Preoperative anxiety is observed in nearly half of children undergoing surgery.1 Children who are anxious preoperatively have more frequent emergence delirium and postoperative maladaptive behavior.2 In addition, these patients experience higher pain scores and have increased postoperative analgesic requirements.3 The beneficial effects of decreasing preoperative anxiety in the pediatric population are rarely disputed and various techniques to alleviate children’s anxieties have been reported. These techniques include distraction, premedication with an anxiolytics, and parental presence during induction of anesthesia (PPIA). Here we report a case where PPIA was associated with an unpredicted untoward event and discuss how the situation was handled.
A 7-year-old male (24.6 kg, 123 cm) presented for umbilical herniorraphy. His medical history was significant for mild asthma triggered by exercise and weather changes. The child had a prior anesthetic for dental rehabilitation performed at another hospital. At that time parental presence during induction was not conducted. During the preoperative interview for the herniorraphy, the mother expressed some hesitation to the anesthesiologist and surgeon in providing consent for the procedure. However, after consultation with another family member, the mother agreed to proceed because the child complained of periodic periumbilical abdominal pain and the mother understood the risks of hernia incarceration. During discussion of the anesthetic plan, the mother was against the administration of oral midazolam because she wished to limit the amount of medication that her child received for the procedure. An attempt was made to bring the child to the operating room, at which point the previously calm child became quite anxious and started crying and requested that his mother be present. The mother then also requested that she be allowed to be present for induction of anesthesia. After discussion with the mother about the expected events, the mother acknowledged understanding the upcoming events during induction of anesthesia and appeared cooperative. Accordingly, the parent and the patient were escorted to an induction room. With his mother present, the child appeared calm and accepted placement of a facemask and the administration of increasing doses of sevoflurane (up to 8%) in a nitrous oxide and oxygen mixture. The mother was fully engaged and encouraging to her son during anesthesia induction. As a member of the surgical team attempted to escort the mother out of the induction room, she turned back, picked her child off of the stretcher, and began to shake and call his name in an attempt to wake him. Consequently, the mother disconnected the child from all monitoring equipment. The anesthesia team called for additional help and attempted to control the mother. The members of the anesthesia team were able to observe that, while the child was anesthetized in his mother’s arms, the boy was breathing spontaneously. At the same time, a nurse was able to convince the mother that the safest course of action was to return her son to the induction room stretcher. After a few minutes the mother agreed and reluctantly handed him back to the anesthesia personnel. There were no signs of cyanosis or airway obstruction during the incident. A decision to abort the anesthetic was made. The patient soon emerged from anesthesia without exhibiting emergence delirium. The operative procedure was cancelled; the patient was transferred to the postanesthesia care unit and discharged upon meeting recovery criteria. After the incident the mother stated that the induction unexpectedly brought back traumatic memories of another incident from her life. She later called the anesthesiologist, apologized, and stated that she wished to reschedule the procedure.
For the last 40 years, our institution has adopted the practice of allowing and often encouraging induction of anesthesia with parental presence for healthy children older than 1 year and weighing <45 kg and who have no significant airway concerns. The case described above is the first episode where a parent attempted to remove her child from the induction room after induction of general anesthesia. To our knowledge, similar events have not been reported. For those providing care to children, the hazard associated with such an event are readily apparent. We had an anesthetized child who, albeit briefly, was unmonitored and the anesthesiologists had no access to the child’s airway. Furthermore, we had a distraught parent who, for unanticipated reasons, created and exposed her child to undue risk during induction of anesthesia.
This case presents several points worthy of consideration. First is the importance of parental selection in PPAI. We did not anticipate that this parent would display the behavior described above during the induction of general anesthesia. In fact she was of great help alleviating her child’s anxiety during induction. It is generally accepted that an anxious child does not benefit from parental presence of an overly anxious parent.4 However, in this case the child appeared calm during induction with the presence of his mother. Second, it is notable that much of the research done so far has been on the effect of PPIA on the child and very little is reported on the effect of the experience on the parents. This case clearly illustrates that PPIA can impact parents and can uncover deeply repressed memories that can trigger disruptive and risky behaviors. Finally, given the pitfalls and potential risks related to the practice, it is critical that additional staff be present to direct the parents and intervene in the event of display of disruptive and unsafe behavior.
We reviewed in detail the events of this incident and questioned whether any cues could have potentially anticipated this parent’s behavior during induction of her son’s anesthesia. The surgeon and anesthesiologists involved recognized that the mother displayed evidence of anxiety, but it was seemingly commensurate with the upcoming anesthesia and surgery for her child. However, upon further discussing with the mother the incident, it is clear that the potential emotional response was underestimated. Therefore, for those allowing PPIA, it is important to recognize pitfalls of the triage methods used to screen parents suitable for PPIA. Finally, given the pitfalls and potential risks related to the practice, it is critical that additional staff be present to direct the parents and intervene in the event of display of disruptive and unsafe behavior.
The practice of allowing family participation during medical procedures is not unique to pediatric anesthesia. The American Heart Association endorses the concept of inviting family members to witness resuscitation efforts. In addition, the longstanding practice of paternal presence during cesarean delivery has shown to be beneficial in father-child interaction.5 Nonetheless, there are anecdotal reports that some institutions have stopped family members being present during cesarean deliveries secondary to concern for distraction among health care workers should the family member have syncope. More recently, the practice of taking photographs and videotaping a child’s birth has been banned at some hospitals, citing the safety of mother and child and privacy concerns. Others have speculated that the increasing trend of this practice is secondary to the potential medical-legal implications.
At our institution we are enthusiastic proponents of family-centered care for children and allow family participation in the care of their children during induction of anesthesia and cardiac arrests and trauma resuscitations. It is not our intention to voice opposition to PPIA, rather this report simply illustrates that even when it is frequently practiced, PPIA can be associated with unforeseen and untoward effects to parents and medical personnel that can add undue risk to the patients. Recognizing the importance of preparation before PPIA, our hospital includes educational material via preoperative packet, online video, and preoperative tour before the surgical date. However, an important part of preventing events such as we described from occurring includes not only educating families as to the events that will occur, but also assessing their potential response. By using these modalities in addition to the interview with the anesthesiology team, we are able to manage parental expectations which are a critical part of PPIA. However, despite the best attempts, there are real risks associated with efforts to provide family-centered care and PPIA.
Name: Yewande J. Johnson, MD.
Contribution: This author helped conduct the study and write the manuscript.
Attestation: Yewande J. Johnson approved the final manuscript.
Name: Michael Nickerson, MD.
Contribution: This author helped conduct the study.
Attestation: Michael Nickerson approved the final manuscript.
Name: Zenaide M. N. Quezado, MD.
Contribution: This author helped write the manuscript.
Attestation: Zenaide M. N. Quezado approved the final manuscript.
This manuscript was handled by: Peter J. Davis, MD.
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