Ambardekar, Aditee P. MD; Litman, Ronald S. DO; Schwartz, Alan Jay MD, MSEd
From the Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
Accepted for publication October 11, 2012.
Published ahead of print February 13, 2013
The authors declare no conflicts of interest.
Reprints will not be available from the authors.
Address correspondence to Aditee Ambardekar, MD, Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Main Bldg., 9th Floor, Room no. 9336, Philadelphia, PA 19104. Address e-mail to firstname.lastname@example.org.
Service and companion animals have increasingly become a part of pediatric and adult medical care. As their psychological and medical benefits become recognized in health care practice, anesthesiologists will interface with these important companions just as often as our nonsurgical colleagues. By incorporating service animals into our model of family-centered care, a widely accepted practice especially in pediatric medicine, we can improve the quality of the perioperative experience for our patients and their families. Allowing the presence of the service dog, as described below, is one such example. Parental consent was obtained for the use of photographs and publication of this case report.
A 12-year-old girl presented to the gastroenterology suite for esophagoduodenoscopy and esophageal manometry under general anesthesia to evaluate symptoms of dysphagia. Her medical history also included autism, postural orthostatic tachycardia syndrome, chronic pain related to scoliosis, and severe anxiety.
The patient was accompanied by her mother and service dog, which provided her anxiolysis and emotional support for her medical visits and procedures. The patient was admitted to the suite earlier in the day for IV placement and preprocedure fluid hydration to prevent anesthetic-induced hypotension. For her procedure, we planned an IV induction with 2% lidocaine and propofol, a natural airway, oxygen supplementation via nasal cannula, and propofol infusion for maintenance of general anesthesia.
In our institution, induction of general anesthesia in the gastroenterology suite often involves the presence of one or both parents in lieu of premedication with oral midazolam. The patient also requested presence of her service dog for induction. With agreement from the nursing and technician staff, we allowed the dog to be present at the patient’s side (Fig. 1). However, the patient became extremely upset when we began to administer the propofol. Therefore, at her request, we “allowed” her service dog to administer the propofol, which greatly calmed the patient (Fig. 2) and facilitated a smooth induction of general anesthesia.
Service animals are increasingly valued in the wellness of patients with mental and physical disabilities. Historically, specially trained dogs have been used to help integrate children with autism and improve their social and communication skills as part of their daily activities.1 Furthermore, the companionship that develops among the service dog, the autistic child, and the parents supports the family unit that can otherwise be strained by the presence of mental illness.2 Adults with physical disabilities have also benefited from the addition of a service dog; measures of psychological well-being, social integration, and physical independence are all improved.3
The biomedical literature supports the use of service or companion animals in decreasing the adrenergic reaction in response to stress in both adults and children. Hypertensive adults receiving angiotensin-converting enzyme-inhibitor therapy showed decreased lability in heart rate and arterial blood pressure responsiveness to stressful situations when in the presence of their companion dogs.4 Cortisol responsiveness in autistic children after the introduction of a service dog was blunted, and subsequent removal of the companion increased salivary cortisol levels to baseline high levels.5 Similarly, the presence of a companion dog during stressful medical and dental encounters alleviated anxiety in healthy children.6,7
The prevalence of service or companion dog use is difficult to ascertain. However, the increasing prevalence of children diagnosed with autism spectrum disorders is certain.8 There are wide variations among regions of the country and among races, but the overall prevalence has increased to 1 in 88 children compared with 1 in 110 children in 2004. With a growing body of literature pointing toward utility of service dogs in the daily routine and medical care of patients, we have begun to see the integration of these animals into the families and lives of patients for whom we provide anesthesia care.
Patient-centered and family-centered care has gained momentum in many fields within pediatric medicine. The American Academy of Pediatrics has developed specific recommendations for pediatricians in hospitals, clinics, and community settings to integrate family-centered care into their practice.9 Policy statements and technical reports from the American Academy of Pediatrics’ Committee on Pediatric Emergency Medicine have encouraged institutional policies for incorporation of family-centered practices.10,11 Neonatologists have developed and are implementing care plans for their practitioners to understand and integrate the medical, developmental, and psychosocial needs of patients and their families during the typical clinical course of a neonate. These care plans include methods for involving families as the care progresses from admission to discharge and also incorporate resources and strategies for family involvement during deviations in typical care, including clinical setbacks and even death.12 Our critical care colleagues are also advocating family presence during many aspects of pediatric critical care including daily work rounds, insertion of invasive monitors, and cardiopulmonary resuscitation.13 Without lengthening the time of rounds, families are more satisfied with the care they receive when they participate in the morning discussion and have special needs from the medical care team in the first 24 hours of admission to the pediatric intensive care unit.14 Even parents who witnessed resuscitative efforts had positive trends in their psychological health 3 months after an event.15
While there has been promotion of this philosophy of family-centered care in the perioperative period, specific practice guidelines and policy statements are not available for pediatric anesthesiologists.16 In many institutions, pharmacologic anxiolysis is standard unless a medical diagnosis or allergy precludes its administration; however, parental presence may be offered as an additional option as there is theoretical value in parental presence at induction for decreasing patient anxiety.
A Cochrane review summarizes 17 studies of 1796 patients in the value of parental and other nonpharmacologic interventions during induction of general anesthesia.17 While only 8 of these 17 studies were specifically related to the child’s anxiety level and cooperation with parental presence, none of these studies would suggest that parental presence universally diminished the child’s anxiety on mask induction. Without increasing the length of or compromising the safety at induction of general anesthesia, Kain et al.18 found that only children older than 4 years who were introspective or shy benefit from parental presence at induction as measured by a series of behavioral assessments and cortisol levels. Although parental presence at induction of anesthesia was not superior in reducing anxiety in the child when combined with oral midazolam, it did result in increased satisfaction of care by families.19
The Cochrane review goes on to suggest that we should explore nontraditional, nonpharmacologic interventions as these show promise in diminishing anxiety and improving cooperation during induction of general anesthesia.17 Minimizing sensory overload that often occurs in the operating rooms and preoperative distraction techniques using hypnosis, music therapy, video games, and clown doctors have in small, randomized, controlled trials shown to diminish anxiety in the child either preoperatively or at induction of general anesthesia.20–24
One such example of a nonpharmacologic intervention, especially for our growing population of special needs patients, is the presence of service dogs at induction of general anesthesia. As our case suggests, the simple extension of family-centered care to include these important care-facilitators makes a potentially traumatic experience less stressful for patients and their families. In this particular case, the dog’s presence was undoubtedly more feasible in the gastroenterology suite; concerns for maintaining sterility in the operating room will preclude the presence of such companions. One might consider, however, the use of an induction room whereby the dog’s presence would not compromise the sterility of the surgical procedure.
This case is an excellent example of incorporating family-centered care to improve the quality and satisfaction of patient care. With the growing number of children with special needs and an awareness of complementary methods to improve the well-being of our special needs population, we as pediatric anesthesiologists will be faced with these circumstances more often. An understanding of the service dog’s role and an appreciation for family-centered care is necessary to successfully care for these challenging patients.
Name: Aditee P. Ambardekar, MD.
Contribution: This author performed the literature search and helped prepare the manuscript.
Attestation: Aditee P. Ambardekar has approved the final manuscript.
Name: Ronald S. Litman, DO.
Contribution: This author obtained written parental consent, provided the images, and helped prepare the manuscript.
Attestation: Ronald S. Litman has approved the final manuscript.
Name: Alan Jay Schwartz, MD, MSEd.
Contribution: This author helped prepare the manuscript.
Attestation: Alan Jay Schwartz has approved the final manuscript.
This manuscript was handled by: Peter J. Davis, MD
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