Mifflin, Katherine A. BSc(Hons)*†; Hackmann, Thomas MD, FRCPC‡§; Chorney, Jill MacLaren PhD, RPsych†|
Separation from parents, fear, or exposure to a foreign environment may cause children to display high levels of distress during anesthesia induction. Indeed, induction of anesthesia has been identified as the most stressful time for children throughout the perioperative process, and up to 50% of children display significant distress at this point.1,2 Distress during induction is not without consequence. Children who experience high levels of distress at anesthesia induction may have more pain during recovery, longer hospital stays, and more negative behavior changes after surgery.2 There is also evidence from other invasive procedures (e.g., immunization, venipuncture) that children who experience high levels of distress and anxiety at one point are less cooperative when undergoing further procedures and with repeated exposure may show increased distress and anxiety.3
Pediatric anesthesiologists typically use nonprocedural talk, game playing, and humor as distractions to dissipate fear and strive for smooth induction of anesthesia. Although using these verbal distraction strategies may be effective, they require skill and practice to implement, and anesthesiologists often revert to less-effective strategies (e.g., reassurance, restraint) when children become distressed.4 Recently, there has been attention to using stimuli as distractors in the operating room (OR). Patel et al. asked children to use handheld videogames during induction and found this to be more effective in reducing anxiety than parental presence or oral premedication.5 Others reported favorably on using an Apple iPhone™ as a useful method of distraction.6
There is a large body of research concerning the effectiveness of different distraction methods for children’s distress during general medical procedures. In particular, cartoon movies have been identified as an effective and easy to implement intervention.4 Cohen et al. used cartoons as an effective distractor during immunizations and in another study demonstrated that playing age-appropriate videos before medical procedures was a more effective distractor than was an interactive toy.7,8
Fairly recent advances in technology have made it possible for the monitors in OR suites, commonly used for video-assisted surgery, to connect to the Internet or other types of video feed. With this technology, it is possible to stream video clips for children during induction as a distraction method. Although it has been shown that cartoons and videos are effective distraction methods for minor medical procedures, these distraction techniques have not been studied in the perioperative setting. The goal of this study was to determine whether video distraction can be used as a clinical tool by anesthesiologists to help reduce anxiety in their pediatric patients. On the basis of the previous research with cartoon and video use in minor medical procedures, it was expected that playing a video clip during anesthesia induction would be effective at reducing anxiety.
Inclusion criteria were healthy children between the ages of 2 and 10 years, ASA physical status I or II, who had no previous exposure to anesthesia or surgery, and who presented for ambulatory surgery. Exclusion criteria were children requiring surgery for emergency indications (e.g., appendectomy), those with language barriers, those with developmental disabilities, and those taking psychoactive medications.
The State–Trait Anxiety Inventory was used to evaluate parents’ anxiety on the day of surgery.9 This is a self-report anxiety assessment instrument containing 2 separate, 20-item rating scales for measuring trait and state anxiety. Total scores for state and trait anxiety range from 20 to 80 each; higher scores denote higher levels of anxiety.
The Yale Preoperative Anxiety Scale (mYPAS) was used to evaluate children’s anxiety on the day of surgery.10 The mYPAS is an observational measure of preoperative anxiety consisting of 27 items in 5 domains (Activity, Emotional Expressivity, State of Arousal, Vocalization, and Use of Parents). The adjusted mYPAS total score ranges from 22.9 to 100, with higher scores indicating greater anxiety. An independent research assistant double-coded 20% of data to assess interrater reliability.
The study was approved by the institutional research ethics board. Written informed consent was obtained from parents or guardians of eligible children on the day of surgery. Assent was also obtained from children older than 8 years of age. Parents of the participants completed the State–Trait Anxiety Inventory and a general demographic questionnaire. The mYPAS was used to assess children’s baseline anxiety before surgery by a trained observer. After completing baseline measures, participants were assigned to either the experimental video distraction group or control using the method of sealed envelopes whose sequence had been determined by a random number generator. Participants in the video distraction group were then presented with a list of age-appropriate videos to choose from. Participants in the video distraction group were then asked what they enjoyed viewing at home, and a similar clip was found on YouTube™ for the child to view during induction. Allowing the participant to select the video not only allowed for parental approval of the video but also gave the child the opportunity to become familiar with the content, thus becoming engaged with the distractor and possibly avoiding anticipatory anxiety. All video clips used were found on the YouTube™ Website and were available in all ORs. Parental presence at anesthesia induction is optional at this institution but not actively promoted.
The mYPAS was used to assess child anxiety during the induction by the same trained observer. All children received a gentle mask induction. The stated goal was to provide gentle mask induction without causing emotional upset. Facemasks were unscented. Because all children were healthy, ASA class I or II, a pulse oximeter was the only monitor applied on induction. The children were encouraged to lie down for the induction but were permitted to remain sitting if they wished. Using a circle system, oxygen (2 L/min) and nitrous oxide (4 L/min) were offered for the first minute and then sevoflurane was added in increments to reach the maximum vaporizer setting of 8% within a few breaths.11 The remainder of the noninvasive monitors, electrocardiogram and blood pressure cuff, were applied after loss of consciousness. For patients in the control group, anesthesiologists used their usual distraction techniques (imagery, storytelling, game-playing, nonprocedural talk, or humor). The attention of the children in the video distraction group was directed to the large screens playing the preselected video clips while the mask was held close to their faces.
Power analyses were conducted using G*Power 126.96.36.199 Estimates of effect sizes were made on the basis of previously demonstrated effects of interventions for anxiety at anesthesia induction. Patel et al. demonstrated a 12.2-point difference in mean mYPAS scores between a control group and a group of children playing a video game at anesthesia induction.5 Kain et al. evaluated a multimodal, family-based preparation intervention and demonstrated a 15-point difference between mean scores between the preparation and no-preparation groups.13 In another study examining environmental influences on children’s anxiety at induction, Kain et al. found an approximate 18-point difference between mean mYPAS scores in a low sensory stimulation (low light, 1 person communicating with child) and a control condition.14 Assuming a mean control group mYPAS score of 55 and a mean intervention group mYPAS score of 40 (15-point difference) with an SD of 25, a corresponding effect size of 0.61 was used for these analyses. A sample size of 35 participants per group would provide 80% power to detect this effect size using nonparametric Mann–Whitney test with a set α of 0.05. Forty-five participants per group were to be recruited to account for attrition due to withdrawal of consent or change in anesthetic/surgical plan (e.g., rescue premedication needed).
Preliminary analyses were conducted to examine differences in demographic and baseline variables between groups: child age, parent anxiety, child anxiety in holding (t tests or Mann–Whitney), and interrater reliability (intraclass correlations). The primary outcome measure in the study is the mYPAS score. Scores on the mYPAS were not normally distributed and are therefore analyzed in the holding area and at induction using nonparametric tests (Mann–Whitney). Medians of each group and corresponding approximate 95% confidence intervals (CI) are reported. To better describe the difference between groups, we compared the score for each participant in the control group with the score of each participant in the video distraction group (resulting in 1974 difference scores).15 The median and approximate 95% CI of these differences are reported. Change in children’s anxiety from holding to induction were calculated by subtracting holding mYPAS scores from induction mYPAS scores (positive scores represent higher anxiety at induction than in holding; negative scores represent lower anxiety at induction). Change scores were normally distributed and were compared between groups using independent-samples t tests. Given that there was a small subset of children who had parents present at induction, analyses were repeated with these participants excluded to determine whether the effect of the intervention held.
Of the 99 candidates who were approached on the day of surgery, 7 declined to participate, and 1 did not meet the inclusion criteria. Of the remaining 91 patients, 47 were allocated to the control group and 44 to the video distraction group (Fig. 1). In the video distraction group, 1 patient withdrew consent and 1 patient received premedication. Thus, 89 participants were used for the main study analysis. Both video distraction (n = 42) and control groups (n = 47) were similar with respect to their ages, and their baseline characteristic measures (Table 1). Five children in the study had their parents present at anesthesia induction (3 in the control group and 2 in the video distraction group). Surgical services and types of operations (ear, nose, throat, 57; urology, 7; general surgery, 4; dentistry, 15; and 7 others) were comparable between groups as well. Intraclass correlation (ICC) revealed a strong relation between independent raters (ICC = 0.90, P < 0.001).
There was no significant difference between the control and video distraction groups on children’s anxiety in the holding area (Mann–Whitney U = 984.5, z = 0.21, P = 0.99). There was, however, a significant difference between the control and video distraction groups at anesthesia induction (Mann–Whitney U = 497.0, z = 4.11, P < 0.001) with children in the distraction group displaying less anxiety. Figure 2 shows the raw mYPAS scores in the control and video distraction groups at anesthesia induction. The median mYPAS score in the distraction group was 22.9 (95% CI, 22.9–35.4), and the median mYPAS score in the control group was 58.3 (95% CI, 50.0–68.8). The median of the differences between scores in each group was 31.2 (95% CI, 27.1–33.3). Results excluding the 5 children with parents present showed the same pattern of results. There was no significant difference between groups in holding (Mann–Whitney U = 856.0, z = 0.22, P = 0.83), except the video distraction group displayed less anxiety at induction than did the control group (Mann–Whitney U = 424.5, z = 4.17, P < 0.001). Figure 3 shows the change in children’s mYPAS scores from holding to induction. Children in the control group showed a significantly greater increase in anxiety from holding to induction than did children in the video distraction group (t(87) = 3.31, P < 0.001).
The purpose of the current study was to examine streamed video clips as a distraction intervention for children’s anxiety at anesthesia induction. Children were randomly assigned to distraction or no distraction, and children’s anxiety was assessed using the mYPAS.10 Results showed a significant difference between groups, with children in the video distraction group displaying less anxiety at anesthesia induction and having a smaller increase in anxiety from holding to induction than did children in the standard care group. The median mYPAS score at induction for children in the video distraction group was 22.9, which is well below the previously identified cutoff for identification of high anxiety of 30.2
Induction of anesthesia is commonly achieved in children with a facemask using inhalation anesthetics. Children typically display the greatest anxiety at induction (in comparison with other preoperative stages).1,2 Stressful experiences may impact pain and responses to future procedures (e.g., greater fear and less cooperation during later procedures).3 Therefore pediatric anesthesiologists have long sought ways to alleviate this unpleasant and upsetting stage. Allowing parents to be present during the induction in the hope of calming children and lessening their anxiety has gained widespread acceptance. However, several systematic reviews on parental presence have come to the conclusion that children do not necessarily benefit from their parents accompanying them to the ORs.16–18 Another approach is to offer sedative preoperative medication, mostly oral midazolam. This requires good timing and the child’s willingness to take the medication, and the medication is not universally effective.19 Additionally, investigators have evaluated nonpharmacologic methods to distract children and facilitate smooth induction of anesthesia by lessening anxiety.
A variety of imaginative approaches for distraction have been described. Such interventions have included preoperative preparation by child life specialists, dimming the OR lights, playing music, having clown doctors, and others.14,20–22 Video distraction techniques have been previously investigated in anxiety-provoking situations similar to the OR. One study in children undergoing dental treatment using video eyeglasses demonstrated that the glasses facilitated cooperative behavior, and there were reported high levels of patient satisfaction.23 Yet there is some conflicting evidence with regard to the use of video eyeglasses in adults, because some studies report reduced anxiety levels and others show no effect.24,25 This may be related to the difference in dental procedures being done and the use of nitrous oxide gas in addition to video glasses.
Patel et al. showed that having children play an interactive video game while receiving anesthesia by facemask was a better distractor than parental presence or oral midazolam.5 Moreover, these authors suggested that the interactive part of the videogame was more engaging than its video component, which would be ineffective because of its passive nature.5 The present study counters the notion that actively playing a videogame affords the distraction, because it was demonstrated that the passive act of watching a video clip is an effective distractor. This is consistent with literature from other medical procedures that suggests that interaction with the distractor is not necessary for effectiveness.8 Low and Pittaway anecdotally observed that children responded favorably to watching animated videos on an iPhoneTM while undergoing inhaled induction, again demonstrating the effectiveness of passive distraction methods.6 Because there is conflicting research regarding the use of passive and interactive distraction techniques, further research should examine differences in their relative effectiveness.
This study shows that streaming video clips provide a better means of distraction for children who undergo inhaled induction of anesthesia than the usual efforts of nonprocedural talk, humor, or game playing. The groups were comparable with respect to their ages, sex distribution, and preoperative child and parent anxiety scores. Because parents were present on induction for only 5% of cases, we were able to study a homogeneous group of nonpremedicated children who had no prior exposure to anesthesia or surgery. Inclusion or exclusion for this 5% did not change the effects of the intervention. Overall, the study demonstrated not only a statistically significant but also an effect that was larger than that found with a more intensive psychological preparation intervention.13 Unlike Patel et al.’s study, the use of existing equipment and technology avoided the added cost of video games, making video streaming an inexpensive distraction option.
A limitation of this study, and others of similar nature, is the possibility of observer bias, because the main dependent measure used is an observational scale and a single rater collected the data. Although the observer was blinded preoperatively before the randomization of subjects was revealed, we did not blind the observer during the induction phase. To account for possible observer bias, we used 2 coders for 20% of the observational data gathering. An interclass correlation showed that there were no significant differences in the 2 mYPAS coded scores (r = 0.9), indicating high interrater reliability. It is notable, however, that a high correlation does not necessarily mean lack of bias, because 1 observer may have been consistently recording scores that were higher or lower than the other. It is conceivable to have the induction sequence videotaped and the children’s anxiety rated by an independent, blinded observer, but we opted for simplicity in order not to inconvenience the OR staff and not to delay surgery. Although a major strength of this study is that it included a relatively homogenous sample, the exclusion of children who were premedicated limits generalizability to some contexts; further research will be needed to determine whether video distraction is effective for children who receive sedative premedication. Similarly, although including the few children with parental presence did not change the effects of video distraction, the sample of children with parents present in this study was relatively small, and further investigation is needed. Further studies should also include longer-term impacts of distraction intervention, including measures in the recovery room and at home. A final limitation of this study is that data on the behavior of anesthesiologists in the control group were not collected as part of this study. It is possible that anesthesiologists in the control group did not use best practices of distraction (e.g., game playing, humor), thus accounting for the relatively large difference between the control and video distraction groups. Although we do not have data to support this point, we do not believe this was the case. Anesthesiologists in this study were all trained pediatric practitioners and are very skilled in interacting with children at induction. Anecdotally, our observer saw many instances of anesthesiologists using distraction in the control group; a situation that we believe is representative of typical practice. Further studies should, however, consider observational measures of anesthesiologists’ behavior when evaluating interventions such as this one.
Overall, it was determined that video streaming during inhaled induction is an effective method of reducing anxiety for young children. This study presents empirical evidence to pediatric anesthesiologists to incorporate this distraction method into their practice to help reduce the anxiety of children who need anesthesia. E
Name: Katherine A. Mifflin, BSc(Hons).
Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.
Attestation: Katherine A. Mifflin has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.
Name: Thomas Hackmann, MD, FRCPC.
Contribution: This author helped design the study and write the manuscript.
Attestation: Thomas Hackmann approved the final manuscript.
Name: Jill MacLaren Chorney, PhD, RPsych.
Contribution: This author helped design the study, analyze the data, and write the manuscript.
Attestation: Jill MacLaren Chorney has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.
This manuscript was handled by: Peter J. Davis, MD.
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