Case Studies in Pediatric Anesthesia-4.preoperative - Anxiety

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Chapter

Preoperative Anxiety

4 Rebecca Evans and William D. Ryan

Parent-Related
A four-year-old female presents for a tonsillectomy.
She is accompanied by her mother and father. She is  High anxiety
extremely anxious and will not separate from her  Parents who use avoidance coping mechanisms
parents.  Parents who have undergone multiple medical
procedures
 Divorced parents
At What Age Are Patients Most Likely to Environment-Related
Develop Separation Anxiety?  Sensory overload and conflicting messages
Between 7–10 months of age, infants will become  Parental anxiety
anxious when being separated from their parents. The preoperative period is often a stressful and
This separation anxiety can persist throughout all anxiety-provoking phase for children and their
ages of childhood. family. It is not unusual for the parents to be
frightened and to project their fear and anxiety on
What Is the Incidence of Preoperative the child, thereby unintentionally contributing to the
child’s fear and anxiety. Increased parental anxiety is
Anxiety in Children? noted in parents of children less than one year of age,
Estimates reveal that at least 60% of children develop and in children with repeated hospital admissions.
significant fear and anxiety before surgery. Many
children and families list the separation from parents
and induction of anesthesia as the most stressful time What Are the Overall Benefits of
during the surgical experience. Reducing Preoperative Anxiety?
The most important outcomes related to preoperative
What Are the Risk Factors for distress in children are postoperative behavioral dis-
orders. These include nightmarish sleep disturbances,
Preoperative Anxiety in Children? feeding difficulties, apathy, withdrawal, increased
There are child, parent, and environmentally related level of separation anxiety, aggression toward author-
risk factors for children having preoperative anxiety. ity, fear of subsequent medical procedures and hos-
Child-Related
pital visits, and regressive behaviors such as bed
wetting. Although these disturbances are primarily
 Age: 1–5 years present within the first two postoperative weeks, in
 Poor previous experience with medical procedures some children they may last for several months. Much
 Chronic illness has been made of this issue in the recent literature,
 Shy/inhibited temperament but the concept is not new.
 Lack of developmental maturity/social Children who were anxious in the preoperative
adaptability period were found to have more postoperative pain,
 High cognitive ability require more pain medications while hospitalized and
 Not enrolled in daycare during their first 3 days at home, and have a greater

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Rebecca Evans and William D. Ryan

incidence of emergence delirium, postoperative anx- What Are the Methods Used to Reduce
iety, behavioral changes (apathy, withdrawal, enur-
esis, temper tantrums, eating disturbances), and Preoperative Anxiety?
sleep disturbances. In adults, increased preoperative Many different modalities have been used in an
anxiety is associated with poor postoperative clinical attempt to decrease fear and anxiety in patients and
and behavior recovery. their families. There are two broad categories of
interventions:
How Should You Prepare the Parents  Behavioral interventions: preoperative
preparation programs (child life therapy),
Prior to Induction? distraction techniques, parental presence at
One of the most important preoperative responsibil- induction, preoperative interview, and tour of
ities of the pediatric anesthesiologist is to allay anx- hospital and/or operating complex.
iety in the parents and other family members.
 Pharmacological/premedication: midazolam (IV,
During the preoperative visit the anesthesiologist, oral, nasal, or rectal routes of administration),
while talking to the parents, should initiate contact dexmedetomidine (oral or nasal).
and communication with the child. It does not
matter if the child is too young to understand or is
too premedicated to remember any events. The What Is the Efficacy of Behavioral
parents will key in on the anesthesiologist’s manner
and how he or she relates to the child. Asking chil-
Interventions?
dren about their interests and performing a simple In carefully performed and controlled studies, these
fist-bump will establish confidence and minimize aforementioned behavioral interventions do not fare
parental anxiety. much better than placebo in decreasing the incidence
A controversial issue in pediatric anesthesia is the of postoperative behavioral disturbances. Although
extent to which the anesthesiologist should reveal the distraction techniques are often effective for allaying
risks of anesthesia to the parents. Will this discussion anxious behavior during induction of anesthesia, pre-
increase or decrease parental (or child) anxiety? medication with an anxiolytic drug is the only proven
Should the anesthesiologist discuss the risk of death? intervention to decrease these undesirable outcomes.
What risks are appropriate to reveal? The answers to
these questions are not easily found and may partly What Are the Benefits and Risks
depend on the informed consent laws of the state in Associated with Parental Presence
which one practices. Studies universally demonstrate
that anxiety is decreased with more information, even During Induction?
though that information may allude to more harmful There is controversy surrounding the benefits to par-
risks. For example, in a questionnaire study, most ental presence during induction of anesthesia. Poten-
parents whose anesthesiologist mentioned the risk of tial benefits include reducing the need/amount of
death indicated they were satisfied to hear about this preoperative sedatives and avoidance of anxiety
rare risk. Many parents whose anesthesiologist did caused by parental separation. Parental presence
not specifically mention the risk of death indicated during induction has been correlated with greater
that it should have been mentioned. parent satisfaction with the anesthetic experience.
During the preoperative informed consent pro- However, parental presence can place additional
cess, it is helpful to know the modern-day risks of stress on the anesthesiologist, crowd the OR, and
general anesthesia in children. A study from the Mayo may not be all that effective in decreasing the child’s
Clinic revealed an incidence of cardiac arrest in anxiety.
anesthetized children (for noncardiac surgery) of 2.9 One randomized controlled trial found that only
per 10,000, although when attributed only to anes- children younger than 4 years of age who have a calm
thetic causes, the incidence decreased to 0.65 baseline personality, or who have a parent with a calm
per 10,000 anesthetics. Only a small percentage of baseline personality, benefit from parental presence
these patients were initially healthy prior to the during induction. Another study comparing parental
procedure. presence versus oral midazolam found that children

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4 Preoperative Anxiety

who were given midazolam were significantly less for midazolam. Few centers in the United States
anxious and more compliant than children with only administer intramuscular premedication, or place IV
parental presence during induction. However, seda- catheters preoperatively.
tive and parental presence together has been shown to There are various options for treatment of pre-
be more effective than sedative alone. Furthermore, operative anxiety. None, however, are ideal; each has
many parents are terrified as they observe the placing drawbacks. A benzodiazepine is the best treatment for
of a mask over their child’s face, watching their child preoperative anxiety. Options include midazolam, the
become limp as consciousness is lost, and the occa- most commonly administered premedication, and
sional episode of upper airway obstruction that may diazepam.
occur. Yet when queried, parents who have been with
their child in the OR during induction universally feel Midazolam
that they have done the right thing for their child and
Oral midazolam is the most common preoperative
are happy to have experienced a sense of
anxiolytic for children. This is because it possesses
schadenfreude.
most of the properties of the ideal premedication.
If a decision is made to allow a parent into the OR
The one exception is that it usually leaves a bitter
during induction, the anesthetist should fully explain
aftertaste when administered orally, even as a spe-
the events that will occur during induction. Three
cially formulated oral syrup and given with an apple
major points should be addressed:
juice chaser. Therefore, many children will attempt to
1. There should be an explanation of the nature of spit it out if it is not swallowed rapidly. After oral
the procedure and the possible effects on the child administration, the commercially available midazo-
(excitation, limpness, airway obstruction, etc.). lam syrup is rapidly absorbed from the stomach.
2. The parent must agree to leave immediately at any The absolute bioavailability of midazolam averages
time when requested by an OR staff member. 36%, within a variable and large range (9–71%). This
3. The parent must agree to leave immediately once large range in bioavailability is consistent with most
the child has lost consciousness. One of the oral medications administered to children. In a large
surgical team members or another OR staff study, the plasma concentration/time curves of mid-
member should accompany the parent from the azolam and its α-hydroxy metabolite were highly
OR to the parents’ smoking area. variable, and independent of the age of the child and
Some institutions will ask parents to sign a written the dose administered. Approximately 14% of chil-
agreement to these terms, as well as a waiver of dren who receive oral midazolam do not demonstrate
liability should parents suffer an injury secondary to effective anxiolysis.
fainting or other calamity. Caution should be observed in children who are
receiving erythromycin (or its derivatives), since it
can prolong the duration of action of midazolam via
What Premedication Can Be Used to cytochrome P-450 inhibition. In children who are
Reduce Preoperative Anxiety? currently receiving erythromycin, the midazolam
Premedication of pediatric patients prior to induction dose should be reduced by at least 50%.
of anesthesia can accomplish several goals, the pri- Clinical sedative effects are seen within 5–10 min-
mary one being anxiolysis, with a subsequent decrease utes of oral midazolam administration and appear to
in the incidence of postoperative negative behaviors. peak 15–30 minutes after administration. By 45 min-
Other indications include preinduction of anesthesia, utes, its sedative effects have dissipated in most
pain relief, drying of secretions prior to airway children. Pharmacodynamic studies indicate that sed-
manipulation, vagolysis, and decreasing the risk for ation level is directly correlated with plasma concen-
pulmonary aspiration of gastric contents. Preopera- tration of midazolam. Plasma midazolam
tive sedation may be administered via any route, the concentrations greater than 50 ng/mL are associated
most common being oral administration since the with adequate preoperative sedation. However,
vast majority of children do not have an existing IV plasma concentrations of midazolam do not correlate
catheter. Rectal premedication is acceptable in tod- with anxiety scores at the time of mask induction of
dlers, and in some centers the nasal route is preferred anesthesia.

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Rebecca Evans and William D. Ryan

The sedative effect of midazolam is best described which can then be titrated to effect, depending on
as inebriation rather than sleepiness. Therefore, after the clinical situation.
administration, children should be confined to a bed
or their parent’s arms and be directly observed at all Diazepam
times by medical personnel. Clinically important car-
Since the advent of midazolam, diazepam has not
diorespiratory side effects are not observed in healthy
been used routinely for premedication of children.
children but may be seen in children at risk of upper
This is primarily due to its relatively long onset of
airway obstruction. Dysphoria may occur in some
action and greater duration of action. Diazepam may
children. Anterograde amnesia is a favorable clinical
be indicated for children or adolescents who require
effect following most doses of oral midazolam and
anxiolysis prior to approximately one hour before
may be responsible for the decrease in postoperative
surgery. It can be administered orally at a dose of
behavioral disturbances.
0.3 mg/kg. It should not be given IV because of the
Most anesthesiologists find that an oral dose of
extreme pain associated with injection.
0.5–0.7 mg/kg results in the best clinical efficacy.
However, a pharmacodynamic study showed that a
dose as low as 0.25 mg/kg results in reliable preopera- Clonidine
tive anxiolysis. There are no data to indicate the most Clonidine, an α2-adrenergic agonist, has been tested
appropriate maximum dose, but most anesthesiolo- as an orally administered sedative premedication in
gists use between 10 and 20 mg. children. In doses between 2 and 4 mcg/kg, oral
Studies are conflicting, but some evidence indi- clonidine will produce adequate sedation and anxio-
cates that midazolam premedication results in longer lysis prior to induction of general anesthesia.
times to discharge postoperatively following surgeries A distinct advantage of clonidine is its ability to
of relatively short duration. Nevertheless, its pre- decrease intraoperative anesthetic requirements.
operative advantages outweigh this disadvantage. However, its onset of action is greater than 90 min-
Nasal administration of midazolam can be accom- utes, so it is not suitable for use in the ambulatory
plished in the form of nose drops or a nasal spray. setting. Furthermore, when compared with oral mid-
The required dose (0.2–0.3 mg/kg) is lower than with azolam for children undergoing tonsillectomy, cloni-
oral administration and its reliability in producing dine provides less anxiolysis at the time of separation
anxiolysis is excellent. However, its administration is of the child from the caretaker and at induction of
associated with an unpleasant burning of the nasal anesthesia. An additional disadvantage of clonidine is
cavity and most children are quite upset following its its ability to blunt the heart rate response to adminis-
use. In addition, plasma concentrations of midazolam tration of atropine. For these reasons, clonidine is not
are generally higher after nasal administration when used routinely as a premedication in children.
compared to the oral route. Respiratory depression
has been reported on occasion following nasal admin- Ketamine
istration. For these reasons, pediatric anesthesiolo- Ketamine can be used as a premedication in children,
gists tend use the nasal route of administration in both oral and rectal forms. At a dose of 5 mg/kg, it
infrequently. reliably produces a state of sedation and disassoci-
If a child has a preexisting IV catheter, it should be ation within 20 minutes of its administration. Larger
used to administer midazolam. Pharmacokinetic doses have been associated with more reliable anxio-
studies indicate a β-elimination half-life of less than lysis at the expense of longer postoperative times to
two hours in children. The half-life of both midazo- awakening and discharge. Advantages of its use
lam and its major metabolite tend to increase with include a low incidence of respiratory depression,
advancing age during childhood. The onset of IV and a possible decrease in intraoperative anesthetic
midazolam is 2–3 minutes and the peak sedative effect requirements. It also possesses analgesic and amnestic
is shortly thereafter. The duration of action varies properties. Disadvantages include increased oral and
between two and six hours, with most of the sedative airway secretions, an increased incidence of post-
effect dissipating within 30 minutes of a single dose. operative emesis, and an occasional association with
A standard dose of IV midazolam is 0.05 mg/kg, adverse psychological reactions such as delirium,

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4 Preoperative Anxiety

dysphoria, nightmares, and hallucinations. These delayed adolescents who are unable to understand
latter effects have not been observed when ketamine their circumstances and will not cooperate with IV
has been used as a premedication. To date, studies catheter placement or inhalational induction. To
have not demonstrated any clear advantages of keta- reduce the volume of the amount injected, the con-
mine over midazolam as a premedication in children. centrated form (100 mg/mL) should be used, in a dose
However, it may be a useful substitute in children of 2–6 mg/kg. Larger doses result in greater efficacy at
known to exhibit dysphoric reactions to midazolam, the expense of longer times to emergence from gen-
or as an additive to midazolam in children who may eral anesthesia, especially for surgeries of relatively
be in pain, or difficult to calm. short duration. We prefer a lower dose with the
Intramuscular ketamine is used when children are modest goal of obtaining sufficient sedation to facili-
unusually combative and refuse all attempts at med- tate IV catheter insertion or mask induction. Some
ical attention, including refusal to ingest an oral pre- anesthesiologists will include atropine in the injectate
medication. It is most often used in developmentally in an attempt to reduce airway secretions.

Suggested Reading undergoing surgery: A hierarchical


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children: When a funny thing Analg. 1993;77:256–60. PMID:
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Anesthesiology. 1996;84:1060–7. happens on the way to the
PMID: 8623999. operating room. Anesthesiology. Maranets I, Kain ZN. Preoperative
2011;115(1):4–5. PMID: anxiety and intraoperative
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Parental presence during induction Analg. 1999; 89:1346–51. PMID:
of anesthesia vs. sedative Litman RS, Berger AA, Chhibber A. An
evaluation of preoperative anxiety 10589606.
premedication: Which intervention
is more effective? Anesthesiology. in a population of parents of infants McCann ME, Kain ZN. The
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Kain Z, Mayes L, Wang S, et al. Anaesth. 1996;6:443–7. PMID: Anesth Analg. 2001;93(1):
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premedicant for children

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