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Approaches to Decreasing Preoperative Anxiety in Pediatric Patients Approaches to Decreasing Preoperative Anxiety in Pediatric Patients

Approaches to Decreasing Preoperative Anxiety in Pediatric Patients - PowerPoint Presentation

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Approaches to Decreasing Preoperative Anxiety in Pediatric Patients - PPT Presentation

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

parental anxiety child children anxiety parental children child induction presence preoperative parents ppia anesthesia surgery midazolam pharmacologic video phbc

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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

Slide2

Disclosures

No relevant financial relationships

Slide3

Learning 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

Slide4

Effects of Preoperative Anxiety

Negative Post Hospitalization Behavior Changes (PHBC): Nightmares/nighttime cryingSeparation anxietyEating disorders

Enuresis

Temper tantrums

Increased stress

Slide5

Duration 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

Slide6

Effects of Preoperative Anxiety

Adverse post operative outcomes with future anesthetics

Increased postoperative pain

Increased analgesic requirements

Prolonged recovery and hospital stay

Slide7

Risk 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

Slide8

Major risk factors:

Underlying anxiety in child or parentPrevious bad hospital experience

Emergence delirium

Preschool age

Longer hospital stay

Risk Factors of Negative PHBC

Slide9

Additional 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

Slide10

Incidence varies due to

Cultural differencesInstitutional differencesStudy design

Differences in how Post Hospitalization Behavior Questionnaire (PHBQ) is used in studies

Negative PHBC

Slide11

Post Hospitalization Behavior Questionnaire (PHBQ)

The most commonly used measurement tool

Developed in 1960s by Vernon et al

5

27 behavior items rated by parents

Slide12

Questions 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?

Slide13

Reasons 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

Slide14

Does 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

Slide15

Does 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

Slide16

Does 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

Slide17

Does 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

Slide18

PPIA

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

Slide19

Randomized, 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

Slide20

Preoperative 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

Slide21

Non-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

Slide22

Non-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

Slide23

Pharmacologic 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

Slide24

Midazolam (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

Slide25

Pharmacologic 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

Slide26

Pharmacologic 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

Slide27

Clonidine:

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

Slide28

Pharmacologic 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

Slide29

Fentanyl

Available routes: oral, intranasal, IV, or IMOral transmucosal (lollipop form) Not as effective for anxiolysisCan cause nausea/vomiting

Pharmacologic

Premedication

Slide30

Pearls & 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*

Slide31

Pearls & Practical Advice:

Vital Capacity Breath Technique

For kids who can follow directions!

Able to take vital capacity breaths

Prime circuit!

Slide32

Pearls & 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

Slide33

Engage 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

Slide34

References:

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

Anaesth

. 2015;25(7):738-745.

Slide35

References:

Cameron JA, Bond MJ, Pointer SC. Reducing the anxiety of children undergoing surgery: parental presence during anaesthetic induction. J

Paediatr

Child Health

. 1996;32(1):51-56.

Messeri

A,

Caprilli

S, Busoni P.

Anaesthesia

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

Paediatr

Anaesth

. 2004;14(7):551-556.

Chundamala

J, Wright JG, Kemp SM. An evidence-based review of parental presence during anesthesia induction and parent/child anxiety. Can J

Anesth

. 2009(56):57-70.

Sadeghi, A.

Khaleghnejad

Tabaria

A, Mahdavi A,

Salarain

S,

Razavi

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.

Slide36

References:

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. 

Paediatr

Anaesth

. 2017;27(8):827-834.