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Anesthesia & Analgesia:
doi: 10.1213/ANE.0b013e31826af970
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Are Our Children All Right?

Cladis, Franklyn P. MD; Davis, Peter J. MD

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From the Department of Anesthesiology, Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.

Accepted for publication July 13, 2012.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Franklyn P. Cladis, MD, Department of Anesthesiology, Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, 4401 Penn Ave., Pittsburgh, PA 15224. Address e-mail to cladfp@anes.upmc.edu.

Reducing pain and fear in a child during the perioperative period is a paramount concern for patients, parents, and pediatric health care providers. Postoperative consequences of preoperative anxiety include emergence delirium, increased postoperative pain, poor eating and sleeping, and behavioral changes, such as increased separation anxiety and oppositional defiant behavior.1 Although the adverse effects typically last for approximately 2 weeks, they may persist for many months in a small percentage of children.2 Given these consequences, it would seem only reasonable to pursue therapeutic interventions that reduce preoperative anxiety and subsequent postoperative behavioral changes.

Oral midazolam is the only therapeutic intervention for preoperative anxiety that has demonstrated a reduction in postoperative outcomes. In a prospective blinded study, Kain et al.3 demonstrated a significant reduction in postoperative sequelae at 2 weeks in children treated preoperatively with 0.5 mg/kg oral midazolam. Unfortunately, midazolam comes with its own side effects. It is difficult to mask midazolam’s unpleasant taste, and some children refuse to take it. Intranasal administration is also unpleasant. Midazolam may cause disinhibition or a paradoxical reaction in a small percentage of children.4 Others have reported delayed discharge and negative postoperative behavioral changes.5,6

Nonpharmacologic alternatives have been pursued and include preoperative preparation programs, parental presence, use of toys, and environmental modifications including lighting and the number of personnel in the operating room.7 Distraction techniques with multimedia technology such as video games and iPhones present a unique opportunity in the preoperative environment.8 These techniques have been described in non-operative environments such as pediatric and dental offices, but have not been described in the preoperative setting. Two studies in this issue of Anesthesia & Analgesia investigated the use of video as a nonpharmacologic intervention to reduce preoperative anxiety in children having elective surgery.9,10

In a Canadian study, Mifflin et al.9 investigated the use of a preselected video to reduce anxiety. They prospectively randomized healthy children from 2 to 10 years of age to standard preoperative care that did not include midazolam versus a patient-selected YouTube video that was viewed during the inhaled induction of anesthesia. The authors used the Yale Preoperative Anxiety Scale to rate anxiety preoperatively and found a significant difference between the groups on induction of anesthesia. The median score in the video distraction group was below the level indicating anxiety. The median score in the control group was within the range suggesting anxiety.

In the study from South Korea, Lee et al.10 randomized children 3 to 7 years of age to 1 of 3 interventions during induction: preselected video, favorite toy, or no intervention (control). All children were accompanied by a parent into the operating room. Anxiety score as measured by the Yale Preoperative Anxiety Scale was significantly lower in the video distraction group (31) during induction compared with a toy or standard induction technique (43 and 57, respectively).

These 2 studies demonstrate the effectiveness of nonpharmacologic techniques to reduce preoperative anxiety. The authors have done a commendable job providing data that are both valid and applicable to our patient population. Both studies were prospective, randomized, and used the Yale Preoperative Anxiety Scale, which makes it easier to compare the results from 2 study sites. Both studies used similar inclusion and exclusion criteria. Parental presence posed a potential challenge but Lee et al. removed this confounding variable by allowing parental presence for all of their subjects.

Two findings are particularly interesting. First, video distraction was equally beneficial for both inhaled and IV induction of anesthesia. Second, the Yale Preoperative Anxiety Scale found almost no increase in anxiety when video distraction was used. These are similar to the results seen by Kain et al.3 with oral midazolam. It would seem that video distraction is equally effective to oral midazolam in reducing anxiety during the induction of anesthesia.

This is an important finding. A significant consequence of preoperative anxiety is adverse postoperative behavioral changes. If video distraction reduces preoperative anxiety to the same degree as midazolam, then video distraction might also reduce the postoperative behavioral changes. We do not know this, because the studies in this issue of the journal were not designed to assess postoperative changes in behavior. Additionally, because a Yale Preoperative Anxiety Scale score >30 is associated with high anxiety, and high anxiety is associated with negative postoperative behavioral outcomes, then even in the video intervention group (mean score = 31) in the study by Lee et al., approximately half of the children would still be at risk for behavioral disturbances after surgery.10

Without knowing how anxiety measurements at induction translate into negative postoperative behavior, it becomes difficult to evaluate the real impact of these interventions by Lee et al. and Mifflin et al. Although the current studies were not designed to answer this question, they have provided the framework to answer the real question: Are our children alright?

The authors are to be commended for demonstrating scientifically what many of us have seen in clinical practice and at home. Distraction is an incredibly powerful tool. Done properly, distraction is an effective tool to mitigate preoperative anxiety in children having elective surgery. Any technique that distracts, engages, or immerses the child in an alternate activity should achieve this beneficial effect. Video is particularly effective. Any one of us with children already knows this. Trying to interact with our children when “Cars” or “SpongeBob” is on television is futile. If our children can tune into their favorite alternative realities upon induction of anesthesia, then they may be alright.

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RECUSE NOTE

Dr. Peter J. Davis is the Section Editor for Pediatric Anesthesiology for Anesthesia & Analgesia. This manuscript was handled by Dr. Steven L. Shafer, Editor-in-Chief, and Dr. Davis was not involved in any way with the editorial process or decision.

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DISCLOSURES

Name: Franklyn P. Cladis, MD.

Contribution: This author helped write the manuscript.

Attestation: Franklyn P. Cladis approved the final manuscript.

Name: Peter J. Davis, MD.

Contribution: This author helped write the manuscript.

Attestation: Peter J. Davis approved the final manuscript.

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REFERENCES

1. Kain ZN, Wang SM, Mayes LC, Caramico LA, Hofstadter MB.. Distress during the induction of anesthesia and postoperative behavioral outcomes. Anesth Analg. 1999;88:1042–7

2. Kain ZN, Mayes LC, O’Connor TZ, Cicchetti DV. Preoperative anxiety in children: predictors and outcomes. Arch Pediatr Adolesc Med. 1996;150:1238–45

3. Kain Z, Mayes LC, Wang S, Hostadter MB.. Postoperative behavioral outcomes in children. Anesthesiology. 1999;90:758–65

4. Finley GA, Stewart SH, Buffett-Jerrott S, Wright KD, Millington D.. High levels of impulsivity may contraindicate midazolam premedication in children. Can J Anaesth. 2006;53:73–8

5. Viitanen H, Annila P, Viitanen M, Tarkkila P.. Premedication with midazolam delays recovery after ambulatory sevoflurane anesthesia in children. Anesth Analg. 1999;89:75–99

6. McGraw T, Kendrick A.. Oral midazolam premedication and postoperative behaviour in children. Paediatr Anaesth. 1998;8:117–21

7. Yip P, Middleton P, Cyna AM, Carlyle AV.. Non-pharmacological interventions for assisting the induction of anaesthesia in children. Cochrane Database Syst Rev. 2009;3:CD006447

8. Low DK, Pittaway AP.. The ‘iPhone’ induction: a novel use for the Apple iPhone. Paediatr Anaesth. 2008;18:573–4

9. Mifflin K, Hackman T, Chorney J.. Streamed video clips to reduce anxiety in children during inhalation induction of anesthesia. Anesth Analg. 2012;115:1162–7

10. Lee J, Lee J, Lim H, Son J, Lee J, Kim D, Ko S. . Cartoon distraction alleviates anxiety in children during induction of anesthesia. Anesth Analg. 2012;115:1168–73

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