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Anesth Analg 2004;98:1252-1259
© 2004 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000111183.38618.D8

PEDIATRIC ANESTHESIA

Trends in the Practice of Parental Presence During Induction of Anesthesia and the Use of Preoperative Sedative Premedication in the United States, 1995–2002: Results of a Follow-Up National Survey

Zeev N. Kain, MD*,{dagger},{ddagger}, Alison A. Caldwell-Andrews, PhD*, Dawn M. Krivutza, MA*, Megan E. Weinberg, MA*, Shu-Ming Wang, MD*, and Dorothy Gaal, MD* Section Editor

Departments of *Anesthesiology, {dagger}Pediatrics, and {ddagger}Child Psychiatry, Yale University School of Medicine, New Haven, Connecticut

Address correspondence and reprint requests to Zeev N. Kain, MD, MBA, Department of Anesthesiology, Yale University School of Medicine, 333 Cedar St., New Haven, CT 06510. Address e-mail to kain{at}biomed.med.yale.edu


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 References
 
Both parental presence during induction of anesthesia and sedative premedication are currently used to treat preoperative anxiety in children. A survey study conducted in 1995 demonstrated that most children are taken into the operating room without the benefit of either of these two interventions. In 2002 we conducted a follow-up survey study. Five thousand questionnaires were mailed to randomly selected physician members of the American Society of Anesthesiologists. Mailings were followed by a nonresponse bias assessment. Twenty-seven percent (n = 1362) returned the questionnaire after 3 mailings. We found that a significantly larger proportion of young children undergoing surgery in the United States were reported to receive sedative premedication in 2002 as compared with 1995 (50% vs 30%, P = 0.001). We also found that in 2002 there was significantly less geographical variability in the use of sedative premedication as compared with the 1995 survey (F = 8.31, P = 0.006). Similarly, we found that in 2002 parents of children undergoing surgery in the United States were allowed to be present more often during induction of anesthesia as compared with 1995 ({chi}2 = 26.3, P = 0.0001). Finally, similar to our findings in the 1995 survey, midazolam was uniformly selected most often to premedicate patients before surgery.

IMPLICATIONS: Over the past 7 yr there have been significant increases in the number of anesthesiologists who use preoperative sedative premedication and parental presence for children undergoing surgery.


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 References
 
Anxiety before surgery is a common clinical phenomenon that occurs in up to 60% of all young children undergoing surgery (1). Both sedative premedicants (e.g., midazolam) and parental presence during induction of anesthesia (PPIA) are currently used to treat this clinical phenomenon (2). The frequency with which preoperative sedatives or PPIA is used in the United States, however, is not well documented and to date has only been described in one study (3). In 1995, we surveyed 5000 randomly selected anesthesiologists actively practicing in the United States (3), published in Anesthesia & Analgesia. We found very wide variability in the use of sedative premedicant drugs. This variability was based both on geographical area and patient age. We found that, whereas the majority of adult patients were treated with sedative preoperative medication, most pediatric patients were taken to the operating room awake and alone. We also found that sedative premedications were selected more often than PPIA when treating preoperative anxiety in children (3).

We believe that over the past 7 yr many changes have occurred in the "practical standard of care" of anesthetic management of children and adults and that, therefore, a follow-up survey study was appropriate. The importance of identifying changes in the practical standard of care has been underscored in an editorial in the Journal of the American Medical Association as well as in the medical literature (4,5). Thus, the purpose of the current investigation was to assess the 2002 practice of sedative premedication and PPIA and to compare that practice with that of 1995/1996. To make such comparison valid, we chose to use identical methodology as that used in our previous survey study.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 References
 
Respondents
The data processing unit of the American Society of Anesthesiology (ASA, Park Ridge, IL) provided a database to the investigators containing the names of 5000 randomly selected anesthesiologists (n = 5000/38,200). Retired physicians, physicians practicing anesthesia outside the United States, and trainees were excluded from the study. The study protocol was approved by the Yale IRB.

Questionnaire
In 1995, our study group developed a survey that consisted of questions regarding anesthesiologists’ current practices for the use of sedative premedication and PPIA. During the pilot phase of the 1995 survey, the questionnaire was pretested by 250 anesthesiologists and subsequently revised based on analysis of their responses. The questionnaire used for our 2002 survey was modified from that used by our study group for the 1995 survey. That is, we eliminated several questions regarding reasons for the use of premedication and limited the 2002 questionnaire to 37 questions regarding the actual practice of PPIA and sedative premedication. It is important to note that all the remaining questions in the 2002 survey were identical in content, format, and wording to the questions in the 1995/1996 survey. This was done to assure the appropriateness of comparing these two surveys.

The 2002 survey1 included 37 questions in three sections:

  1. Frequency and type of sedative premedication used.
  2. Opinions and practice regarding sedative premedication, PPIA, and parental presence in the postanesthesia care unit.
  3. Demographics of the respondent.

Several types of scales were used in the study, all of which are commonly used in survey research (6). We used categorical scales to assess frequencies of premedication usage and rank ordinal scales to assess routes used for administration of premedication (e.g., orally, IV).

We mailed questionnaires to potential participants in May 2001. Although the survey was anonymous, return envelopes were coded to permit the identification of nonrespondents to whom we sent additional surveys in September 2001 and in February 2002. To measure potential nonresponse bias, we randomly selected a subsample (n = 200) of anesthesiologists who had not responded by June 2002 and mailed them a shortened, anonymous questionnaire containing 8 items from the initial survey.

Data were analyzed with the use of SPSS version 11.0 (SPSS Inc., Chicago, IL). Demographic data were summarized as mean and standard deviation (SD) for continuous data, frequency for categorical data, and median and range for skewed data. For each item in the questionnaire, we computed frequency or mean response, with SD or range and 95% confidence intervals. We compared means between subgroups using the independent samples t-test. Categorical items were analyzed by frequency distribution and {chi}2 analysis. In the case of skewed data, medians and ranges are reported and nonparametric tests such as the Mann-Whitney U-test were used for analysis. Significance level was determined at P < 0.05.

To address variability that existed in premedication practices between 1995 and 2002, we performed Levene’s test for equality of variances to compare these two sets of data. We examined differences in the number of respondents who never used PPIA in 1995 and 2002 versus respondents who did use PPIA in 1995 and 2002 using {chi}2 analysis to compare physicians who never used PPIA in 1996 and 2002 with physicians who used PPIA in 1996 and 2002.

We also addressed the association between health maintenance organization (HMO) penetration and frequency of sedative premedication use. To accomplish this, we obtained data concerning HMO penetration by state, kindly supplied by InterStudy (St. Paul, MN). We stratified these data according to geographic regions as described below.

The frequency of premedication and PPIA was classified by geographic locations in the United States to determine whether differences existed in six regions:


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 References
 
We sent surveys to 5000 anesthesiologists who were members of the American Society of Anesthesiology. Of the anesthesiologists surveyed, nine had retired and seven had left no forwarding address. Of the remaining anesthesiologists, 1362 (27%) returned the questionnaire after 3 mailings. The demographic and professional characteristics of the respondents are shown in Table 1. It should be noted that the 1995/1996 respondents were similar to 2002 respondents in terms of their demographic characteristics (Table 1).


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  		Table 1. Demographic Characteristics of Respondents in 1995 and 2002
 
Sedative Premedication Usage
We found that the reported prevalence of premedication use varied among age and geographical regions in the United States (Fig. 1A). Sedative premedicants were used in approximately 50% (median) of all children and adults undergoing outpatient surgery. When analyzed by geographical regions, premedicants were used least often in the Northeast region (Fig. 1A). Respondents’ premedication practices for inpatient surgery cases did not differ from outpatient surgery cases. Both geographical and age patterns contrast to the findings in the survey conducted in 1995/1996 (Fig. 1B), in which results had shown significantly more variability between age groups and geographical areas (F = 8.31, P = 0.006). Overall, respondents reported premedicating a larger proportion of young children (younger than 4 yr old) in the 2002 survey as compared with the 1995/1996 survey (50% vs 30%, respectively; P = 0.001).



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  		Figure 1. A, Frequency of sedative premedication practice in the United States as of 2002. B, Frequency of sedative premedication practice in the United States as of 1996. Data reported are medians (range = 0%–100%).

 
Respondents were asked to specify the age (in children) younger than which they would never administer premedication. The median age younger than which respondents reported that they would never administer premedication was 12 mo for both outpatient and inpatient.

Results from the 1995/1996 survey indicated that HMO regional penetration was associated with anesthesiologists’ practices regarding administration of sedative premedication (3). We performed a similar analysis for this survey, using current HMO penetration data supplied by InterStudy. The analysis showed that, in contrast to the 1995/1996 survey, regional HMO penetration did not seem to be associated with anesthesiologists’ premedication practices with the exception of adults older than age 65 (r = –0.95, P = 0.004; Table 2).


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  		Table 2. The Association Between Health Maintenance Organization (HMO) Regional Penetration and Frequency of Premedication in 1995 and 2002
 
We next compared anesthesiologists who reported that they never premedicated outpatient children with anesthesiologists who reported that they did premedicate outpatient children. Results showed that anesthesiologists who premedicated children were younger, practiced in a geographical area with less HMO penetration, had worked fewer years in practice, and had more pediatric patients in their practice (Table 3). We also found that only 1.9% of anesthesiologists who practiced at a children’s hospital never premedicated their patients as compared with 25.3% of anesthesiologists who practiced at free-standing surgery centers. There were no gender differences between anesthesiologists who never premedicated children and those who did premedicate children (P = 0.68).


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  		Table 3. Demographic Differences in Anesthesiologists Who Premedicate Childrena Versus Anesthesiologists Who Do Not Premedicate Children
 
Among adult outpatients, benzodiazepines were the most commonly used sedative premedicants (<95%). The most commonly used benzodiazepine was midazolam (89%), followed by diazepam (5%) and lorazepam (1%). The remaining respondents used mostly fentanyl and diphenhydramine. Adult inpatients received midazolam most often (89%), followed by diazepam (3%), fentanyl (2%) and lorazepam (1%). Similarly, for children, midazolam was used by >96% of the respondents; the remaining respondents used mostly fentanyl and ketamine. Pediatric inpatient premedication use mirrored outpatient premedication.

Comparable to the 1995 survey, midazolam (80%–82%) and IV fentanyl (14%–17%) were the most commonly administered drugs in preinduction. However, the frequency of midazolam use increased significantly from 1995/1996 to 2002 (48%–59% vs 80%–82%, P = 0.001). The majority of 2002 respondents premedicated adults in the holding area using the IV route (83%), followed by oral route (10%), and IM route (5%) (P = 0.001). In contrast, most respondents premedicated pediatric outpatients using the oral route (93%).

PPIA Usage
Overall, 10% of respondents used PPIA in >75% of cases and 27% of respondents reported PPIA in <25% of cases. Approximately 50% of all respondents never had PPIA. The reported prevalence of PPIA varied widely among the different geographical locations in the United States (Fig. 2A). When analyzed by geographical regions, PPIA was practiced most often in the Northeast region and least often in the South Central region (Fig. 2A). The patterns observed in 2002 contrast to findings from our previous survey (Fig. 2B). Overall, there was an increase in the practice of PPIA from 1995/1996 to 2002 ({chi}2 = 26.3, P = 0.0001), and the number of respondents who never used PPIA decreased in every geographical region (Fig. 2, A and B). To underscore this issue, Figure 3 illustrates the particularly dramatic decrease in the practice of never using PPIA that we observed in the Northwest region of the United States.



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  		Figure 2. A, Frequency of parental presence during induction of anesthesia (PPIA) practice in the United States as of 2002. B, Frequency of PPIA practice in the United States as of 1995/1996. Data reported are medians (range = 0%–100%).

 


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  		Figure 3. Frequency of parental presence during induction of anesthesia (PPIA) practice in the Northwest region of the United States in 1995/1996 as compared with 2002. Data reported are medians (range = 0%–100%).

 
We also found that anesthesiologists who more frequently used PPIA had a larger percentage of pediatric patients and practiced in a geographical area with smaller HMO penetration (Table 4). Overall, female anesthesiologists were more likely to allow PPIA than male anesthesiologists (58% vs 48%, P = 0.004). Only 13% of anesthesiologists who practiced at a children’s hospital never used PPIA as compared with 60% of anesthesiologists who practiced at free-standing surgery centers.


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  		Table 4. Demographic Differences in Anesthesiologists Who Use Parental Presence During Induction of Anesthesia (PPIA) Versus Anesthesiologists Who Do Not Use PPIA
 
When asked about the policy of their hospital toward parental presence, 32% of respondents indicated that PPIA was allowed in their hospital, and 11% indicated that PPIA was encouraged by their hospital. In contrast, 23% reported no formal hospital policy, and PPIA was against hospital policy for 26% of those surveyed. Ninety-two percent of all respondents never used an induction room and 5.8% of respondents used an induction room in <25% of all pediatric cases. Only 5% of all respondents indicated that they routinely obtained a separate written consent for PPIA.

Finally, 15% of the respondents never allowed parents to be present in the postanesthesia care unit, 28% of respondents allowed parents in the postanesthesia care unit for <25% of pediatric cases, and 37% of respondents allowed parental presence in the postanesthesia care unit in 75%–100% of pediatric cases.

Bias Assessment
The "nonresponse survey" indicated that the nonresponders did not differ significantly from the responders either in the frequency of usage of premedication and PPIA or in the type of premedication used. Demographics of nonresponders were similar to those of the responders.


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
References
 
Overall, we found that significantly more children undergoing surgery in the United States were reported to receive sedative premedication in 2002 as compared with 1995. We also found that in 2002 there was significantly less geographical variability in the use of sedative premedication as compared with 1995 data. Similarly, we found that parents of children undergoing surgery in the United States were more frequently allowed to be present during induction of anesthesia in 2002 as compared with 1995. This change in the practice of PPIA was particularly noticeable in the Northwest region of the United States. Interestingly, the 2002 survey indicated that the relationship between HMO penetration and geographic variations in use of sedative premedication was less strong as compared with the 1995 survey. Finally, similar to our findings in the 1995 survey, midazolam was selected most often as the sedative premedication of choice for patients before surgery.

Overall, there has been a significant increase in the frequency of the use of both PPIA and sedative premedication since 1995. This change in national practice is particularly intriguing when one considers that the use of both sedative premedication and PPIA is associated with an increased operational cost for hospitals. We surmise that significantly increased research efforts regarding PPIA and premedication, and the resulting medical literature, may therefore have had an impact on this change in practice. It may also be that more anesthesiologists were aware of the benefits of reducing preoperative anxiety in children and were acting upon this awareness. The perioperative surgical and anesthetic process has been documented to be associated with significant anxiety in children and adults (7,8). Increased preoperative anxiety in adult patients undergoing surgery is associated with adverse outcomes, such as increased postoperative analgesic requirements and a prolonged postoperative recovery process (9,10). Furthermore, Kain et al. (11) recently reported that increased preoperative anxiety also retards the postoperative recovery process in children undergoing surgery. In addition, the use of sedative premedication and PPIA to reduce preoperative anxiety have been reported to positively impact outcomes such as reducing maladaptive behavioral changes after surgery and increasing parental satisfaction (12,13). Thus, there is a clear rationale for the use of preoperative interventions such as sedative premedication and PPIA before surgery.

Similar to our findings in 1995, midazolam was selected most frequently to premedicate patients before surgery. In fact, the frequency at which midazolam was chosen has increased and the reported frequency of use of other sedative premedicants has decreased, as shown in the current survey. This finding is hardly surprising, considering that respondents to our 1995 survey indicated that decreased anxiety and increased cooperation were the most important determinants in choosing a sedative premedicant (3). Studies have demonstrated that midazolam reduces preoperative anxiety, increases cooperation, and has minimal side effects, a short half-life, and good absorption after oral administration (2).

Finally, there are several methodological issues related to this study. First, this was a follow-up to a survey conducted in 1995. We considered a priori the idea of sending the questionnaire to the same individuals who answered our survey in 1995. This, however, was not possible because that survey was anonymous (as was this current survey). In addition, if one accepts that the respondents of the original survey were representative of the entire United States’ anesthesiology community in 1995, and that the respondents of the current survey also represented the entire 2002 anesthesiology community in 2002, then there was no need to survey the same original 1995 respondents.

In conclusion, we found that in 2002, significantly more children received sedative premedication and/or had PPIA as compared with 7 years ago. Although all the reasons for this shift in practice are not known, we believe that an increased awareness of issues related to children’s and parents’ preoperative anxiety are responsible for most of this change in practice. We think that the entire medical community in the United States should be encouraged by the progress that has been made with this issue over the past 7 years.


   Acknowledgments
 
ZNK is supported in part by the National Institutes of Health (NICHD, R01HD3700701, Bethesda, MD).


   Footnotes
 
1 The questionnaire is available in its entirety from the investigators. Back


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 

  1. Kain ZN, Mayes LC, O’Connor TZ, Cicchetti DV. Preoperative anxiety in children: predictors and outcomes. Arch Pediatr Adolesc Med 1996; 150: 1238–45.[Abstract/Free Full Text]
  2. McCann M, Kain ZN. Management of preoperative anxiety in children: an update. Anesth Analg 2001; 93: 98–105.[Free Full Text]
  3. Kain ZN, Mayes LC, Bell C, et al. Premedication in the United States: a status report. Anesth Analg 1997; 84: 427–32.[Abstract]
  4. Argy O. A piece of my mind: standards of care. JAMA 1996; 275: 1296.[Free Full Text]
  5. Wellington N, Rieder MJ. Attitudes and practices regarding analgesia for newborn circumcision. Pediatrics 1993; 92: 541–3.[Abstract/Free Full Text]
  6. Alreck P, Settle R. The survey research handbook. 2nd ed. Chicago: Irwin, 1995: 113–42.
  7. Badner N, Nielson W, Munk S, et al. Preoperative anxiety: detection and contributing factors. Can J Anaesth 1990; 37: 444–7.[Web of Science][Medline]
  8. Kain ZN, Mayes L, Caramico L, Hofstadter M. Distress during induction of anesthesia and postoperative behavioral outcomes. Anesth Analg 1999; 88: 1042–7.[Abstract/Free Full Text]
  9. Kiecolt-Glaser JK, Page G, Marucha P, et al. Psychological influences on surgical recovery. Am Psychol 1998; 53: 1209–18.[Medline]
  10. Kain ZN, Sevarino F, Alexander GA, et al. Predictors for postoperative pain in women undergoing surgery: a repeated measures design. J Psychosom Res 2000; 49: 417–22.[Web of Science][Medline]
  11. Kain ZN, Caldwell-Andrews A, LoDolce M, et al. The perioperative behavioral stress response in children. Anesthesiology 2002; 96: A1242.
  12. Kain ZN, Mayes L, Caramico L, et al. Postoperative behavioral outcomes in children: effects of sedative premedication. Anesthesiology 1999; 90: 758–65.[Web of Science][Medline]
  13. Kain ZN, Mayes L, Wang S, et al. Parental presence and a sedative premedicant for children undergoing surgery: a hierarchical study. Anesthesiology 2000; 92: 939–46.[Web of Science][Medline]
Accepted for publication November 13, 2003.




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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press