34References:
Kain ZN, Mayes LC, O’Connor TZ, Cichetti DV. Preoperative Anxiety in Children: Predictors and Outcomes. Arch Pediatr
Adolesc
Med. 1996;150:1238-1245.
Fortier MA, Kain ZN. Treating perioperative anxiety and pain in children: a tailored and innovative approach.
Paediatr
Anaesth
2015;25:27-35.
Kotiniemi
LH,
Ryhanen
PT,
Moilanen
IK.
Behavioural
changes in children following day-case surgery: a 4-week follow-up of 551 children.
Anaesthesia
1997;52:970-6.
Power NM, Howard RF, Wade AM, et al. Pain and behavior changes in children following surgery. Arch Dis Child 2012;97:879-84.
Vernon DT, Schulman JL, Foley JM. Changes in children’s behavior after hospitalization. Some dimensions of response and their correlates. Am J Dis Child 1966;111:581-93.
Jenkins BN, Kain ZN, Kaplan SH, et al. Revisiting a measure of child postoperative recovery: development of the Post Hospitalization Behavior Questionnaire for Ambulatory Surgery.
Paediatr
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. 2015;25(7):738-745.
Slide35References:
Cameron JA, Bond MJ, Pointer SC. Reducing the anxiety of children undergoing surgery: parental presence during anaesthetic induction. J
Paediatr
Child Health
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Messeri
A,
Caprilli
S, Busoni P.
Anaesthesia
induction in children: a psychological evaluation of the efficiency of parents' presence.
Paediatr
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Chundamala
J, Wright JG, Kemp SM. An evidence-based review of parental presence during anesthesia induction and parent/child anxiety. Can J
Anesth
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Sadeghi, A.
Khaleghnejad
Tabaria
A, Mahdavi A,
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SS. Impact of parental presence during induction of anesthesia on anxiety level among patients and their parents: a randomized clinical trial.
Neuropsychiatr
Dis Treat. 2017;12:3237-3241.
Kain ZN, Caldwell-Andrews AA, Mayes LC, et al. Family-centered preparation for surgery improves perioperative outcomes in children: a randomized controlled trial. Anesthesiology 2007;106:65-74.
Bailey KM, Bird SJ, McGrath PJ,
Chorney
JE. Preparing parents to be present for their child’s anesthesia induction: A randomized controlled trial. Anesthesia-Analgesia 2015;121:1001-10.
Slide36References:
Vagnoli L, Caprilli S, Robiglio A,
Messeri
A. Clown Doctors as a Treatment for Preoperative Anxiety in Children: A Randomized, Prospective Study. Pediatrics 2005;116 (4):e563-e567.
Agostini F, Monti F,
Neri
E,
Dellabartola
S, de
Pascalis
L,
Bozicevic
L. Parental anxiety and stress before pediatric anesthesia: a pilot study on the effectiveness of preoperative clown intervention.
J Health Psychol
. 2014;19(5):587-601.
Bradt
J,
Dileo
C, Shim M. Music interventions for preoperative. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD006908.
Kim H, Jung SM, Yu H, Park SJ. Video Distraction and Parental Presence for the Management of Preoperative Anxiety and Postoperative Behavioral Disturbance in Children: A Randomize Controlled Trial. Anesthesia-Analgesia 2015;121(3):778-784.
Sola C,
Lefauconnier
A,
Bringuier
S,
Raux
O,
Capdevila
X,
Dadure
C. Childhood preoperative anxiolysis: Is sedation and distraction better than either alone? A prospective randomized study.
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