Anesth Analg 2003;96:970-975
© 2003 International Anesthesia Research Society
PEDIATRIC ANESTHESIA
Parental Intervention Choices for Children Undergoing Repeated Surgeries
Zeev N. Kain, MD*,
,
Alison A. Caldwell-Andrews, PhD*,
Shu-Ming Wang, MD*,
Dawn M. Krivutza, MA*,
Megan E. Weinberg, MA*, and
Linda C. Mayes, MD
,
Departments of *Anesthesiology,
Pediatrics, and
Child Psychiatry, Yale University School of Medicine, New Haven, Connecticut
Address correspondence and reprint requests to Zeev N. Kain, MD, Department of Anesthesiology, Yale School of Medicine, 333 Cedar St., New Haven, CT 06510. Address e-mail to kain{at}biomed.med.yale.edu
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Abstract
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No studies have examined parental preference for a preoperative intervention in healthy children undergoing subsequent surgeries. We collected data prospectively from 83 children who previously underwent surgery and were part of an investigation by our study group, then returned for a subsequent surgery. At the initial surgery, children were assigned (no parental intervention) to receive oral midazolam (n = 13), or parental presence during the induction of anesthesia (PPIA, n = 27), or PPIA + midazolam (n = 10) or no intervention (n = 33). At a subsequent surgery, parents chose the preoperative intervention. We found that >80% of all parents chose PPIA (with or without midazolam) at the subsequent surgery regardless of the intervention they received previously. Of parents whose children received PPIA at the initial surgery, 70% chose PPIA again. In contrast, only 23% of the patients who received midazolam at the initial surgery requested midazolam at the subsequent surgery and only 15% of the patients who received no intervention at the initial surgery requested no intervention at the subsequent surgery. All parents of very anxious children at the initial surgery chose some intervention at the subsequent surgery (P = 0.022). Parents of children who underwent a subsequent surgery preferred PPIA regardless of any previous intervention. Also, parents’ intervention preferences at the subsequent surgery were influenced by children’s anxiety at the initial surgery.
IMPLICATIONS: Parents of children who undergo a subsequent surgery prefer to be present during the induction of anesthesia regardless of whether the child was medicated or had parents present or did not receive anything at the initial surgery. Also, parents’ preference for medication or parental presence at the subsequent surgery was influenced by the child’s anxiety at the initial surgery.
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Introduction
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A significant number of children who undergo surgery at a young age may require a subsequent surgery. For example, a child who has had pressure equalizing tube placement in an initial surgery may later undergo surgery for tonsillectomy. There is general agreement that many of these children will experience significant anxiety and distress during the induction of anesthesia (1). Currently, interventions such as sedatives, parental presence during the induction of anesthesia (PPIA), and a combination of both PPIA and a sedative are used to treat anxiety in this patient population (1).
Of particular interest is the question of whether an intervention children receive at an initial surgery will influence parental choices at a subsequent surgery. For example, would parents whose children received midazolam at an initial surgery choose midazolam in a subsequent surgery? There are no studies that have addressed this issue with children undergoing two subsequent outpatient surgical procedures. In addition, the influence of variables such as child and parental anxiety at an initial surgery on parental choice of intervention at a subsequent surgery is not known. Thus, the purpose of this longitudinal prospective investigation was to examine the impact of an intervention used in an initial surgery on parent’s choice for an intervention used at a subsequent surgery.
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Materials and Methods
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Over the past 6 yr, our laboratory has kept a central database of all subjects who were part of previous investigations related to the issue of the perioperative behavioral stress response. Every day, our research staff examines the operating room (OR) outpatient schedule to identify any patients who were part of a previous study and who are present for a subsequent elective surgery.
Because of the unique psychological profile of children who undergo surgery secondary to cancer or chronic diseases, only patients with an ASA physical status I–II and no history of chronic illness, prematurity, or developmental delay were included in this cohort, and only patients who were part of a previous study in which the preoperative intervention was assigned (i.e., dictated by study constraints and without parental input) were eligible for the cohort presented in this report. The IRB approved the study protocols, and an assent (if appropriate) and informed consent were obtained from the children and their parents respectively.
Behavioral Assessments
State-Trait Anxiety Inventory (STAI) is a 40-item parental self-report measure that contains 20 items measuring state anxiety and 20 items measuring trait anxiety. Total scores for state and trait portions separately range from 20 to 80; higher scores denote higher levels of anxiety (2).
Modified Yale Preoperative Anxiety Scale (mYPAS) is an observation measure of anxiety that was previously developed by our laboratory. This measure has good reliability and validity when compared with the STAI and with cortisol (3,4) .
EASI Scale of Child Temperament (EASI) is used to assess baseline temperament of the child and includes 20 items in four categories: emotionality, activity, sociability, and impulsivity (5). Completed by the parents, this instrument is widely used and has good reliability and good validity (6,7) .
Induction Compliance Checklist (ICC) is an observational scale that measures the compliance of a child during the induction of anesthesia (8). For the purpose of analysis of this report, we considered a perfect induction to be a score of 0 (no adverse behaviors), and an imperfect induction to be a score of 1–9 (adverse behaviors such as child turns head away from mask, pushes mask away with hands, etc.).
Study Protocol
Initial Surgery.
Detailed protocols were presented in the various manuscripts describing the initial investigations that included our study cohort. Briefly, child’s temperament (EASI) and parental trait anxiety (STAI) were evaluated by using validated instruments. On the day of surgery, anxiety of the child (mYPAS) and parent (STAI) were evaluated prior to administering any intervention. Next, according to the particular initial study protocol, children were randomly assigned to receive a preoperative intervention such as oral midazolam (0.5 mg/kg, up to 20 mg total), PPIA, PPIA +oral midazolam, or no intervention. Anesthesia was induced in all patients using an O2/N2O/sevoflurane or halothane technique. An independent observer evaluated the child’s anxiety and compliance (mYPAS, ICC) upon entering the OR and upon introduction of the anesthesia mask. Parental anxiety was assessed immediately after separation from their child (in the PPIA groups, parental anxiety was assessed as the parent left the OR immediately after the induction of anesthesia). No other data gathered in the initial surgery were used for this manuscript.
Subsequent Surgery.
Eligible patients were identified from the OR schedule and from our central database. On the day of surgery, child’s anxiety (mYPAS) and parental anxiety (STAI) were assessed in the preoperative holding area before the administration of any intervention. Next, the parent and child were asked for their preference for one of the following options: oral midazolam (0.5 mg/kg) in the preoperative holding area, PPIA, PPIA + oral midazolam, or no intervention. As in the initial surgery, patients were brought into the OR, a scented anesthesia mask was introduced, and anesthesia was induced using O2/N2O/sevoflurane. An independent observer evaluated the child’s anxiety (mYPAS) upon entering the OR and upon introduction of the anesthesia mask. Parental anxiety was assessed immediately after separation.
Descriptive statistics provide an overview of the relationships between child and parent variables and children’s anxiety levels. Data were presented as mean ± SD. Differences among groups were examined using inferential statistics, including t-tests and one-way analysis of variance. Anxiety levels at the initial and subsequent surgery were compared by using repeated-measures analysis of covariance with age as a covariate. Data that were significantly skewed were reported as median and range, and were analyzed using Kruskal-Wallis tests. A univariate analysis of covariance was performed using the total number of behavioral changes over time as the dependent variable, intervention choice as the independent variable, and age as a covariate.
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Results
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Data were collected from 83 children who underwent surgery at Yale New Haven Hospital, were part of a previous or continuing investigation, and returned for a subsequent surgery. Thus, it should be noted that partial data regarding the initial surgery of some of these patients were included in previous publications by our laboratory [n = 4, (1); n = 5, (8); n = 6, (9); n = 5, (10); n = 16, (11)]. Baseline psychological and demographic characteristics of these children and their parents at the initial surgery are shown in Table 1. The four groups were similar with regard to age, sex, parental anxiety, and temperament. The average time interval between the initial and subsequent surgery was 1.3 ± 1.2 yr. Parents were randomly assigned to interventions at the initial surgery as follows: midazolam (n = 13), PPIA (n = 27), no intervention (n = 33), and midazolam + PPIA (n = 10).
Parental Preference for Intervention
At the subsequent surgery, parents chose interventions as follows: midazolam (n = 8), PPIA (n = 46), no intervention (n = 8), and midazolam + PPIA (n = 21). Figure 1 compares the intervention to which children were randomly assigned at the initial surgery to the intervention that parents chose for the subsequent surgery. We found that >80% of all parents chose PPIA (with or without midazolam) at the subsequent surgery, regardless of which intervention they received at the initial surgery. Of parents whose children received PPIA at the initial surgery, 93% chose PPIA again (PPIA: 74%; PPIA+ midazolam: 19%). Similarly, 80% of parents whose children received midazolam + PPIA in the initial surgery chose midazolam in the subsequent surgery (midazolam + PPIA: 70%; midazolam: 10%). In contrast, only 38% of the patients who received midazolam at the initial surgery requested midazolam at the subsequent surgery (midazolam: 23%; midazolam + PPIA: 15%). Similarly, only 15% of the patients who received no intervention at the initial surgery requested no intervention at the subsequent surgery.
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Figure 1. Data regarding the parental intervention choice in the subsequent surgery as a function of the initial surgery. For example, 23% of the parents who were assigned to the premedication group in the initial intervention chose to be in the premedication group in the subsequent surgery. Similarly, 46% of the parents who were assigned to the premedication group in the initial intervention chose to be in the premedication group in the subsequent surgery. PPI = parental presence during the induction of anesthesia.
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Parents’ intervention preferences at the subsequent surgery were influenced by children’s anxiety and compliance during the induction of anesthesia at the initial surgery. That is, all of the parents of children who were most anxious (upper 25%) during the initial surgery chose some intervention (PPIA or midazolam or PPIA + midazolam) at the subsequent surgery rather than choosing no intervention (likelihood ratio = 0.022; Table 2). Similarly, parents of children who had a perfect compliance with the induction of anesthesia during the initial surgery were more likely to choose no intervention as compared with parents of children who did not have a perfect induction of anesthesia during the initial surgery (18.8% versus 4.3%, P = 0.039). It should also be noted that among the children who received an intervention, both the most and least (lower 75%) anxious children received approximately the same proportion of the various interventions (P = 0.35, Table 2). Age of the child was not a factor in these choices, because age among groups did not significantly differ at the initial surgery (P = 0.15), or at the subsequent surgery (P = 0.19).
Parents’ and Children’s Anxiety
In the initial surgery, children assigned to the midazolam and the PPIA + midazolam groups were less anxious during the induction of anesthesia as compared with the no-intervention and PPIA groups (P = 0.04, Table 3). Interestingly, however, group assignment during the initial surgery had no impact on children’s anxiety in the holding area before the subsequent surgery (P = 0.58, Table 3).
In contrast to the initial surgery, children’s anxiety during the induction of anesthesia at the subsequent surgery did not differ based on the preoperative intervention (Table 4). Children whose parents chose midazolam, however, were significantly more anxious in the preoperative holding area during the subsequent surgery as compared with the other groups (Table 5). When analyzed as one cohort (without stratification based on intervention), children’s anxiety in the holding area and during the induction process did not differ between the initial and subsequent surgeries (P value ranges from 0.58 to 0.90) (Table 5).
Parents’ anxiety was significantly reduced at the subsequent surgery, both in the holding area (42.5 ± 10.9 versus 39.9 ± 9.9; P = 0.04), and at separation (46.9 ± 12.6 versus 42.9 ± 11.9, P = 0.004) as compared with the initial surgery (Table 5). The change in parental anxiety was not affected by group assignment during the first surgery (repeated-measures analysis of variance, F(1,76) = 3.37; P = 0.212). Parents’ anxiety at the subsequent surgery was not related to children’s anxiety at the initial surgery in the holding area (r = -0.09) or during the induction of anesthesia (r = 0.06). When children who were the most anxious (highest 25%) during the induction of anesthesia at the initial surgery were compared with least-anxious children (lowest 25%), there were no differences at the subsequent surgery in parents’ state anxiety in the holding area (41.69 ± 9.9 versus 41.74 ± 12.7, P = 0.99) or at separation (45.3 ± 13.1 versus 42.0 ± 10.1, P = 0.36).
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Discussion
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We found that, of children who were assigned to receive PPIA at an initial surgery, the parent’s likelihood of choosing to be present again during the induction of anesthesia at a subsequent surgery was 70%. In contrast, of children assigned to receive midazolam, parents were only 23% likely to choose midazolam again. Similarly, of children who received no intervention during the initial surgery, parents were only 15% likely to choose no intervention at the subsequent surgery. We also found that, overall, parents of children who underwent a subsequent surgery preferred to be present during the induction of anesthesia regardless of the intervention that was used in the initial surgery. Also, parents’ intervention preferences at the subsequent surgery were influenced by children’s anxiety at the initial surgery. In fact, we found that all of the parents of children who were most anxious at the initial surgery chose an intervention to be given to their child at the subsequent surgery. Finally, we found that parents’ anxiety was significantly reduced at the subsequent surgery, both in the holding area, and at separation as compared with the initial surgery. The change in parental anxiety was not affected by group assignment during the first surgery.
The literature reports that a majority of parents who were present during the induction of anesthesia indicated that if their child needed a subsequent surgery, they would again like to be present during the induction of anesthesia (12–14) . The present investigation confirmed these findings and indicated that indeed when these parents and children return for a subsequent surgery, PPIA is their intervention of choice. Of particular interest is the finding that only 23% of the parents whose child received midazolam in the initial surgery chose midazolam again. In contrast, 46% of this group of parents preferred to be present during the induction of anesthesia process. Thus, it seems that parental desire to be present during the induction of anesthesia is indeed very strong and is not related to child’s anxiety during the initial surgery.
We also found that children randomly assigned to the midazolam groups (midazolam or PPIA + midazolam) at the initial surgery were less anxious during the initial surgery as compared with the no-intervention and PPIA groups. This finding is in agreement with published data from randomized controlled trials (8,11) . However, we also found that, at the subsequent surgery, children’s anxiety during the induction of anesthesia was not less in the midazolam groups. These findings underscore the difference between a randomized controlled trial and an observational study. That is, children in the midazolam groups at the subsequent surgery were significantly more anxious in the preoperative holding area. We infer that parents chose midazolam for the most anxious children whereas the calmest children were not given an intervention. The end result was no difference in anxiety among groups during the induction of anesthesia.
Interestingly, group assignment during the initial surgery had no impact on children’s anxiety in the preoperative holding area at the subsequent surgery. One can make the argument that children who were more anxious during the induction of anesthesia at the initial surgery might be "sensitized" and therefore more anxious in the holding area before the subsequent surgery. We should note that during the induction of anesthesia at the initial surgery, children in the PPIA and no-intervention groups were most anxious and children in the midazolam groups were least anxious. One might also predict that children in the midazolam groups during the initial surgery would be less anxious at the subsequent surgery because of their previous positive experience. However, these children, although appearing less anxious during the induction at the initial surgery, did not have a recollection of their initial "calm" induction [because of the amnesic effects of midazolam (10)] and thus may have not retained a positive, coping-enhancing memory of this experience that could be of benefit to them at the subsequent surgery.
We also found that parents were less anxious after separation at the subsequent surgery. Intuitively, one can hypothesize that because parents were able to choose the intervention at the subsequent surgery, this reduction in anxiety is likely attributable to the fact that parents had some control over how they were separated from their child. It may also be, however, that parents were simply less anxious because they had experienced their child undergoing surgery before.
We conclude that parents of children who undergo a subsequent surgery prefer to be present during the induction of anesthesia regardless of the intervention that was used in the initial surgery. Also, parents’ intervention preferences at the subsequent surgery are influenced by the child’s anxiety at the initial surgery.
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Acknowledgments
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ZNK was supported in part by the National Institutes of Health (NICHD, R01HD37007-01) and the Patrick and Catherine Weldon Donaghue Medical Research.
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References
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- Buss AH, Plomin R. Theory and measurement of EAS. In: Buss AH, Plomin R, eds. Temperament: early developing personality traits. Hillsdale, NJ: L. Erlbaum Associates, 1984: 98–130.
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Accepted for publication December 26, 2002.
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Abstract
Introduction
