An interim analysis of a cohort study on the preoperative anxiety and postoperative behavioural changes in children having repeat anaesthetics

Introduction Anxiety in the preoperative period and at induction of anaesthesia in children is associated with disturbances in postoperative behaviour 1 - 4 ). There is little work looking at the effects of repeat anaesthetic procedures on anxiety and subsequent postoperative behaviour disturbances. The aim of this study was to see if the effect of repeat anaesthetics was cumulative on postoperative behavioural problems and whether repeated anaesthetics provoke increasing anxiety. We investigated factors that may identify children who are susceptible to behavioural changes following repeat anaesthetics. We present an interim analysis of data on 8 patients as part of a long‐term cohort study on 40 children with retinoblastoma who have required repeat anaesthetics for assessment and treatment of their condition. Method Approval for this study was granted by the East London and City Health Authority ethics committee. 40 patients are being recruited and being followed over a two year period. All children have retinoblastoma and are between the ages of 18 months to 4 years. The anaesthetic technique was not standardised but details of it were collected. Data collected were demographic details of child (age, sex, weight, ASA grade, siblings, stressful events in the last 3 months, recent immunisations, number of previous anaesthetics, problems with previous general anaesthetics, medical history of children, temperament of child using the EASI scoring system ( 4 ); demographic data of parents (age, parental education, family members affected, baseline measure of parental anxiety using State trait anxiety inventory (STAI). Anxiety on entry into the anaesthetic room and at induction was measured by the modified Yale preoperative anxiety scale (mYPAS), cooperation of the child at induction was measured by the Induction compliance checklist (ICC). Anxiety of the parent after induction was measured by the STAI score. Behaviour was measured at 1 day, 1 week, 1 month and 4 months after each procedure by means of the post hospital behaviour score (PHBQ) ( 5 ). A comparison with preoperative behaviour was made and data is presented of the percentage of children with new negative behavioural problems. A detailed analysis of the types of behaviour change was noted. anova for repeat measures with multiple dependent measures was used to analyse data on child anxiety and postoperative behavioural problems. Results Eight patients have had 3 separate anaesthetics over one and a half years. These have been at 4 monthly intervals. There was no significant increase in anxiety levels with repeat anaesthetics. The median mYPAS score at induction were 100 for all 3 anaesthetics. (P = 0.41). The type of behavioural change was variable and demonstrated no trend. No patient was identified as being prone to behavioural changes after every anaesthetic. Patients who displayed new negative behavioural problems would have them after any anaesthetic with no obvious cumulative effect with each repeat anaesthetic. Conclusions Our patients had maximum anxiety scores at induction, so the mYPAS scoring system is not sensitive enough to show that repeat anaesthetics provoke increasing anxiety. There is a very random pattern to behavioural disturbances after repeat anaesthetics with no evidence that negative behavioural changes are compounded with repeated anaesthetics. Collection of complete data from the remaining 32 patients may yield some trends regarding behavioural disturbances but our use of the mYPAS to measure anxiety in this very anxious population is unlikely to be helpful.     

Répercussions psychocomportementales en périopératoire chez l’enfant

The relevant literature since the 1940s has been collected from the Medline database, using the keywords: child, operation, anxiety, distress, postoperative complications, preparation, premedication, parental presence, prevention. Preoperative anxiety, emergence delirium, and postoperative behavior changes are all manifestations of psychological distress in children undergoing surgery. Preoperative anxiety is most prominent during anaesthesia induction. Emergence delirium is frequent and somewhat independent of pain levels. Postoperative behavior changes most often include separation anxiety, tantrums, fear of strangers, eating problems, nightmares, night terrors and bedwetting. These difficulties tend to resolve themselves with time but can last up to one year in some children. The major risk factors for postoperative behavior problems are young age, prior negative experience with hospitals or medical care, certain kinds of hospitalization, postoperative pain, parental anxiety, and certain personality traits of the child. Currently, tools exist for quantifying anxiety (m-YPAS) and postoperative behavior (PHBQ). It is possible to identify those children who are at risk for postoperative complications during the preanaesthesia consultation by paying close attention to children under six years with higher levels of emotionality and impulsivity and poorer socialization skills with anxious parents. Suggested strategies for reducing child distress include preoperative preparation, premedication, parental presence during anaesthesia induction, and interventions affecting the child's environment, such as hypnosis. There are numerous ways to provide preoperative preparation (information, modeling, role playing, encouraging effective coping) and their effectiveness is proven in the preoperative setting but not during anaesthesia induction or in the operating room. Midazolam has been shown to be an effective preoperative sedative for reducing anxiety. Parental presence during induction has been shown to effectively reduce preoperative anxiety in children in certain contexts (when the parent is calm and the child is anxious). It is worthwhile if it is integrated into a family-centered anxiety management program and remains one of several options offered to families. Overall, taking into account the child's psychological needs should be considered an essential part of paediatric anaesthesia. Tools and techniques are available for assessing and managing the perioperative distress experienced by children.     

Oral midazolam premedication for paediatric day case patients

Forty-nine children having day-stay surgical procedures were randomly assigned to receive oral midazolam 0.75 mg·kg^?1 or placebo in a double blind fashion. The child's level of anxiety was assessed before premedication using parental, child and observer scales. The child and observer anxiety scores were repeated in the anaesthetic room. Most children presented for anaesthesia in a calm state, irrespective of whether they had received midazolam. Parents tended to overestimate their child's level of anxiety. Observer anxiety scores reliably predicted behaviour during induction of anaesthesia in the absence of a sedative. Observer scores decreased in the midazolam group (P<0.02), but not in the placebo group, children below six years having the greatest decrease with midazolam. The median time to discharge from hospital was delayed by 30 min in the midazolam group (P<0.01). Children do not require routine sedative premedication for day case procedures, but oral midazolam is useful in producing calm behaviour in those children with high observer anxiety scores.     

Preoperative parental information and parents' presence at induction of anaesthesia

Preoperative preparation of paediatric patients and their environment in order to prevent anxiety is an important issue in paediatric anaesthesia. Anxiety in paediatric patients may lead to immediate negative postoperative responses. When a child undergoes surgery, information about the child's anaesthesia must be provided to parents who are responsible for making informed choices about healthcare on their child's behalf. A combination of written, pictorial, and verbal information would improve the process of informed consent. The issue of parental presence during induction of anaesthesia has been a controversial topic for many years. Potential benefits from parental presence at induction include reducing or avoiding the fear and anxiety that might occur in both the child and its parents, reducing the need for preoperative sedatives, and improving the child's compliance even if other studies showed no effects on the anxiety and satisfaction level. The presence of other figures such as clowns in the operating room, together with one of the child's parents, is an effective intervention for managing child and parent anxiety during the preoperative period.     

The effect of videotaped preoperative information on parental anxiety during anaesthetic induction for elective paediatric procedures

Introduction: It has long been recognised that parents of children scheduled for elective surgery experience high levels of pathological anxiety (1). Providing parents with information about anaesthesia, surgery and postoperative recovery has been identified as a tool for reducing anxiety (2–4). The purpose of this study was to determine whether audiovisual information, describing the process of undergoing and recovering from anaesthesia, could reduce anxiety levels and desire for information in parents before their child's induction of anaesthesia. Methods: The study was approved by our local ethics committee. 111 Parents were recruited into this study. Of these 56 were randomised to a control group and 55 to an intervention group. All parents completed the Amsterdam Preoperative Anxiety and Information Scale (APAIS) questionnaire on admission to hospital on the day of surgery and then again just before accompanying their child to the anaesthetic room. This is a tool for assessing preoperative anxiety and need for information, which has previously been validated in the parents of children presenting for surgery (5). In addition to the normal preoperative preparation, parents randomised into the intervention group watched a short 8 min information video after completing the first questionnaire. The video illustrated the events and procedures surrounding a child's admission to hospital for day‐case surgery, including the induction of anaesthesia. Results: There was no statistically significant difference in child demographics, type of surgical procedure, parental demographics, parental experience or STAI‐Trait scores between the two groups (P > 0.1). A repeated measures ANOVA for APAIS scores revealed a significant group × time interaction for all three measures, Anxiety Scale (F (1,109) = 6.2; P < 0.05), Need for Information Scale (F (1,109) = 7.7; P < 0.01) and total score (F (1,109) = 11.1; P < 0.001). Further analysis revealed that the intervention group demonstrated a reduction in anxiety (effect size 0.47), need for information (effect size 0.53) and total scores (effect size 0.63) as measured by the APAIS, compared with controls ( Figure 1 ).

Figure 1 Open in figure viewer PowerPoint APAIS scores: means and standard error bars for anxiety, desire for information and total, pre and postvideo.     

Anaesthesia induction in children: a psychological evaluation of the efficiency of parents' presence

BACKGROUND: The induction of anaesthesia for surgery is a stressful time for both child and parents. To treat preoperative anxiety in children, pharmacological methods (premedication) and behavioural methods (the presence of parents during the induction of anaesthesia) have been used, both independently and in combination. The purpose of this investigation was to study the effect of both premedication and parental presence on preoperative anxiety in a homogeneous population. METHODS: In this study conducted between January and April 2001 in the Meyer Hospital in Florence (Anaesthesia Department and Surgical Department), we studied 39 Italian speaking children aged 2-14 years who were undergoing minor surgery. Before the surgical intervention the State Trait Anxiety Inventory (STAI) questionnaire and a questionnaire for the social-demographic characteristics were given to the parents. The stress of the children was evaluated during induction of anaesthesia. We also studied behavioural areas of both children and parents with two specific questionnaires administered after the surgery. RESULTS: The STAI scores showed that the mothers had a higher level of anxiety compared with the fathers. The induction of anaesthesia for surgery was a stressful time for 23% of children of our sample. The correlation between stress of the child at induction and state (P = 0.034) and trait (P = 0.049) anxiety of parents was statistically significant. The child's loss of consciousness was for the majority of parents (56%) the moment of greatest stress and 97% of parents did feel useful during the induction of anaesthesia. There was a significant difference, P = 0.032, in the presence or absence of stress depending on whether the mother or father accompanied the child to the operating room. There was no significant difference in the presence of stress between children who did and did not receive premedication. CONCLUSIONS: Maternal presence, compared with the father's presence, is fundamental in helping to overcome anxiety in a child receiving anaesthesia. If the parents are present during the induction, the addition of premedication does not offer further benefit. Parents themselves judged their presence during the induction of anaesthesia in their child as a positive event. We also found a statistical significant correlation between anxiety of the parents with the level of the stress of the child during induction of anaesthesia.     

Should parents be present and assist during inhalational induction of their child? A survey of the APA

Introduction During the entire peri‐operative period the most stressful procedure a child experiences is the induction of anaesthesia ( 1 ). In our experience it may often be the fear of a stranger holding a mask over the child's face that precipitates the child attempting to escape. We have found that some children will more readily accept the facemask if it is held by the familiar parent/carer rather than a trained stranger. This can reduce the stress the child experiences at induction. The aim of this survey was to determine a consensus view from UK paediatric anaesthetic consultants regarding their practice of involving parents in inhalational induction of children. Methods A postal questionnaire was sent to all UK members of the APA. The results of replies were analysed. Results The response rate was 64% (141/220). (4 retired members returned blank questionnaires). 51.8% (65/137) said that they would sometimes allow parents to hold the facemask where appropriate. 41.6% (57/137) of respondents have never allowed it and 6.6% (9/137) stated that they routinely allow it. Six respondents said that the concept had never occurred to them. Two of these six expressed an interest in trying this option in future practice. 79.6% (109/137) of responding APA members report that they have always been comfortable with controlled parental presence in the anaesthetic room. 62 of these 109 members have routinely or sometimes allowed these parents to assist in holding the facemask, quoting both a general reduction in child and parental anxiety in a stressful and alien environment allowing a smoother induction. 20.4% (28/137) said that during their consultant paediatric anaesthetic career their views towards parental presence and involvement during induction had changed. The majority of these respondents (22) said that they were more likely to involve the parents and a minority (six) stated that their views had become more negative and found their presence and involvement ‘rarely of help’ and ‘more trouble than it's worth'. 32% (44/137) reported having experienced a variety of critical incidents whilst involving parents in induction. 61 incidents were reported (17 respondents experienced more than one type of critical incident). Parents refusing to let go of their child once asleep was the most common problem (28/61), followed by parents fainting in the anaesthetic room during their childs induction (25/61). Six consultants said that they had experienced a child becoming cyanosed at induction and two reported a laryngospasm. Overview The results of the survey show that the majority of responding APA members have always had (109/137), or have developed (22/137), positive views towards parental presence and assistance, where appropriate. The remaining 6 respondents expressed a fear of relinquishing control of the airway to an untrained person and in particular to one who is emotionally involved with the patient, although there were few reports of significant desaturation or laryngospasm. Of these six, three members said that involving the parent made induction slower and more demanding. The other three members stated that involving parents was unnecessary and inappropriate as they did not have the FRCA, and that this practice may as well lead to parents injecting propofol and performing regional blocks on their child! Discussion The majority of responses to this survey indicate that there is already an environment within paediatric anaesthesia which accepts managed parental presence, with or without assistance at induction, yielding benefits for both parent and child if not always for the anaesthetist. It is possible that the failure of recent studies to show a benefit of parental presence, may be explained by the inclusion of data reflecting unmanaged parents who transmit their anxiety to their child, or the effects of the lack of an active, well briefed parental role ( 2 - 4 ). The issue which may require more investigation is that of how to manage the roles available to parents in varying states of anxiety balanced with the preoperative state of their child and the demands placed on the anaesthetist to control risk, thus maximising the real and perceived benefits available.     

Audiovisual aid viewing immediately before pediatric induction moderates the accompanying parents' anxiety

Background: Parents accompanying their child during induction of anesthesia experience stress. The impact of audiovisual aid (AVA) on parental state anxiety and assessment of the child’s anxiety at induction have been studied previously but need closer scrutiny. Methods: One hundred and twenty parents whose children were scheduled for day‐care surgery entered this randomized, controlled study. The intervention group (n = 60) was exposed to an AVA in the holding area. Parental anxiety was measured with the Spielberger State‐Trait Anxiety Inventory and the Amsterdam Preoperative Anxiety and Information Scale (APAIS) at three time points: (i) on admission [T1]; (ii) in the holding area just before entering the operating theater [T2]; and (iii) after leaving [T3]. Additionally, at [T3], both parent and attending anesthetist evaluated the child’s anxiety using a visual analogue scale. The anesthetist also filled out the Induction Compliance Checklist. Results: On the state anxiety subscale, APAIS parental anxiety at T2 (P = 0.015) and T3 (P = 0.009) was lower in the AVA intervention group than in the control group. After induction, the child’s anxiety rating by the anesthetist was significantly lower than by the parent, in both intervention and control groups. Conclusions: Preoperative AVA shown to parents immediately before induction moderates the increase in anxiety associated with the anesthetic induction of their child. Present results suggest that behavioral characteristics seem better predictors of child’s anxiety during induction than anxiety ratings per se and that anesthetists are better than parents in predicting child’s anxiety during induction.     

Parents and paediatric anaesthesia: a prospective survey of parental attitudes to their presence at induction.

Parental presence at induction of anaesthesia is controversial and of disputed value. Ninety out of 117 parents replied to a preoperative questionnaire designed to identify their preference and motivation with regard to accompanying their children to the anaesthetic room. Half the parents wished to be present at induction, irrespective of the child's age or previous surgical experience and the most commonly cited reasons for this were the child's anxiety or the parents' sense of duty; 32% of these parents changed their preference if their child were to be adequately sedated preoperatively. In addition, 18% of all parents felt that they would prefer not to be present at induction. The results suggest that in circumstances where parents are to be excluded from induction, adequate preoperative explanation and sedative premedication would contribute to allaying parental anxiety, but that a flexible policy may be most appropriate.     

When are parents helpful? A randomized clinical trial of the efficacy of parental presence for pediatric anesthesia

Purpose

To examine the utility of parental presence to alleviate anxiety in a narrow age range of children undergoing outpatient surgery. We hypothesized that parental presence would lower anxiety scores as measured by the modified Yale Preoperative Anxiety Scale (mYPAS) at two time-points during pediatric outpatient surgery, i.e., separation from parents and placement of the face mask for anesthetic induction.

Method

Sixty-one children ages three to six years scheduled for various day surgery procedures participated in this study. The children were assigned randomly to either parental presence (n = 30) or parental absence (n = 31) groups. Observer-rated anxiety was measured by the mYPAS at five time-points during the surgery experience.

Results

Child anxiety was significantly lower in the parental presence group than in the parental absence group at the time-point when the children in the parental absence group were separated from their parents, t[59] = 2.15 (P = 0.001). However, no significant group differences in anxiety scores were noted at other time-points.

Conclusions

Our results suggest that anxiety levels in children undergoing day surgical procedures differ as a function of parental presence at the point when children are separated from parents. Future research should examine the types of interactions that occur during this time-point that may explain this finding.     

Pre-operative parent information and attitudes towards general anaesthetic induction technique in paediatric patients: An audit

Introduction It is a standard practice at our hospital to allow a parent to be present during induction of anaesthesia. Parents demonstrate a high degree of anxiety prior to their child's surgery. A struggling, crying child who then goes limp is emotionally upsetting to the parents ( 1 ). An anxious parent may increase the child's anxiety leading to various complications at induction. Adequate pre‐operative information regarding problems encountered during anaesthetic induction would help parents cope with this stress ( 2 ). The best practice would be that all the parents should be told about the preferred induction technique, intravenous or gas, an alternative technique if this fails and complications related to both. All parents should find the induction experience ‘better than’ or ‘as expected’ and be able to discuss their worries afterwards with a proficient member of the staff. The aim of this audit was to find out whether we gave adequate pre‐operative information to parents regarding anaesthetic induction and what were their attitudes towards this. Methods We designed a questionnaire which had two parts. Part A was filled in by the anaesthetist and part B by the parent who attended the induction. Results 50 patients were audited over a period of 3 months. Only 40% were told about both gas and intravenous induction. Only 58% were told why either technique was chosen. 10% of the parents found the induction experience to be ‘worse than expected’. 16% of the parents felt that the information given was ‘too little’. 12% were not able to discuss their worries afterwards with a proficient member of the staff. Conclusion Overall, the level of satisfaction was high with 90% of the parents finding the induction experience ‘better than’ or ‘as expected’. We fell short of the standards that we set up at the beginning of the audit. To improve parental satisfaction, adequate pre‐operative information is a must. Hence, considering a preoperative educational programme seems appropriate to improve our standards. We therefore make the following recommendations:

• 1 Detailed explanation by the anaesthetist to the parent regarding the general anaesthetic induction technique.
• 2 Use of audio‐visual aids, video‐tapes showing an anaesthetic induction.
• 3 Parental visit to the induction room to familiarise themselves with the environment.
• 4 Distribution of information leaflets to the parents explaining what to expect at anaesthetic induction.

Our next step is to design an information leaflet, put it on trial and then re‐audit.     

Anaesthesia induction in children. Ability to predict cooperation

This study identifies some of the preoperative characteristics that may influence a child's cooperation during induction of anaesthesia, and the ability of both resident and staff anaesthetists to predict cooperation. Five hundred unmedicated children aged 2–12 participated in the study. The characteristics that influenced cooperation were identified. Children four years of age or younger cooperated less regardless of race, gender or the technique used. Children who had had prior anaesthetics cooperated significantly less than those who had no previous anaesthesia. The child's response to a previous anaesthetic correlated with cooperation for the current anaesthetic. The child's cooperation during blood drawing correlated with cooperation during induction. Preoperative preparation resulted in improved cooperation ratings. No differences in cooperation were observed for different induction techniques. Success in prediction was correlated with the anaesthetist's training and experience. Anaesthetists had more trouble predicting difficult than smooth inductions.     

父母干预对患儿术前焦虑影响的研究进展

随着我国经济的发展和科技的进步,患儿围术期舒适化医疗也在逐步推进中。舒适化医疗不仅减轻了患儿身体的病痛,更避免了手术和麻醉等操作对其心理造成的永久性创伤。患儿术前焦虑发生率高于成年患者,可对患儿围术期及预后产生不良影响。不同患儿父母的特征,如父母焦虑水平、父母受教育程度、父母社会经济背景、家庭组成及种族和语言等因素会影响患儿的术前焦虑水平。父母参与指导患儿麻醉前准备、管理患儿禁食禁饮和陪伴患儿接受麻醉诱导等干预措施可缓解患儿的术前焦虑水平。对于残疾患儿,父母在围术期与医务人员的信息沟通和对患儿的干预管理更为重要。与传统的术前准备方案比较,基于互联网的家庭术前准备平台可以为患儿家庭提供更加全面、有效、个性化的信息指导,保障患儿围术期舒适化医疗。     

Parental Presence during Induction of Anesthesia versus Sedative Premedication: Which Intervention Is More Effective?

Background: Both midazolam and parental presence during induction of anesthesia are routinely used to treat preoperative anxiety in children. The purpose of this investigation was to determine which of these two interventions is more effective.

Methods: Anxiety of the child during the perioperative period was the primary end point. Secondary end points included anxiety of the parent and compliance of the child during induction. Children (n = 88) were randomly assigned to one of three groups: (1) 0.5 mg/kg oral midazolam; (2) parental presence during induction of anesthesia; or (3) control (no parental presence or premedication). Using multiple behavioral measures of anxiety, the effect of the intervention on the children and their parents was assessed.

Results: Observed anxiety in the holding area (T1), entrance to the operating room (T2), and introduction of the anesthesia mask (T3) differed significantly among the three groups (P = 0.032). Post hoc analysis indicated that children in the midazolam group exhibited significantly less anxiety compared with the children in the parental-presence group or control group (P = 0.0171). Similarly, parental anxiety scores after separation were significantly less in the midazolam group compared with the parental-presence or control groups (P = 0.048). The percentage of inductions in which compliance of the child was poor was significantly greater in the control group compared with the parental-presence and midazolam groups (25% vs. 17% vs. 0%, P = 0.013).     

Parents in the anaesthetic room: a questionnaire survey of departments of anaesthesia

Thirty departments of paediatric anaesthesia in the United Kingdom were sent a questionnaire about their policies and practices regarding parental presence in the anaesthetic room. Of 22 respondents, 100% left the decision about whether a parent should be present for induction of anaesthesia to the individual anaesthetist and only 14% had written policy guidelines. All departments permitted parental presence at induction for elective surgery, compared with 77% for emergency surgery and 55% for a rapid sequence induction. The minimum age of child below which parents were not allowed at induction varied between no age limit and one year.     

Parental Presence during Induction of Anesthesia: A Randomized Controlled Trial

Background: To determine whether parental presence during induction of anesthesia is an effective preoperative behavioral intervention, a randomized controlled trial with children undergoing outpatient surgery was conducted.

Methods: Eighty-four children were randomly assigned to a parent-present or parent-absent group. Using multiple behavioral and physiologic measures of anxiety, the effect of the intervention on the children and their parents was assessed. Predictors for the response to the intervention were examined using multivariate linear regression analysis.

Results: When the intervention group (parent-present) was compared to the control group (parent-absent), overall there were no significant differences in any of the behavioral or physiologic measures of anxiety tested during induction of anesthesia. Using the child's serum cortisol concentration as the outcome, parental presence, the child's age and baseline temperament, and trait anxiety of the parent, were identified as predictors of the child's anxiety during induction. Analysis of variance demonstrated that three groups showed diminished cortisol concentrations with parental presence: children older than 4 yr (P = 0.001), children whose parent had a low trait anxiety (P = 0.02), and children who had a low baseline level of activity as assessed by temperament (P = 0.05).     

Anaesthetic information for parents is IT the answer?

Introduction It is well documented that informing children and their parents about anaesthesia improves satisfaction ( 1 , 2 ), alleviates anxiety ( 3 ), increases co‐operation from the child and produces better postoperative behavioural outcomes ( 4 ). However the delivery of this information is problematic. Anaesthetic clinics are not the norm in this country, literature may not be read and pre‐anaesthetic assessment on the day of surgery provides little time to establish rapport and dissipate anxiety. Anecdotally it is becoming apparent that patients and their representatives are turning to die Internet to seek medical information. We postulated that a dedicated website might be used to provide appropriate information in a timely manner for parents of children scheduled for anaesthesia. We investigated whether parents have access to the Internet. whether they would be interested in such a website, if so how they would use it and whether this would influence anxiety levels and satisfaction In an initial questionnaire 90% of parents questioned replied that it would probably or definitely be useful, 28% of those who supported the idea had no Internet access. Methods The Local Ethics Committee granted approval. We produced a website, purpose‐designed to inform and advise the target population, layered to provide increasingly detailed information as the visitor navigated the site. Children scheduled for anaesthesia during a two‐week period were identified and written invitations and information were sent parents or guardians two weeks prior to the child's admission. They were contacted by telephone to establish eligibility to enrol. Telephone consent was taken 24 hours later, a pre‐operative anxiety and information scale APAIS ( 5 , 6 ) was completed and password‐coded access to the website was offered. Two to three days prior to anaesthesia they performed a further APAIS and the first part of a structured telephone interview was conducted. On the day of anaesthesia further APAIS were completed before and after the pre operative visit by the anaesthetist. Following discharge the structured telephone interview was completed. Results Sixty children were identified with a parent or guardian who could potentially be recruited into the study. Fifteen of these were excluded according to the study protocol (not contactable, wrong procedure date or ASA 3). Twelve (27%) of the remaining 45 parents did not wish to participate in the study (many volunteered that they were not interested in computers, not anxious or already well informed). Two enrolled but subsequently didn't complete the study because their child was postponed at short notice. Of the remaining 31, 4 (13%) parents participated but declined Internet access. The remaining 27 (60% of those invited) were given a password for the website. Fourteen of these parents used the website and the results show high levels of satisfaction. Sixteen of the 17 who did not use the site would have liked to, but did not because of lack of access to the Internet. The majority thought access to this information in outpatients or at pre‐assessment would have been helpful. The effect of the website information on the parental anxiety and satisfaction will be presented. Discussion There was enthusiasm for web based information even in parents with no Internet access. However, the high desire for parents to access more information about their child's anaesthetic was not reflected by a high number of Internet hits. Our data suggests the website is a useful source of information for the parents and in some cases provides considerable reassurance. A lack of computer availability disadvantages 53% of those parents who would have wished to see the website. Potential solutions are to provide access to the website in outpatients or to advertise the website with information about Internet access available to the public. Acknowledgements This project did not receive any financial support.     

Experience with parents’ presence during anaesthesia induction in children

Parents of 50 unpremedicated children were invited to be present during induction of anaesthesia in their children. The presence of the parents resulted in a significant decrease in the number of very upset or turbulent children during the pre-induction and induction periods, when compared to a control group that was induced without the parents’ participation. There was no difference in the children’s behaviour in the recovery room or at home following surgery. Most parents were calm and supportive during induction, and there were no complications related to their presence. It is concluded that for some preschool children, allowing the parents to support an anxious child during anaesthesia induction can be very effective in relieving anxiety, and minimizes the need for premedication.     

Distraction with a hand-held video game reduces pediatric preoperative anxiety

BACKGROUND: Video games have received widespread application in health care for distraction and behavior modification therapy. Studies on the effect of cognitive distraction during the preoperative period are lacking. We evaluated the efficacy of an interactive distraction, a hand-held video game (VG) in reducing preoperative anxiety in children. METHODS: In a randomized, prospective study of 112 children aged 4-12 years undergoing outpatient surgery, anxiety was assessed after admission and again at mask induction of anesthesia, using the modified Yale Preoperative Anxiety Scale (mYPAS). Postoperative behavior changes were assessed with the Posthospital Behavior Questionnaire (PHBQ). Patients were randomly assigned to three groups: parent presence (PP), PP+a hand-held VG, and PP+0.5 mg.kg-1 oral midazolam (M) given>20 min prior to entering the operating room. RESULTS: There was a statistically significant increase in anxiety (P<0.01) in groups M and PP at induction of anesthesia compared with baseline, but not in VG group. VG patients demonstrated a decrease in anxiety from baseline (median change in mYPAS -3), the difference compared with PP (+11.8) was significant (P=0.04). The change in anxiety in the M group (+7.3) was not statistically different from other groups. Sixty-three percent of patients in VG group had no change or decrease in anxiety after treatment, compared with 26% in M group and 28% in PP group (P=0.01). There was no difference in anxiety changes between female and male patients. CONCLUSIONS: A hand-held VG can be offered to most children as a low cost, easy to implement, portable, and effective method to reduce anxiety in the preoperative area and during induction of anesthesia. Distraction in a pleasurable and familiar activity provides anxiety relief, probably through cognitive and motor absorption.