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Preoperative preparation, communication and premedication
J. Berghmans M.D.
28/01/2016 1
Department of Anesthesia, ZNA Middelheim, Queen Paola Children’s Hospital, Antwerp, Belgium Departments of Child and Adolescent Psychiatry/Psychology & Anesthesia, Erasmus University Medical Centre - Sophia Children’s Hospital, Rotterdam, The Netherlands
BAPA RC
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Why is perioperative distress, anxiety and fear soimportant?
• managing an uncooperative frightened child at induction is distressing
• associated with postoperative behavioral changes
• influence on subjective perception and associated withhigher levels of postoperative pain
• poor compliance with future medical therapy
• neuroendocrine changes
28/01/2016 2
Kain, et al. Anesth Analg 2004
Bringuier, et al. Anesth Analg 2009
Kain, et al. Pediatrics 2006
Proczkowska-Bjorklund, et al. J Child Health Care 2010
Davidson, et al. Curr Opin Anaesthesiol 2011
BAPA RC
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Why is perioperative distress, anxiety and fear soimportant?
40% some distress behavior
17% significant distress
33% efforts to escape
Chorney, et al. Anesth Analg 2009
Davidson, et al. Curr Opin Anaesthesiol 2011
28/01/2016 3BAPA RC
Frequent!
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28/01/2016 BAPA RC 4
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28/01/2016 BAPA RC 5
Human behavior is complexExpression of perioperative distress, anxiety and fear can be verbal or behavioral, subtle or extreme
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28/01/2016 BAPA RC 6Chorney, et al. Anesth Analg 2009
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28/01/2016 7BAPA RC
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Behavior profiles by child age28/01/2016 8BAPA RC
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• age
• attachment and separation
• trait anxiety
• temperament / personality
• emotional-behavioral functioning
• cognitive development and understanding of illness
• quality of previous medical encounters
28/01/2016 BAPA RC 9
CHILD - risk factors
Kain, et al. Arch Pediatr Adolesc Med 1996
Kain, et al. Anesthesiol Clin North America 2005
Berghmans, et al. Minerva Anestesiol 2014
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28/01/2016 BAPA RC 10
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• age
• attachment and separation
• trait anxiety
• temperament / personality
• emotional-behavioral functioning
• cognitive development and understanding of illness
• quality of previous medical encounters
28/01/2016 BAPA RC 11
CHILD - risk factors
Kain, et al. Arch Pediatr Adolesc Med 1996
Kain, et al. Anesthesiol Clin North America 2005
Berghmans, et al. Minerva Anestesiol 2014
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28/01/2016 BAPA RC 12
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• age
• attachment and separation
• trait anxiety
• temperament / personality
• emotional-behavioral functioning
• cognitive development and understanding of illness
• quality of previous medical encounters
28/01/2016 BAPA RC 13
CHILD - risk factors
Kain, et al. Arch Pediatr Adolesc Med 1996
Kain, et al. Anesthesiol Clin North America 2005
Berghmans, et al. Minerva Anestesiol 2014
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• age
• attachment and separation
• trait anxiety
• temperament / personality
• emotional-behavioral functioning
• cognitive development and understanding of illness
• quality of previous medical encounters
28/01/2016 BAPA RC 14
CHILD - risk factors
Kain, et al. Arch Pediatr Adolesc Med 1996
Kain, et al. Anesthesiol Clin North America 2005
Berghmans, et al. Minerva Anestesiol 2014
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• age
• attachment and separation
• trait anxiety
• temperament / personality
• emotional-behavioral functioning
• cognitive development and understanding of illness
• quality of previous medical encounters
28/01/2016 BAPA RC 15
CHILD - risk factors
Kain, et al. Arch Pediatr Adolesc Med 1996
Kain, et al. Anesthesiol Clin North America 2005
Berghmans, et al. Minerva Anestesiol 2014
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• age
• attachment and separation
• trait anxiety
• temperament / personality
• emotional-behavioral functioning
• cognitive development and understanding of illness
• quality of previous medical encounters
28/01/2016 BAPA RC 16
CHILD - risk factors
Kain, et al. Arch Pediatr Adolesc Med 1996
Kain, et al. Anesthesiol Clin North America 2005
Berghmans, et al. Minerva Anestesiol 2014
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• age
• attachment and separation
• trait anxiety
• temperament / personality
• emotional-behavioral functioning
• cognitive development and understanding of illness
• quality of previous medical encounters
28/01/2016 BAPA RC 17
CHILD - risk factors
Kain, et al. Arch Pediatr Adolesc Med 1996
Kain, et al. Anesthesiol Clin North America 2005
Berghmans, et al. Minerva Anestesiol 2014
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Parent – risk factors
• trait / state anxiety
• monitors / blunters
• SES
• gender
• cultural differences
28/01/2016 BAPA RC 18
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Parent – risk factors
• trait / state anxiety
• monitors / blunters
• SES
• gender
• cultural differences
28/01/2016 BAPA RC 19
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Parent – risk factors
• trait / state anxiety
• monitors / blunters
• SES
• gender
• cultural differences
28/01/2016 BAPA RC 20
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Parent – risk factors
• trait / state anxiety
• monitors / blunters
• SES
• gender
• cultural differences
28/01/2016 BAPA RC 21
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Parent – risk factors
• trait / state anxiety
• monitors / blunters
• SES
• gender
• cultural differences
28/01/2016 BAPA RC 22
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Health care provider
28/01/2016 23
adult behavior
affect children’s
distress
BAPA RC
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28/01/2016 BAPA RC 24
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28/01/2016 25
• distracting behavior
• humor
• nonprocedural talk
Coping promoting behavior
• reassurance
• empathy
• criticism
• apology
Distress promoting behavior
Caldwell-Andrews, et al. Anesthesiology 2005Martin, et al. Anesthesiology 2011
BAPA RC
One person should talk rather than several people all talking at the same time
Essential to understand non-verbal expressions and actions of the child!
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• self-report (STAIC)
• measures of cooperation (ICC)
• physiological measures
• observer measures
28/01/2016 BAPA RC 26
modified Yale Preoperative Anxiety Scale m-YPAS
development of a short version of the modified Yale Preoperative Anxiety Scale m-YPAS-SF
How to assess perioperative anxiety?
Kain, et al. Anesth Analg 1997
Jenkins, et al. Anesth Analg 2014
Caldwell-Andrews, et al. Anesthesiology 2005
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•activity
•emotional expressivity
•state of arousal
•vocalisation
•use of parents
28/01/2016 BAPA RC 27
The modified Yale Preoperative Anxiety Scale (m-YPAS)
Five behavior categories
Kain, et al. Anesth Analg 1997
Jenkins, et al. Anesth Analg 2014
m-YPAS-SF
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28/01/2016 28
Perioperative Adult Child Behavioral Interaction Scale(PACBIS)
Sadhasivam, et al. Anesth Analg 2010.
BAPA RC
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What can be done to relieve distress, anxiety andfear?
• educational
• behavioral
• alternative
• pharmacological
28/01/2016 29BAPA RC
Interventions
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28/01/2016 BAPA RC 30
Educational interventions
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28/01/2016 BAPA RC 31
Preparation appears to be a simple concept: to tell the
child and parent, what is going to happen
In reality, however, preparation is not so simple!
What information, when and how it is provided and by
who, are all key factors
Coping skills > modeling > play therapy > operating tour
> printed material
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Educational interventions
• preparation programs / information
(relaxation, coping, distraction, desensitization, rolerehearsal, narrative information)
• age-appropriate needs (f.i. children ≥ 6 yr)
• negative behavior (f.i. children ≤ 3 yr)
• previous experience!
• should also be directed to parents
28/01/2016 BAPA RC 32
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28/01/2016 BAPA RC 33
Behavioral interventions
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28/01/2016 BAPA RC 34
Kain, et al. Anesthesiology 2007
Cuzzocrea, et al. Pediatr Anesth 2013
Fortier, et al. Br J Anaesth 2011
• Anxiety reduction
• Distraction
• Video modeling
• Adding parents
• No excessive reassurance
• Coaching
• Exposure and shaping
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28/01/2016 BAPA RC 35
Effective!
High cost!
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28/01/2016 BAPA RC 36
Shaping and exposure (i.e. practise with the anesthesia mask) and parental use of distraction in the surgical setting
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Parental presence at induction
• experimental evidence does not support the routine use of parental presence (past versus new research)
recent systematic review
• but it increases parental satisfaction
• respect to the child and parental rights and it should be allowed
28/01/2016 BAPA RC 37
Not helpful?
Manyande, et al. Cochrane Database Syst Rev 2015
Rosenbaum, et al. Pediatric Anesthesia 2009.
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Parental presence at induction
• conflicting data!
• dependent on parental personality
• extremely context sensitive (cultural, religious, ethnic differences)
(studies US vs non-US countries)
28/01/2016 BAPA RC 38
Manyande, et al. Cochrane Database Syst Rev 2015
Rosenbaum, et al. Pediatric Anesthesia 2009
Wright, et al. Can J Anaesth 2010
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Parental presence at induction
28/01/2016 BAPA RC 39
Preparing parents to be present for their child’s anesthesia induction: a randomized controlled trial
More self-efficacy about their role in the OR
Audiovisual aid viewing immediately before pediatric
induction moderates the accompanying parents’ anxiety
Moderates the increase in anxiety associated with the anesthetic induction of their child
Bailey, et al. Anesthesia & Analgesia 2015
Berghmans, et al. Paediatr Anaesth 2012
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28/01/2016 BAPA RC 40
Alternative interventions
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Alternative interventions
28/01/2016 41
parental acupuncture
clown doctors
hypnosis
low sensory stimulation
hand-held video games
maybe helpful in reducing
children’s anxiety and
improving their cooperation
Manyande, A., et al. Cochrane Database Syst Rev 2015
BAPA RC
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28/01/2016 42
Alternative interventions
Is an effective method of reducing anxiety
Mifflin, et al. Anesth Analg 2012
Lee, et al. Anesth analg 2012
Streamed video clipsCartoon distraction
BAPA RC
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28/01/2016 BAPA RC 43
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28/01/2016 44
Alternative interventions
Fortier, et al. Pediatric Aesth 2015
Seiden, et al. Padiatric Anesth 2014
BAPA RC
Tablet-based interactive distraction (TBID) vs oral midazolam
to minimize perioperative anxiety in pediatric patients
Treating perioperative anxiety and pain in children: a
tailored and innovative approach - Web-based
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Alternative interventions
28/01/2016 BAPA RC 45
• environmental interventions
• equipment modification
• social interventions, including communication
Other potential areas for future research
Manyande, et al. Cochrane Database Syst Rev 2015
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28/01/2016 BAPA RC 46
Pediatric Anesthesia Teams
Use Sweet Smells to Calm
Preoperative Patients
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28/01/2016 BAPA RC 47
Premedication
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Why premedication?
• perioperative anxiety is associated with adverse outcomes
• premedication is associated with reduced anxiety (childand parents)
• reduced postoperative behavioral changes
• parents more satisfied with surgical experience
• premedication with clonidine reduces postoperative pain
• midazolam results in antegrade amnesia
28/01/2016 BAPA RC 48
Rosenbaum, et al. Pediatr Anesth 2009
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Premedication
28/01/2016 49BAPA RC
Short-acting, water-soluble benzodiazepine
Route/oral 0.25 – 0.5 mg/kg
nasal 0.2 mg/kg
Midazolam
Clonidine
Route/oral 2 – 4 μg/kg
nasal 2 – 4 μg/kg
α2 – adenoreceptor agonist
Route/oral 1 – 4 μg/kg
nasal 1 – 2 μg/kg
Dexmedetomidine α2 – adenoreceptor agonist (affinity x8)
Coté J, et al. A practice of Anesthesia for Infants and Children. Fifht edition, Saunder Elsevier, 2013
Rosenbaum, et al. Pediatr Anesth 2009
Onset of
action
delayed
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Disadvantages - midazolam
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Disadvantages - midazolam
• high levels of impulsivity may be a contra-indication
• 14.1 % of children do not respond to midazolam and still exhibit extreme distress in a subgroup of younger children who are more emotional and more anxious at baseline
• preoperative sedation was associated with increased incidence of adverse postoperative behavior changes
• paradoxally midazolam does not diminish EA/EDFinley, et al. Can J Anaesth 2006
Kain, et al. Anesthesiology
McGraw, et al. Pediatric Anesth 1998
Dahmani, et al. Anesthesiol 2012
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Advantages – clonidine
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Premedication / clonidine vs midazolam
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Dahmani, et al. Acta Anaesthesiol Scand 2010
• clonidine is superior in producing sedation
• decreasing post-operative pain and ED/EA
• superiority of clonidine for PONV prevention remains unclear while other
factors such as nausea prevention might interfere with this result
• premedication with oral clonidine appeared to be superior
• quality of mask acceptance comparable between both groups
• clonidine better accepted by the child
• more effective preoperative sedation
• trend towards better recovery from anesthesia and had a higher degree
of parental satisfaction
Almenrader, et al. Paediatr Anaesth 2007.
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Dexmedetomidine
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Sun, et al. Pediatr Anesth 2014
Pasin, et al. Pediatr Anesth 2015
Two recent meta-analyses comparing dexmedetomidine and midazolam
premedication
• better satisfactory sedation upon parent separation and mask
acceptance
• reduced rescue analgesia
• reduced agitation or delirium and shivering postoperative period
• prolonged sedation and risks of heart rate and blood pressure
decrease
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Dexmedetomidine
‘The significance and the optimal dose of nasal dexmedetomidine
still need to be defined. It may be that, in the future, a small dose of
midazolam combined with dexmedetomidine will be the optimal
choice.’
Johr, M. and T. M. Berger. Curr Opin Anaesthesiol 2015
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Why we should not use premedication
• premedication to a child who does not want it and maystruggle may not be recorded
• implementation of multimodal information packages is a valid alternative
• parental presence will also reduce its need
• midazolam has a number of undesirable characteristics
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blocking behavioral change with sedation may interfere withadaptive responses
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Restraint
• positive application of force, with the intension of overpoweringthe child, applied without the child’s consent
• controversial – ethical dilemma
• could be regarded as physical assault and consent should beasked from the parents - the parents may feel that temporaryrestraint is justified
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Homer, J. R. and S. Bass. Paediatr Anaesth 2010
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Risk inhalation vs IV induction
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Aguilera, et al. Paediatr Anaesth 2003
Ortiz, et al. The Cochrane Library 2014
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Conclusions (1)
• minimize psychological trauma related to anesthesia andsurgery
• could be predicted to some extent
• hospital-related stress cannot be focused completely on just theinduction
• pyramid of increasing preparation programs
• not all children need full application of all methods (only a few children require a psychologist)
• for most of the children distress, anxiety and fear associatedwith anesthesia is transient
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Conclusions (2)
• shaping and exposure (i.e. practise with the anesthesia mask)
• parental use of distraction – enhancement of parental self-efficacy
• avoid distress promoting behavior
• maybe consider premedication in 6 months to 4 years old (these children are less likely to cope unless the anesthesiologist knows how to handle them)
• streamed video clips in the OR, tablets
• web-based development
• environment and equipment modification
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FAMILY-CENTERED
PEDIATRIC
PERIOPERATIVE
CARE
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Chorney, et al. Anesthesiology 2010.
BAPA RC
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Thank you for your
attention!