Parental presence during induction enhances the effect of oral midazolam on emergence behavior of children undergoing general anesthesia

Research trends related to emergence agitation in the post-anaesthesia care unit from 2001 to 2023: A bibliometric analysis

Background

Emergence agitation (EA) is a behavioural disturbance encountered during the recovery phase of patients following general anaesthesia. It is characterised by restlessness, involuntary limb movements, and drainage tube withdrawal and may significantly harm patients and medical staff. The mechanism of EA has not been fully understood and is still a challenging subject for researchers.

Methods

We extracted relevant publications published between 1 January 2001 and 31 December 2023 on the Web of Science Core Collection platform. VOSviewer software was utilised to analyse the retrieved literature and predict the development trends and hotspots in the field.

Results

The results show that the number of publications grew annually, with China contributing the most, followed by the United States and South Korea. The co-occurrence of keywords "children," "propofol," "risk factors" are current research hotspots. Owing to its self-limiting and short-duration characteristics, EA lacks standardised clinical time guidelines and objective assessment tools, which may be the focus of future research in this field.

Conclusions

Understanding the research hotspots and the latest progress in this field, this study will help to continuously improve the clinical understanding and management of EA, and help to timely identify environmental risk factors for EA in clinical practice.

The effect on perioperative anxiety and emergence delirium of the child or parent's preference for parental accompaniment during anesthesia induction in children undergoing adenotonsillectomy surgery

BACKGROUND

Pediatric emergence delirium (ED) occurs in the early postoperative period and is defined as a complex psychiatric disorder. Non-pharmacological methods of treatment, such as perioperative parental presence, have been the focus of many studies, but the impact on preventing ED of which parent accompanies the child during anesthesia induction has not been identified as yet. Therefore, the aim of this study was to determine whether the selection made by children undergoing adenotonsillectomy of which parent will accompany them during anesthesia induction has the effect of reducing postoperative delirium scores and incidence compared to selections made by the parents.

METHODS

The study included 80 children of both genders, aged 5-12 years, who underwent day-case surgery in the otorhinolaryngology clinic. The patients were separated randomly into two groups of 40. In Group 1, the children were asked to choose which of their parents would accompany them during general anesthesia induction, and in Group 2, the parents were asked to decide who would be the accompanying parent. Evaluation of postoperative delirium was made using the Pediatric Anesthesia Emergence Delirium (PAED) scale. The anxiety level of the children was evaluated with the modified Yale Preoperative Anxiety Scale (mYPAS) both in the preoperative waiting area and during the anesthesia induction. The State-Trait Anxiety Inventory (STAI) was used to evaluate the anxiety level of the parents.

RESULTS

The mean PAED scores were similar in both groups (mean difference [95% CI]: -0.1 [-2.8 to 0.7]). The incidence of emergence delirium was also similar in both groups (risk ratio 0.9 [0.4 to 1.8]). The mean mYPAS scores during the induction of anesthesia of Group 1 was lower than that of Group 2 (mean difference [95% CI]: -8.4 [-15.2 to -1.6]). The mean mYPAS scores evaluated in the preoperative waiting area were found to be similar in the two groups (mean difference [95% CI]: -1.9 [-7.5 to 3.5]). The mean STAI anxiety scores of the parents were similar in both groups, with higher scores obtained by mothers compared to fathers, at all measurement times.

CONCLUSION

The incidence or severity of ED did not decrease significantly even though lower anxiety scores were obtained during anesthesia induction in children who were allowed to make the decision of accompanying parent. Based on these findings, it can be concluded that postoperative delirium is a more complicated process that can be affected by many other variables rather than just the parent-child general interaction.

The Effect of Child Preference for Parental Selection on Pediatric Anxiety During Induction in Children Undergoing Elective Day Case Surgery

PURPOSE

The aim of the study was to determine if children were given the right to prefer one parent to accompany them during the perioperative period would impact their anxiety levels.

DESIGN

Prospective observational cohort study.

METHODS

The study included 80 children of both genders, aged 4 to 12 years, who underwent day-case surgeries in the Ear Nose and Throat Clinic of Karaman Training and Research Hospital. The patients were separated randomly into two groups of 40. In Group 1, children were asked which of their parents would accompany them during general anesthesia induction, and in Group 2, the child' preference was not asked, and "accompanying parent" was randomly selected by the physician. The anxiety level of the children was evaluated with the modified Yale Preoperative Anxiety Scale (mYPAS) both in the preoperative waiting area and during the anesthesia induction. The State-Trait Anxiety Inventory (STAI) was used to determine the anxiety level of their parents.

FINDINGS

The mean mYPAS score during the induction of anesthesia of Group 1 was significantly lower than that of Group 2 (38.1 vs 45.2; P = .034). There was no difference between the two groups in the mean mYPAS scores evaluated in the preoperative waiting area (38.0 vs 39.1; P = .761). The mean anxiety scores of the parents evaluated using the STAI were similar in both groups, with higher scores between mothers compared to fathers at all measurement times. No difference was determined between the two groups regarding the mean mYPAS scores according to the gender of the child during the perioperative period (P > .05). There was a significant decrease in the mean STAI scores in the preoperative waiting area with an increase in parent's education level (P = .011), but the educational level had no effect on the scores during the induction of anesthesia.

CONCLUSIONS

Significantly lower anxiety scores were recorded during the induction of anesthesia for the children who had a chance to select their accompanying parent before surgery. Thus, the overall interaction between the child and the parent before the perioperative period may be accepted as an important factor for the reduction of anxiety during anesthesia induction.

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 and intranasal dexmedetomidine for the prevention of anxiety during anesthesia induction in children undergoing tonsillectomy and/or adenoidectomy surgery: A randomized controlled trial

Background: During the perioperative period of pediatric surgery, it is extremely stressful for children and parents to enter the operating room and receive the anesthesia induction. This study was designed to evaluate the perioperative outcomes with parental presence at induction of anesthesia (PPIA), intranasal dexmedetomidine, and combined use of PPIA and intranasal dexmedetomidine. Methods: In this prospective study, 124 children were randomly divided into four groups: control (no parental presence or intranasal dexmedetomidine), PPIA (parental presence), DEX (intranasal dexmedetomidine (1.0 μg/kg)), and PPIA + DEX (parental presence and intranasal dexmedetomidine (1.0 μg/kg)). The anxiety of children was mainly evaluated by the modified Yale Preoperative Anxiety Scale-Short Form (mYPAS-SF). Secondary evaluation methods were, for example, the Induction Compliance Checklist (ICC), the Pediatric Anesthesia Emergence Delirium Scale (PAED), the COMFORT Behavior Scale (COMFORT-B Scale), the State-Trait Anxiety Inventory (STAI), and the Visual Analog Scale (VAS). Results: Children in the PPIA + DEX group exhibited significantly lower mYPAS-SF and ICC scores compared with all three other groups (p < 0.001), and children in that group exhibited significantly lower mYPAS-SF and ICC scores compared with the PPIA and DEX groups (p < 0.05). The children's PAED scores in the PPIA, DEX, and PPIA + DEX groups were significantly lower than the control group (p < 0.001).The STAI-S scores of the PPIA, DEX, and PPIA + DEX groups were significantly lower than the score of the control group (p < 0.001). The VAS scores of the PPIA, DEX, and PPIA + DEX groups were significantly higher than that of the control group (p < 0.001), while the score of the PPIA + DEX group was significantly higher than those of the PPIA and DEX groups (p < 0.05). Conclusion: The combined use of PPIA and intranasal dexmedetomidine is more effective than PPIA or intranasal dexmedetomidine for alleviating the preoperative anxiety of children, improving children's induction compliance and parental 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.

The Effects of Remifentanil and Fentanyl on Emergence Agitation in Pediatric Strabismus Surgery

Emergence agitation (EA) is one of the main concerns in the field of pediatric anesthesia using sevoflurane. We investigated the effects of remifentanil and fentanyl on the incidence of EA in pediatric patients undergoing strabismus surgery. Ninety children were randomly allocated into two groups and received either remifentanil (group R: intraoperatively remifentanil 0.2 μg/kg/min) or fentanyl (group F: fentanyl 2 μg/kg at anesthetic induction) intraoperatively. After surgery, EA incidence was assessed using a four-point agitation scale and Pediatric Anesthesia Emergence Delirium (PAED) scale in the post-anesthesia care unit. Face, leg, activity, cry, and consolability (FLACC) scores for postoperative pain were also assessed. The incidence of EA using the four-point agitation scale (scores ≥ 3) was similar in both groups (remifentanil group, 28.89% vs. fentanyl group, 24.44%). Similar results were obtained using the PAED scale (scores > 12), with an incidence of 33.33% in the remifentanil group and 26.67% in the fentanyl group. Differences in FLACC scores were not found to be statistically significant. A single bolus administration of fentanyl during anesthetic induction and continuous infusion of remifentanil during surgery had similar effects on the EA incidence in these pediatric patients.

Lost in another language: a case report

Background

In foreign language syndrome, patients switch from their native language and fixate for a period of time on a second language. There have been few reported cases. The language switch typically occurs postoperatively and spontaneously resolves after a short period of time. The primary cause of this switching remains unclear. There is speculation about the involvement of anesthesia, but its specific influence remains unclear.

Case presentation

A 17-year-old Dutch Caucasian male lost the ability to understand and speak Dutch for 24 hours after an orthopedic surgery, combined with a brief confused state including disorientation of place and the inability to recognize his parents. During the period, he communicated in English, which he had learned during school classes but had never spoken outside of school. Further follow-up, including neuropsychological examination, revealed no indication of cognitive impairment.

Conclusions

The exact pathophysiology of foreign language syndrome remains unclear, most specifically whether it is a syndrome of its own or a phenotype of emergence delirium. There is still much to be learned, and further research is needed.

Virtual Reality vs. Tablet Video as an Experiential Education Platform for Pediatric Patients Undergoing Chest Radiography: A Randomized Clinical Trial

Virtual reality (VR), which offers an immersive experience, has been implemented into the education of pediatric patients to reduce peri-procedural anxiety. This randomized clinical trial evaluated the effect of VR, compared with standard video, on reducing anxiety and distress in pediatric patients undergoing chest radiography. A total of 120 children aged 4 to 8 years with scheduled chest radiography appointments were randomized into either the tablet or the VR group. Children in the tablet group experienced chest radiography indirectly with a 3 min tablet video, whereas those in the VR group received the same content via a VR experience. The distress of children was measured using the Observational Scale of Behavioral Distress (OSBD) scale. Parental presence and procedural outcomes were also recorded. The number of less distressed children (OSBD score < 5) was significantly higher in the VR group than in the tablet group (49 [81.7%]) vs. 32 [53.3%]) (p = 0.001). The OSBD scores, the need for parental presence, the procedure time, and the number of repeated procedures were all lower in the VR group. The immersive VR experience appears to decrease the degree of anxiety in children and increase the efficiency of the procedures compared with the tablet video with the same content.

Effectiveness of preoperative tour to a simulated anaesthesia induction at operating theatre in reducing preoperative anxiety in children and their parents: a pragmatic, single-blinded, randomised controlled trial/ King Fahad Medical City

Objective

To evaluate the effectiveness of a preoperative tour to a simulated anaesthesia induction at operating theatre on reducing children’s and parents’ preoperative anxiety.

Design

A pragmatic, single-centre, assessor-blinded, randomised controlled trial.

Setting

In preoperative anaesthesia clinic and the operating room at a tertiary care centre in Saudi Arabia.

Participants

One hundred and sixteen children–parents dyads (pairs) (n=57) intervention group (IG); (n=59) control group (CG) with children aged 4–14 years who were planned for day case procedures under general anaesthesia.

Interventions

Participants’ dyads were randomly allocated through a computer to receive either a preoperative tour to a real operating theatre and simulate anaesthesia induction or standard of care.

Main outcome measure

The primary study outcome was children’s anxiety levels as measured by the modified-Yale Preoperative Anxiety Scale (m-YPAS), and the parent’s anxiety level as assessed by the Beck Anxiety Inventory Scale. The children’s anxiety levels were measured at two time points, the preoperative holding area (T0) and before the anaesthesia induction (T1), and the parents’ anxiety level was measured after the anaesthesia induction. The secondary outcomes were the prevalence of preoperative anxiety and children’s somatic signs of anxiety including heart rate and systolic blood pressure.

Results

The Mann-Whitney U test of m-YPAS scores showed significant differences in the children’s anxiety levels between the CG and IG at T0 (Z −5.009); p<0.01) and T1 (Z −6.599); p<0.01). BIAS analysis revealed a significant difference in the parents’ anxiety level between the CG and IG (Z −4.353); p<0.01). The prevalence of children’s anxiety was reported by 55 (93.2%) in the CG compared with 25 (43.9%) in the IG, with a statistically significant difference (p<0.001).

Conclusion

The preoperative simulated anaesthesia induction was effective in reducing preoperative anxiety in children and their parents.

Effects of parental presence during induction of anesthesia on operative and perioperative times in pediatric patients undergoing adenotonsillectomy

OBJECTIVES

To evaluate the overall perioperative times among pediatric patients undergoing adenotonsillectomy (AT) who, in the perioperative period, received either parental presence at induction of anesthesia (PPIA), midazolam, both, or neither.

METHODS

A retrospective chart review of patients under the age of twelve years who underwent AT during 2018 was performed at a tertiary children's hospital. Exclusion criteria were: patients with concomitant procedures done at the time of AT, American Society of Anesthesiologists (ASA) score greater than 3, or unclear documentation of PPIA participation. Patients were categorized into one of four groups: those who received PPIA, those who received midazolam, and those who received both or neither. Time spent in holding, the operating room, and in recovery were recorded. For comparison of continuous variables, either a One-Way ANOVA or a Kruskal-Wallis test was used as appropriate with post-hoc comparisons using a Dunn's Test.

RESULTS

A total of 274 patient charts were reviewed. After application of exclusion criteria, 152 charts were included for analysis. A total of 69 patients had PPIA alone, 18 received midazolam alone, 57 received both, and 8 had neither. The median age of the patients was 5.34 years (range 0.62-11.97). There was no significant difference in median time in holding between groups, but there was a significant difference in both OR and recovery time (p = 0.005 and p = 0.021 respectively). On further analysis with post-hoc pairwise comparisons, the only significant difference was between the midazolam only group and the group who received both PPIA and midazolam (p < 0.05), with patients receiving both having a shorter OR duration.

CONCLUSION

Patients who received both PPIA and midazolam had a shorter OR duration than patients in the midazolam only group. There were no significant differences found in holding time or recovery time between groups. This supports the conclusion that PPIA can be implemented when deemed appropriate without increasing time spent in the operating room and may even have a beneficial effect when compounded with midazolam.

Behavioral and Emotional Disorders in Children and Their Anesthetic Implications

While most children have anxiety and fears in the hospital environment, especially prior to having surgery, there are several common behavioral and emotional disorders in children that can pose a challenge in the perioperative setting. These include anxiety, depression, oppositional defiant disorder, conduct disorder, attention deficit hyperactivity disorder, obsessive compulsive disorder, post-traumatic stress disorder, and autism spectrum disorder. The aim of this review article is to provide a brief overview of each disorder, explore the impact on anesthesia and perioperative care, and highlight some management techniques that can be used to facilitate a smooth perioperative course.

Emergence agitation: current knowledge and unresolved questions

Emergence agitation (EA), also referred to as emergence delirium, can have clinically significant consequences. The mechanism of EA remains unclear. The proposed risk factors of EA include age, male sex, type of surgery, emergency operation, use of inhalational anesthetics with low blood-gas partition coefficients, long duration of surgery, anticholinergics, premedication with benzodiazepines, voiding urgency, postoperative pain, and the presence of invasive devices. If preoperative or intraoperative objective monitoring could predict the occurrence of agitation during emergence, this would help to reduce its adverse consequences. Several tools are available for assessing EA. However, there are no standardized clinical research practice guidelines and its incidence varies considerably with the assessment tool or definition used. Total intravenous anesthesia, propofol, μ-opioid agonists, N-methyl-D-aspartate receptor antagonists, nefopam, α2-adrenoreceptor agonists, regional analgesia, multimodal analgesia, parent-present induction, and preoperative education for surgery may help in preventing of EA. However, it is difficult to identify patients at high risk and apply preventive measures in various clinical situations. The risk factors and outcomes of preventive strategies vary with the methodologies of studies and patients assessed.This review discusses important outcomes of research on EA and directions for future research.

Effect of transportation method on preoperative anxiety in children: a randomized controlled trial

BACKGROUND

This study was performed to evaluate the effect of a wagon as a transport vehicle instead of the standard stretcher car to reduce children's anxiety of separation from parents. The secondary goal was to evaluate whether this anxiolytic effect was related to age.

METHODS

We divided 80 children (age 2-7 years) into two groups. The stretcher group was transferred to the operating room on a conventional stretcher car, whereas the wagon group was transferred using a wagon. The level of anxiety was evaluated three times using the Modified Yale Preoperative Anxiety Scale (mYPAS): in the waiting area (T0), in the hallway to the operating room (T1), and before induction of anesthesia (T2).

RESULTS

The mYPAS score was significantly lower in the wagon group (36.7 [31.7, 51.7]) than in the stretcher group (51.7 [36.7, 83.3]) at T1 (P = 0.007). However, there was no difference in the mYPAS score between the two groups at T2 (46.7 [32.5, 54.2] vs. 51.7 [36.7, 75.0], respectively, P = 0.057). The baseline anxiety tended to be lower with increasing age (r = -0.248, P = 0.031). During transportation to the operating room, the increase in the mYPAS score (T1-T0) was greater as the age of children decreased in the stretcher group (r = -0.340, P = 0.034). However, no correlation was observed in the wagon group (r = -0.053, P = 0.756).

CONCLUSION

The wagon method decreased preoperative anxiety, suggesting that it may be a good alternative for reducing preoperative anxiety in children.

The Effect of Mirroring Display of Virtual Reality Tour of the Operating Theatre on Preoperative Anxiety: A Randomized Controlled Trial

A virtual reality (VR) tour of the operating theatre could reduce preoperative anxiety by providing a realistic experience for children. This randomized clinical trial was designed to determine whether parental co-experience of preoperative VR tour through a mirroring display could further reduce preoperative anxiety. Eighty children scheduled for elective surgery under general anesthesia were randomly allocated into either the control or mirroring group. Children in the control group watched a 4-min immersive VR video showing the operating theatre and explaining the preoperative process, via a head mounted display. In the mirroring group, parents of children watched the same video through mirroring display concurrently while their child experienced the immersive VR tour. Preoperative anxiety and satisfaction score were measured. Eighty children completed the final analysis (control group = 40 and mirroring group = 40). Preoperative anxiety of children (p = 0.025) and parents (p = 0.009) were lower in the mirroring group compared with the control group. Parents' satisfaction in the mirroring group was significantly higher than those in the control group (p = 0.008). Parental co-experience of the VR tour with children through mirroring the display was effective in reducing preoperative anxiety in both children and parents.

The effect of an immersive virtual reality tour of the operating theater on emergence delirium in children undergoing general anesthesia: A randomized controlled trial

BACKGROUND AND AIMS

An immersive virtual reality tour of the operating theater could reduce preoperative anxiety. This study was designed to determine whether a preoperative immersive virtual reality tour demonstrates a reduction in emergence delirium through reducing the preoperative anxiety in children undergoing general anesthesia.

METHODS

Eighty-six children were randomly allocated into either the control or virtual reality group. The control group received conventional education regarding the perioperative process. The virtual reality group watched a 4-minute virtual reality video showing the operating theater and explaining the perioperative process. Incidence and severity of emergence delirium were the main outcomes. Secondary outcomes included preoperative anxiety using modified Yale Preoperative Anxiety Scale and postoperative behavioral disturbance.

RESULTS

Eighty children completed the final analysis (control group = 39, virtual reality group = 41). The incidence (risk ratio [95% CI]: 1.1 [0.5-2.8], P = 0.773) and severity of emergence delirium (mean difference [95% CI]: -0.2 [-2.7 to 2.2], P = 0.791) were similar in the two groups. After the intervention, children in the virtual reality group had a significantly lower modified Yale Preoperative Anxiety score than those in the control group (mean difference [95% CI]: 9.2 [0.3-18.2], P = 0.022). No difference was observed regarding postoperative behavioral disturbance between the two groups at postoperative 1 day (mean difference [95% CI]: -0.1 [-0.3 to 0.1], P = 0.671) and 14 day (mean difference [95% CI]: -0.0 [-0.1 to 0.0], P = 0.329).

CONCLUSION

Preoperative immersive virtual reality tour of the operating theater did not reduce the incidence and severity of emergence delirium, although it was effective in alleviating preoperative anxiety in children.

Parental satisfaction with being present in the operating room during the induction of anesthesia prior to pediatric neurosurgical intervention: a qualitative analysis

OBJECTIVE Parental presence in the operating room during the induction of anesthesia (PPIA) has been shown to decrease parent and child anxiety and increase satisfaction with patient experience in outpatient otolaryngological procedures, such as tympanostomy tube placement. PPIA for other procedures, such as a major neurosurgical intervention, has been a practice at the authors' institutions for many years. This practice is not universally accepted across the United States, and the potential benefits for patients and families have not been formally evaluated. The aim of this study is to provide a qualitative analysis of parental and patient satisfaction with PPIA at the authors' institution. METHODS All patients younger than 18 years who underwent surgical intervention at the authors' institution between August 2013 and December 2015 were identified. All surgeries were performed by a single neurosurgeon. A random sample of 96 parents were contacted by telephone for a qualitative, semiscripted interview; 42 parents completed the interviews. The interview consisted of a validated satisfaction assessment in addition to a standardized open-ended questionnaire. Thematic analysis was performed until saturation was achieved, and responses were coded into the predominant themes. Member checking was performed, and a thick description was created. RESULTS The predominant themes identified with PPIA were 1) perception of induction as traumatizing or distressing to witness, 2) positive feelings regarding having been present, 3) satisfaction regarding the overall experience with surgery, 4) variable feelings in parents who decided not to attend induction, and 5) mixed feelings in the interactions with the care team. Parents expressed an array of positive, negative, and neutral impressions of the experience; however, overall, most experiences were positive. Most parents would choose PPIA again if their child required additional surgery. CONCLUSIONS This is the first study to evaluate the benefit of PPIA for pediatric neurosurgical patients. The results show a unique insight into medical communication and patient satisfaction with high-risk surgeries. PPIA may be able to help shape an environment of trust and increase satisfaction with perioperative care.

ECT-Related Anxiety: A Systematic Review

BACKGROUND

A significant proportion of electroconvulsive therapy (ECT)-treated patients experience anxiety anticipating the treatment, often to such an extent that they refuse or discontinue a much-needed treatment. Despite its great impact on treatment adherence, anxiety in patients receiving ECT is underexposed in the scientific literature.

OBJECTIVES

We aimed to review the prevalence and specific subjects of ECT-related anxiety and therapeutic interventions to reduce it.

METHODS

We performed a computerized search (EMBASE, MEDLINE, and PsycINFO) for articles meeting the following inclusion criteria: (1) qualitative (interview) studies, quantitative (questionnaire) studies, or experimental (interventional) studies that (2) report on anxiety that is related to a planned, ongoing, or past ECT treatment.

RESULTS

Of 1160 search results, 31 articles were included. Electroconvulsive therapy-related anxiety is estimated to be present in 14% to 75% of patients and is most often linked to worries about memory impairment or brain damage. Only a few interventions (chlorpromazine, meprobamate, propofol, a talking-through technique, an information leaflet, and animal-assisted therapy) have been proposed to reduce patients' ECT-related anxiety.

CONCLUSIONS

Electroconvulsive therapy-related anxiety is a highly prevalent phenomenon, and the literature provides little guidance for its clinical management. Most studies are of a low methodological quality and suffer from significant limitations, thereby hampering generalized conclusions. Given the clinical importance of ECT-related anxiety, further study on its nature and evolution through the course of treatment and on anxiety-reducing interventions is warranted.

Emergence Delirium in Pediatric Anesthesia

Emergence delirium (ED) is a complex of perceptual disturbances and psychomotor agitation that occurs most commonly in preschool-aged children in the early postanesthetic period. The incidence of ED varies between 10 and 80% in children and is perceived as a troublesome clinical situation by 42% of pediatric anesthesiologists. Although these events are often short lived, they increase the risk of self-injury and delayed discharge, require additional nursing staff and can increase medical care costs, all of which are causes for concern. The prevalence of ED has increased with the introduction and growing use of sevoflurane and desflurane, two low-solubility inhalational anesthetics. These agents promote early arousal post anesthetic, which contributes to ED. Physiological factors, pharmacological factors, the type of procedure, the anesthetic agent administered, painful stimuli, and various patient factors can all contribute to ED and thus need to be considered. Recent literature debates the cause-effect relationship between ED and pain, suggesting that they often occur concurrently but are sometimes independent findings. The consistent relation between ED and sevoflurane-based anesthesia has guided many studies to investigate its incidence compared with using other anesthetic techniques or various adjuncts. The risk of ED is lowest when propofol is used as a single-agent anesthetic compared with sevoflurane-based anesthetics. Adjunctive agents can be rated in the following order of most effective to least effective interventions: dexmedetomidine, fentanyl, ketamine, clonidine, and propofol bolus at the end of sevoflurane-based anesthesia. This review summarizes the factors that may predict ED and provides an intervention algorithm to guide effective prevention and treatment.

Impact of parental presence during induction of anesthesia on anxiety level among pediatric patients and their parents: a randomized clinical trial

INTRODUCTION

Anesthesia induction is a stressful event for children and their parents, and may have potentially harmful consequences on the patient's physiological and mental situation. Stressful anesthesia induction has psychological adverse effects that recur with repeated anesthesia, can lead to increased pediatric discomfort during the recovery period, and may even induce reactionary postoperative behavior. A randomized controlled trial was performed to assess the impact of parental presence during induction of anesthesia (PPIA) on preoperative anxiety of pediatric patients and their parents at three different times, cooperation of child with anesthesiologist at induction of anesthesia, and parental satisfaction.

PATIENTS AND METHODS

A total of 96 pediatric patients undergoing elective minor surgery (ASA 1-2) were randomly divided into two groups. Both groups received oral midazolam (0.5 mg/kg) at least 20 minutes before surgery, but in the PPIA group, the parents were also present in the operating room until loss of consciousness of child at anesthesia induction. Anxiety in the patients (as measured by the modified Yale Preoperative Anxiety Scale [mYPAS]) and parents (as measured by the State and Trait Anxiety Inventory [STAI]), the Induction Compliance Checklist (ICC), and parental satisfaction (as measured by visual analog scale) were assessed.

RESULTS

There was no significant difference in the mean anxiety scores (mYPAS) of participants in the control and PPIA groups at ward T0 and upon arrival to operating room T1 (P>0.05). However, between the PPIA and control groups, mean mYPAS score was different at the time of induction of anesthesia T2 (35.5±16.6 vs 59.8±22.4; P<0.001). The ICC scores showed that perfect score was significantly different in the PPIA and control groups (66.6% vs 6.3%; P<0.01). The STAI scores of the parents in the two groups did not differ in T0, T1, and T2. The mean parental satisfaction score was higher in the PPIA group than in the control group (7.6±7.0 vs 5.8±6.1; P<0.01).

CONCLUSION

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 on parental state anxiety.

[Evaluation of the scales used to measure anxiety and child behaviour during the induction of anaesthesia. Literature review]

The assessment of children's anxiety during anaesthetic induction is useful to determine if pre-operative strategies have been effective in reducing anxiety. The aim of this study is to review the different tools used to evaluate child anxiety or behaviour during the induction of anaesthesia. The electronic databases with no date limits were reviewed in December 2013, with a second review repeated in September 2014. A data extraction template was applied to find the scales used in the articles. Eight observational scales were found. Six of them can only be used during induction of anaesthesia, and two of those could be applied at various perioperative times, before surgery and during induction of anaesthesia.

Psycho-educational preparation of children for anaesthesia: A review of intervention methods

OBJECTIVE

To systematically review the different methods available for the psycho-educational preparation of children for anaesthesia induction.

METHODS

Articles were searched in Academic Search Premier, OvidSP, Web of Science, and PsycINFO. Inclusion criteria were psychological and educational preparation of children for anaesthesia and anxiety reduction. The titles of papers and abstracts were reviewed and full copies of selected papers were scrutinized.

RESULTS

Forty-four empirical studies were identified. Twenty-one articles described preoperative preparation programmes, twelve examined the effects of distractive techniques and eleven reported the effect of parental presence during anaesthesia's induction. Some general characteristics of the different interventions are discussed together with some key psychological and educational factors mediating anxiety in children undergoing anaesthesia.

CONCLUSION

The effectiveness of interventions were linked to several factors. Psychological and contextual aspects are discussed. Psycho-educational activities should be better described when reporting their effectiveness in children's preparation for an anaesthesia.

PRACTICE IMPLICATIONS

Patient and family characteristics together with organizational and systemic aspects are described in order to guide the choice of the most appropriate preparation method for diverse health care setting.

Clinical effects of sevoflurane anesthesia induction with a portable inhalational anesthetic circuit in pediatric patients

INTRODUCTION

Pediatric anesthesia induction with sevoflurane usually needs a special vaporizer and gas source, which limits its use to the operating room (OR). Many children feel anxious and cry when entering the OR because of being separated from their parents, which impairs anesthesia safety and their physical and mental health. In this study, we used a portable circuit to perform sevoflurane anesthesia induction outside the OR, assessed its effects and compared them with those of ketamine anesthesia in pediatric patients.

MATERIAL AND METHODS

One hundred children had anesthesia induced with either sevoflurane (sevoflurane group) through the portable inhalational anesthetic circuit, or ketamine by intramuscular injection (ketamine group), then were transferred to the OR. Peak inspired concentration (Cp) and steady state concentration (Cs) of sevoflurane were measured. Heart rate (HR) and saturation of peripheral oxygen (SpO2) were monitored. Time for anesthesia induction, awakening, leaving the OR and duration of the operation were recorded. The patients' reaction during anesthesia was also analyzed.

RESULTS

The Cp and Cs of sevoflurane were correlated with bodyweight. Compared with the ketamine group, the sevoflurane group showed shorter time for anesthesia induction (28 ±7 s vs. 195 ±34 s, p < 0.0001), awakening (11.2 ±3.6 s vs. 63.5 ±6.7 s, p < 0.0001) and leaving the OR (20.5 ±5.6 s vs. 43.4 ±10.6, p < 0.0001), less noncooperation during anesthesia induction (10% vs. 80%, p < 0.0001), lower HR (130 ±16 beats/min vs. 143 ±19 beats/min, p = 0.0004) and higher SpO2 (98.9 ±0.9% vs. 96.1 ±2.5%, p < 0.0001) on arrival at the OR.

CONCLUSIONS

Pediatric anesthesia induction by sevoflurane with the portable inhalational anesthetic circuit is convenient, safe and effective outside the OR.

Non-pharmacological interventions for assisting the induction of anaesthesia in children

BACKGROUND

Induction of general anaesthesia can be distressing for children. Non-pharmacological methods for reducing anxiety and improving co-operation may avoid the adverse effects of preoperative sedation.

OBJECTIVES

To assess the effects of non-pharmacological interventions in assisting induction of anaesthesia in children by reducing their anxiety, distress or increasing their co-operation.

SEARCH METHODS

In this updated review we searched CENTRAL (the Cochrane Library 2012, Issue 12) and searched the following databases from inception to 15 January 2013: MEDLINE, EMBASE, PsycINFO and Web of Science. We reran the search in August 2014. We will deal with the single study found to be of interest when we next update the review.

SELECTION CRITERIA

We included randomized controlled trials of a non-pharmacological intervention implemented on the day of surgery or anaesthesia.

DATA COLLECTION AND ANALYSIS

At least two review authors independently extracted data and assessed risk of bias in trials.

MAIN RESULTS

We included 28 trials (2681 children) investigating 17 interventions of interest; all trials were conducted in high-income countries. Overall we judged the trials to be at high risk of bias. Except for parental acupuncture (graded low), all other GRADE assessments of the primary outcomes of comparisons were very low, indicating a high degree of uncertainty about the overall findings. Parental presence: In five trials (557 children), parental presence at induction of anaesthesia did not reduce child anxiety compared with not having a parent present (standardized mean difference (SMD) 0.03, 95% confidence interval (CI) -0.14 to 0.20). In a further three trials (267 children) where we were unable to pool results, we found no clear differences in child anxiety, whether a parent was present or not. In a single trial, child anxiety showed no significant difference whether one or two parents were present, although parental anxiety was significantly reduced when both parents were present at the induction. Parental presence was significantly less effective than sedative premedication in reducing children's anxiety at induction in three trials with 254 children (we could not pool results). Child interventions (passive): When a video of the child's choice was played during induction, children were significantly less anxious than controls (median difference modified Yale Preoperative Anxiety Scale (mYPAS) 31.2, 95% CI 27.1 to 33.3) in a trial of 91 children. In another trial of 120 children, co-operation at induction did not differ significantly when a video fairytale was played before induction. Children exposed to low sensory stimulation were significantly less anxious than control children on introduction of the anaesthesia mask and more likely to be co-operative during induction in one trial of 70 children. Music therapy did not show a significant effect on children's anxiety in another trial of 51 children. Child interventions (mask introduction): We found no significant differences between a mask exposure intervention and control in a single trial of 103 children for child anxiety (risk ratio (RR) 0.59, 95% CI 0.31 to 1.11) although children did demonstrate significantly better co-operation in the mask exposure group (RR 1.27, 95% CI 1.06 to 1.51). Child interventions (interactive): In a three-arm trial of 168 children, preparation with interactive computer packages (in addition to parental presence) was more effective than verbal preparation, although differences between computer and cartoon preparation were not significant, and neither was cartoon preparation when compared with verbal preparation. Children given video games before induction were significantly less anxious at induction than those in the control group (mYPAS mean difference (MD) -9.80, 95% CI -19.42 to -0.18) and also when compared with children who were sedated with midazolam (mYPAS MD -12.20, 95% CI -21.82 to -2.58) in a trial of 112 children. When compared with parental presence only, clowns or clown doctors significantly lessened children's anxiety in the operating/induction room (mYPAS MD -24.41, 95% CI -38.43 to -10.48; random-effects, I² 75%) in three trials with a total of 133 children. However, we saw no significant differences in child anxiety in the operating room between clowns/clown doctors and sedative premedication (mYPAS MD -9.67, 95% CI -21.14 to 1.80, random-effects, I² 66%; 2 trials of 93 children). In a trial of hypnotherapy versus sedative premedication in 50 children, there were no significant differences in children's anxiety at induction (RR 0.59, 95% CI 0.33 to 1.04). Parental interventions: Children of parents having acupuncture compared with parental sham acupuncture were less anxious during induction (mYPAS MD -17, 95% CI -30.51 to -3.49) and were more co-operative (RR 1.59, 95% CI 1.01 to 2.53) in a single trial of 67 children. Two trials with 191 parents assessed the effects of parental video viewing but did not report any of the review's prespecified primary outcomes.

AUTHORS' CONCLUSIONS

This review shows that the presence of parents during induction of general anaesthesia does not diminish their child's anxiety. Potentially promising non-pharmacological interventions such as parental acupuncture; clowns/clown doctors; playing videos of the child's choice during induction; low sensory stimulation; and hand-held video games need further investigation in larger studies.

An evaluation of the effectiveness and safety of midazolam in children undergoing dental surgery

OBJECTIVE

The aim of this study was to evaluate the effectiveness and safety of oral midazolam in children undergoing dental surgery.

MATERIALS AND METHODS

A prospective, randomized, controlled trial was conducted to assess the effectiveness and safety of midazolam in children. Patients aged 2-9 years who underwent dental surgery under general anesthesia were randomly allocated into one of the four groups: midazolam 0.2mg/kg dose group (n=30); midazolam 0.21-0.4mg/kg dose group (n=15); midazolam more than 0.41mg/kg dose group (n=15) or the placebo group (n=31). The effectiveness of midazolam on sedation was assessed by the evaluation of vital signs, such as the respiratory and heart rate, oxygen saturation and the patients' reactive behaviors, in comparison with the placebo.

RESULTS

The scores of the ratings for sleep, movement and crying, as well as patients' reactions at the moment of separation from their parents and their collaboration with the staff were statistically significantly better among patients who received oral midazolam compared with the placebo. There were statistically significant direct correlations between the doses of midazolam and higher sleep, movement, crying and reaction scores 30min after premedication as well as higher scores of patients upon separation from their parents. There were only a few clinically insignificant side effects.

CONCLUSIONS

Oral midazolam, at a single dose from 0.2 to 0.6mg/kg, is effective and safe, and provides the expected sedative effects in children required by premedication for dental surgery.

Effects of sevoflurane versus other general anaesthesia on emergence agitation in children

BACKGROUND

Sevoflurane is an inhaled volatile anaesthetic that is widely used in paediatric anaesthetic practice. Since its introduction, postoperative behavioural disturbance known as emergence agitation (EA) or emergence delirium (ED) has been recognized as a problem that may occur during recovery from sevoflurane anaesthesia. For the purpose of this systematic review, EA has been used to describe this clinical entity. A child with EA may be restless, may cause self-injury or may disrupt the dressing, surgical site or indwelling devices, leading to the potential for parents to be dissatisfied with their child's anaesthetic. To prevent such outcomes, the child may require pharmacological or physical restraint. Sevoflurane may be a major contributing factor in the development of EA. Therefore, an evidence-based understanding of the risk/benefit profile regarding sevoflurane compared with other general anaesthetic agents and adjuncts would facilitate its rational and optimal use.

OBJECTIVES

To compare sevoflurane with other general anaesthetic (GA) agents, with or without pharmacological or non-pharmacological adjuncts, with regard to risk of EA in children during emergence from anaesthesia. The primary outcome was risk of EA; secondary outcome was agitation score.

SEARCH METHODS

We searched the following databases from the date of inception to 19 January 2013: CENTRAL, Ovid MEDLINE, Ovid EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCOhost), Evidence-Based Medicine Reviews (EBMR) and the Web of Science, as well as the reference lists of other relevant articles and online trial registers.

SELECTION CRITERIA

We included all randomized (or quasi-randomized) controlled trials investigating children < 18 years of age presenting for general anaesthesia with or without surgical intervention. We included any study in which a sevoflurane anaesthetic was compared with any other GA, and any study in which researchers investigated adjuncts (pharmacological or non-pharmacological) to sevoflurane anaesthesia compared with no adjunct or placebo.

DATA COLLECTION AND ANALYSIS

Two review authors independently searched the databases, decided on inclusion eligibility of publications, ascertained study quality and extracted data. They then resolved differences between their results by discussion. Data were entered into RevMan 5.2 for analyses and presentation. Comparisons of the risk of EA were presented as risk ratios (RRs) with 95% confidence intervals (CIs). Sevoflurane is treated as the control anaesthesia in this review. Sensitivity analyses were performed as appropriate, to exclude studies with a high risk of bias and to investigate heterogeneity.

MAIN RESULTS

We included 158 studies involving 14,045 children. Interventions to prevent EA fell into two broad groups. First, alternative GA compared with sevoflurane anaesthesia (69 studies), and second, use of an adjunct with sevoflurane anaesthesia versus sevoflurane without an adjunct (100 studies). The overall risk of bias in included studies was low. The overall Grades of Recommendation, Assessment, Development and Evaluation Working Group (GRADE) assessment of the quality of the evidence was moderate to high. A wide range of EA scales were used, as were different levels of cutoff, to determine the presence or absence of EA. Some studies involved children receiving potentially inadequate or no analgesia intraoperatively during painful procedures.Halothane (RR 0.51, 95% CI 0.41 to 0.63, 3534 participants, high quality of evidence) and propofol anaesthesia were associated with a lower risk of EA than sevoflurane anaesthesia. Propofol was effective when used throughout anaesthesia (RR 0.35, 95% CI 0.25 to 0.51, 1098 participants, high quality of evidence) and when used only during the maintenance phase of anaesthesia after sevoflurane induction (RR 0.59, 95% CI 0.46 to 0.76, 738 participants, high quality of evidence). No clear evidence was found of an effect on risk of EA of desflurane (RR 1.46, 95% CI 0.92 to 2.31, 408 participants, moderate quality of evidence) or isoflurane (RR 0.76, 95% CI 0.46 to 1.23, 379 participants, moderate quality of evidence) versus sevoflurane.Compared with no adjunct, effective adjuncts for reducing the risk of EA during sevoflurane anaesthesia included dexmedetomidine (RR 0.37, 95% CI 0.29 to 0.47, 851 participants, high quality of evidence), clonidine (RR 0.45, 95% CI 0.31 to 0.66, 739 participants, high quality of evidence), opioids, in particular fentanyl (RR 0.37, 95% CI 0.27 to 0.50, 1247 participants, high quality of evidence) and a bolus of propofol (RR 0.58, 95% CI 0.38 to 0.89, 394 participants, moderate quality of evidence), ketamine (RR 0.30, 95% CI 0.13 to 0.69, 231 participants, moderate quality of evidence) or midazolam (RR 0.57, 95% CI 0.41 to 0.81, 116 participants, moderate quality of evidence) at the end of anaesthesia. Midazolam oral premedication (RR 0.81, 95% CI 0.59 to 1.12, 370 participants, moderate quality of evidence) and parental presence at emergence (RR 0.91, 95% CI 0.51 to 1.60, 180 participants, moderate quality of evidence) did not reduce the risk of EA.One or more factors designated as high risk of bias were noted in less than 10% of the included studies. Sensitivity analyses of these studies showed no clinically relevant changes in the risk of EA. Heterogeneity was significant with respect to these comparisons: halothane; clonidine; fentanyl; midazolam premedication; propofol 1 mg/kg bolus at end; and ketamine 0.25 mg/kg bolus at end of anaesthesia. With investigation of heterogeneity, the only clinically relevant changes to findings were seen in the context of potential pain, namely, the setting of adenoidectomy/adenotonsillectomy (propofol bolus; midazolam premedication) and the absence of a regional block (clonidine).

AUTHORS' CONCLUSIONS

Propofol, halothane, alpha-2 agonists (dexmedetomidine, clonidine), opioids (e.g. fentanyl) and ketamine reduce the risk of EA compared with sevoflurane anaesthesia, whereas no clear evidence shows an effect for desflurane, isoflurane, midazolam premedication and parental presence at emergence. Therefore anaesthetists can consider several effective strategies to reduce the risk of EA in their clinical practice. Future studies should ensure adequate analgesia in the control group, for which pain may be a contributing or confounding factor in the diagnosis of EA. Regardless of the EA scale used, it would be helpful for study authors to report the risk of EA, so that this might be included in future meta-analyses. Researchers should also consider combining effective interventions as a multi-modal approach to further reduce the risk of EA.

[Effects of ketamine and midazolam on emergence agitation after sevoflurane anaesthesia in children receiving caudal block: a randomized trial]

BACKGROUND AND OBJECTIVES

Emergence agitation is a common postanaesthetic problem in children after sevoflurane anaesthesia. We aimed to compare the effects of ketamine and midazolam administered intravenously, before the end of surgery, for prevention of emergence agitation in children who received caudal block for pain relief under sevoflurane anaesthesia.

METHODS

62 American Society of Anesthesiologists patient classification status I children, aged 2-7 years, scheduled for inguinal hernia repair, circumcision or orchidopexy were enrolled to the study. Anaesthesia was induced with sevoflurane 8% in a mixture of 50% oxygen and nitrous oxide. After achieving adequate depth of anaesthesia, a laryngeal mask was placed and then caudal block was performed with 0.75mLkg(-1), 0.25% bupivacaine. At the end of the surgery, ketamine 0.25mgkg(-1), midazolam 0.03mgkg(-1) and saline were given to ketamine, midazolam and control groups, respectively. Agitation was assessed using Paediatric Anaesthesia Emergence Delirium scale and postoperative pain was evaluated with modified Children's Hospital of Eastern Ontario Pain Scale.

RESULTS AND CONCLUSIONS

Modified Children's Hospital of Eastern Ontario Pain Scale scores were found higher in control group than in ketamine and midazolam groups. Paediatric Anaesthesia Emergence Delirium scores were similar between groups. Modified Children's Hospital of Eastern Ontario Pain Scale and Paediatric Anaesthesia Emergence Delirium scores showed a significant decrease by time in all groups during follow-up in postanaesthesia care unit. The present study resulted in satisfactory Paediatric Anaesthesia Emergence Delirium scores which are below 10 in all groups. As a conclusion, neither ketamine nor midazolam added to caudal block under sevoflurane anaesthesia did show further effect on emergence agitation. In addition, pain relief still seems to be the major factor in preventing emergence agitation after sevoflurane anaesthesia.

Effect of ketorolac on the prevention of emergence agitation in children after sevoflurane anesthesia

Background

The purpose of this study was to evaluate the effects of ketorolac on the incidence and severity of emergence agitation in children recovering from sevoflurane anesthesia.

Methods

Eighty-five children aged 3 to 7 years were randomly assigned to the control group or the ketorolac group (1 mg/kg ketorolac). The children were evaluated by the Pediatric Anesthesia Emergence Delirium Scale and a four-point agitation scale.

Results

The median agitation scores did not differ significantly between the two groups. The overall incidence of emergence agitation was similar in the two groups (41% in the control group vs. 32% in the ketorolac group, P = 0.526). The number of children who received rescue drugs for treatment of emergence agitation was not significantly different between the two groups.

Conclusions

The administration of 1 mg/kg of ketorolac is not effective in decreasing the incidence and severity of emergence agitation in children aged 3 to 7 years after sevoflurane anesthesia.

A psychological preoperative program: effects on anxiety and cooperative behaviors

AIM

To evaluate the effectiveness of a psychological preoperative program in reducing preoperative anxiety and in promoting compliance of pediatric participants with surgical procedures.

METHODS

Fifty children and their mothers were subjected to two conditions of treatment to investigate whether psychological preparation activities and psychologist's support during all phases of the operatory iter (group 1) were as efficient in reducing mothers' and child's anxiety and in increasing the child's compliance as distraction activities (group 2). The observed child anxiety was assessed using mYPAS; compliant behaviors with Induction Compliance Checklist; and mothers' anxiety with Amsterdam Pre-operative Anxiety and Information Scale.

RESULTS

Children of the first group were less anxious and more cooperative in the preoperative period and during anesthesia induction than in the other condition. The psychological program was also more efficient in reducing mothers' anxiety. Finally, the mothers of group 1 showed a significantly higher satisfaction and judged as significantly more effective the program proposed to prepare their children than the mothers of group 2.

CONCLUSIONS

Preparing children through playful dramatization of the operative procedure, manipulation of medical instruments and psychologist's support may be useful in pediatric surgery structures.

A comparison of inhalational inductions for children in the operating room vs the induction room

BACKGROUND

There has been debate about the use of an induction room (IR) compared with an operating room (OR) for inhalational induction in children. The quality of the anesthesia induction between these two physical environments has not been studied previously. We sought to compare child distress, OR utilization and efficiency, and parental satisfaction and safety, between an IR and an OR.

METHODS

In a prospective observational study, we studied 501 developmentally appropriate children ages 1-14 years, American Society of Anesthesiologists (ASA) physical status I-III, presenting for the inhalational induction of anesthesia, undergoing outpatient or outpatient-admit ENT surgery. Inductions were performed in an IR (IR group) or OR (OR group) with parent(s) present. Child behavioral compliance was assessed using the Induction Compliance Checklist (ICC), a validated observational scale from 0 to 10 consisting of 10 behaviors; an ICC score ≥4 was considered poor behavioral compliance. Times for transport, anesthesia start, ready for surgery, surgery finish, out of OR, and total case process times were recorded. OR utilization and OR efficiency was derived using these times. Data on number and experience of clinical providers were also collected. Parent satisfaction with the induction was measured using a satisfaction survey. Safety was measured by recording respiratory complications during induction. The chi-squared test was conducted to determine whether induction location was associated with level of behavioral compliance. A multivariable proportional odds model was used to control for risk factors. OR utilization and efficiency were analyzed using the Wilcoxon-Mann-Whitney test.

RESULTS

There were no significant differences in ICC scores between the groups (P-value = 0.12). Anesthesia, nonoperative, and transport time were statistically less in the OR group when compared with the IR group, although total case process times were similar in both groups. While OR efficiency was significantly higher for the OR group (P-value = 0.0096), OR utilization did not differ between groups (P-value = 0.288). The OR group had a significantly higher number of anesthesia providers and a more experienced surgical team. Parents in the two groups were equally satisfied with their experience during induction, and none of the subjects had respiratory complications during the anesthesia induction.

CONCLUSIONS

We found no differences in child distress, parent satisfaction, and respiratory complications between inductions conducted in the IR vs the OR. Differences in utilization, efficiency, and turnover were minimal and not operationally significant. Capital equipment, space, and staffing strategies should be key drivers in considerations for the use of IRs, and in the design of ORs with IRs.

Midazolam is associated with delay in recovery and agitation after ambulatory general anesthesia for dental treatment in patients with disabilities: a retrospective cohort study

PURPOSE

Some patients with intellectual disabilities (IDs) who undergo total intravenous anesthesia (TIVA) have complications associated with the anesthesia such as prolonged recovery. The purposes of this study were to estimate the frequency of TIVA complications among patients with IDs and to identify factors associated with TIVA complications.

MATERIALS AND METHODS

This study was designed as a retrospective cohort study. Study samples were selected from the clinical records of patients with IDs who underwent ambulatory general anesthesia in a special dental clinic at the Okayama University Hospital, Okayama, Japan. Predictor variables were patient background, anesthesia-related variables, and dental treatment. Outcome variables were delayed recovery and the complication of agitation. Factors affecting delayed recovery and complications were examined with multivariable analysis.

RESULTS

We enrolled 106 cases (81 male and 25 female patients) in this study. The mean age was 23.9 years. Serious complications were not observed in any cases. The amount of intravenous midazolam was an independent determinant of delayed recovery. Oral midazolam contributed to delayed recovery, although it is very useful for induction in patients with a high level of fear. Oral midazolam and a younger age were independent predictors of agitation.

CONCLUSIONS

Intravenous midazolam may not have an advantage in ambulatory general anesthesia. Oral midazolam contributes to delayed recovery and is an independent predictor of agitation.

[Parental presence in the operating room: effect on the quality of anesthetic induction and postoperative agitation in children]

BACKGROUND AND OBJECTIVE

Various nonpharmacologic strategies for reducing anxiety in children and improving cooperation during induction of anesthesia have been investigated. Parental presence during anesthetic induction has been the alternative studied most often, especially in English-speaking populations. Mixed results have been reported, however. The aim of this study was to evaluate the quality of anesthetic induction and the development of postoperative agitation in Spanish children undergoing ear, nose, or throat surgery with or without parental presence in the operating room.

PATIENTS AND METHODS

Children in American Society of Anesthesiologists class 1 or 2 who were scheduled for ear, nose or throat surgery under inhalation anesthesia were randomized to 2 groups for presence or absence of a parent in the operating room. The induction experience was classified as easy, carried out with moderate resistance, or traumatic. The postoperative period was assessed as easy or traumatic.

RESULTS

Forty children were randomized. Time to onset of anesthesia was similar in the 2 groups. Induction was easy for 65% of the children with parental presence and for 25% of the children without a parent present (P < .05). Induction was traumatic for 25% in the parental presence group and for 35% in the parental absence group (P < .05). The incidence of moderate resistance during induction was similar in the 2 groups; the quality of the postoperative experience was also similar.

CONCLUSIONS

Parental presence during induction of inhalation anesthesia improves the induction experience of nonpremeditated Spanish children, increasing the incidence of easy induction and decreasing the presence of traumatic induction. The quality of the postoperative experience is similar.

Pharmacological prevention of sevoflurane- and desflurane-related emergence agitation in children: a meta-analysis of published studies

BACKGROUND

Emergence agitation (EA) in children is increased after sevoflurane anaesthesia. The efficacy of prophylactic treatment is controversial. The aim of this study was to provide a meta-analysis of the studies of the pharmacological prevention of EA in children.

METHODS

A comprehensive literature search was conducted to identify clinical trials that focused on the prevention of EA in children anaesthetized with sevoflurane, desflurane, or both. The data from each trial were combined using the Mantel-Haenszel model to calculate the pooled odds ratio (OR) and 95% confidence interval. I(2) statistics were used to assess statistics heterogeneity and the funnel plot and the Begg-Mazumdar test to assess bias.

RESULTS

Thirty-seven articles were found which included a total of 1695 patients in the intervention groups and 1477 in the control ones. Midazolam and 5HT(3) inhibitors were not found to have a protective effect against EA [OR=0.88 (0.44, 1.76); OR=0.39 (0.12, 1.31), respectively], whereas propofol [OR=0.21 (0.16, 0.28)], ketamine [OR=0.28 (0.13, 0.60)], alpha(2)-adrenoceptors [OR=0.23 (0.17, 0.33)], fentanyl [OR=0.31 (0.18, 0.56)], and peroperative analgesia [OR=0.15 (0.07, 0.34)] were all found to have a preventive effect. Subgroup analysis according to the peroperative analgesia given does not affect the results.

CONCLUSIONS

This meta-analysis found that propofol, ketamine, fentanyl, and preoperative analgesia had a prophylactic effect in preventing EA. The analgesic properties of these drugs do not seem to have a role in this effect.

Quality of recovery from two types of general anesthesia for ambulatory dental surgery in children: a double-blind, randomized trial

BACKGROUND

Pediatric dental procedures are increasingly performed under general anesthesia because of the inability to cooperate, situational anxiety, or other behavioral problems. Volatile anesthetics have been associated with emergence delirium in children, whereas the use of propofol for anesthetic maintenance has been shown to reduce the incidence of emergence delirium after other types of surgeries. The aim of this study is to compare a sevoflurane-based anesthetic with a propofol-based technique as it relates to the incidence of emergence delirium and the quality of recovery after pediatric dental surgery, in patients who present with risk factors for perioperative behavioral issues.

METHODS

We prospectively collected data of 179 pediatric patients scheduled for ambulatory dental surgery using a double-blind and randomized trial design. Subjects were anesthetized following standardized protocols for either a sevoflurane- or a propofol-based technique. The incidence of emergency delirium, as measured by the Pediatric Anesthesia Emergence Delirium score, was the primary outcome. Secondary outcomes included the incidence of postoperative nausea and vomiting (PONV), number of nursing interventions in the recovery room, time to discharge readiness, and parental satisfaction.

RESULTS

We found no difference in the incidence of emergence delirium after both types of anesthesia. However, use of sevoflurane significantly increased both the risk of PONV and the number of postoperative nursing interventions. Discharge criteria were met about 10 min earlier in patients anesthetized with sevoflurane. Parental satisfaction was equally high with both anesthesia regimens.

CONCLUSIONS

A propofol-based anesthetic technique did not lead to a lower incidence of emergence delirium after dental surgery in children but did result in significantly less PONV and fewer postoperative nursing interventions.

Non-pharmacological interventions for assisting the induction of anaesthesia in children

BACKGROUND

Induction of general anaesthesia can be distressing for children. Non-pharmacological methods for reducing anxiety and improving co-operation may avoid the adverse effects of preoperative sedation.

OBJECTIVES

To assess the effects of non-pharmacological interventions in assisting induction of anaesthesia in children by reducing their anxiety, distress or increasing their co-operation.

SEARCH STRATEGY

We searched CENTRAL (The Cochrane Library 2009, Issue 1). We searched the following databases from inception to 14th December 2008: MEDLINE, PsycINFO, CINAHL, DISSERTATION ABSTRACTS, Web of Science and EMBASE.

SELECTION CRITERIA

We included randomized controlled trials of a non-pharmacological intervention implemented on the day of surgery or anaesthesia.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed risk of bias in trials.

MAIN RESULTS

We included 17 trials, all from developed countries, involving 1796 children, their parents or both. Eight trials assessed parental presence. None showed significant differences in anxiety or co-operation of children during induction, except for one where parental presence was significantly less effective than midazolam in reducing children's anxiety at induction. Six trials assessed interventions for children. Preparation with a computer package improved co-operation compared with parental presence (one trial). Children playing hand-held video games before induction were significantly less anxious than controls or premedicated children (one trial). Compared with controls, clown doctors reduced anxiety in children (modified Yale Preoperative Anxiety Scale (mYPAS): mean difference (MD) 30.75 95% CI 15.14 to 46.36; one trial). In children undergoing hypnosis, there was a nonsignificant trend towards reduced anxiety during induction (mYPAS < 24: risk ratio (RR) 0.59 95% CI 0.33 to 1.04 - 39% versus 68%: one trial) compared with midazolam. A low sensory environment improved children's co-operation at induction (RR 0.66, 95% CI 0.45 to 0.95; one trial) and no effect on children's anxiety was found for music therapy (one trial).Parental interventions were assessed in three trials. Children of parents having acupuncture compared with parental sham-acupuncture were less anxious during induction (mYPAS MD 17, 95% CI 3.49 to 30.51) and more children were co-operative (RR 0.63, 95% CI 0.4 to 0.99). Parental anxiety was also significantly reduced in this trial. In two trials, a video viewed preoperatively did not show effects on child or parental outcomes.

AUTHORS' CONCLUSIONS

This review shows that the presence of parents during induction of general anaesthesia does not reduce their child's anxiety. Promising non-pharmacological interventions such as parental acupuncture; clown doctors; hypnotherapy; low sensory stimulation; and hand-held video games needs to be investigated further.

Children in day surgery: clinical practice and routines. The results from a nation-wide survey

BACKGROUND

Day surgery is common in paediatric surgical practice. Safe routines including parental and child information in order to optimise care and reduce anxiety are important. Most day surgery units are not specialised in paediatric care, which is why specific paediatric expertise is often lacking.

METHODS

We studied the practice of paediatric day surgery in Sweden by a questionnaire survey sent to all hospitals, obtaining an 88% response rate. Three specific paediatric cases were enquired for in more detail.

RESULTS

The proportion of paediatric day surgery vs. in-hospital procedures was 46%. Seventy-one out of 88 responding units performed paediatric day surgery. All units had anxiolytic pre-medication as a routine in 1-6-year-olds, and in 7-16-year-olds at 60% of the units. Most units performed circumcision and adenoidectomy, while 33% performed tonsillectomy. Anaesthesia induction was intravenous in older children, and also in 1-6-year-olds at 50% of the units. Parental presence at induction was mandatory. Post-operatively, 93% of units routinely assessed pain. Paracetamol and NSAIDs were the most common analgesics, as monotherapy or combined with rescue medication in the recovery as IV morphine. At 42% of units, take-home bags of analgesics were provided, covering 1-3 days of treatment. Pain was the most frequent complaint on follow-up. Micturition difficulties were common after circumcision, nausea after adenoidectomy and nutrition difficulties after tonsillectomy.

CONCLUSIONS

In Sweden, most day surgery units perform paediatric surgery, most children receive pre-medication, anaesthesia is induced IV and take-home analgesics paracetamol and or NSAIDs are often provided. Still, pain is a common complaint after discharge.

Induction and emergence behavior of children undergoing general anesthesia correlates with maternal salivary amylase activity before the anesthesia

BACKGROUND

The parents of the children who undergo surgery experience stress during the pre-anesthetic period. Such stress influences the mental status of their children, thereby inducing their pre-anesthetic anxiety and problematic behavior at emergence. Recently, measurement of salivary biomarkers was evaluated as stress biomarkers. Especially, alpha-amylase is utilized as an excellent index for psychological stress. In the present study, we tested whether salivary amylase activity of mothers before the surgery of their children correlates with the peri-operative children's behaviors.

METHODS

A total of 22 pairs of mothers and children were analyzed. Maternal salivary amylase activity was evaluated at the entrance of the operation room. The children underwent minor plastic surgery under general anesthesia, and induction and emergence behaviors were assessed.

RESULTS

The higher the maternal salivary amylase activity, the severer the children's induction anxiety (r(s)=-0.667, n=22, P<0.0001), and the higher the maternal amylase activity, the severer the children's emergence agitation (r(s)=0.705, n=22, P<0.0001).

CONCLUSION

Induction and emergence behaviors of children undergoing general anesthesia significantly correlated with their respective maternal salivary amylase activity during the pre-anesthetic period.