Relief of injection pain in adults EMLA cream for 5 minutes before venepuncture

The effectiveness of skin anaesthesia after 5 minutes' topical application of a lignocaine-prilocaine cream was evaluated. One hundred and twenty patients estimated the pain of antecubital venepuncture both on a linear scale and verbally after use of the cream for either 5 or 60 minutes, a placebo cream or no treatment. Reported pain was significantly less after only 5 minutes of the lignocaine-prilocaine cream (p = 0.002). The cream can be used to relieve the pain of all routine injections.     

Local application of EMLA and glyceryl trinitrate ointment before venepuncture

One hundred unpremedicated fit day surgery patients aged between 27 and 68 years were allocated randomly into one of four groups and EMLA, glyceryl trinitrate, EMLA and glyceryl trinitrate or a placebo ointment was applied to the dorsum of a hand. The pain and ease of venepuncture were determined at induction of anaesthesia 60 minutes later. Pain scores were also reassessed 1-2 hours after operation. Lower pain scores and easier venepuncture occurred when EMLA and glyceryl trinitrate ointment was applied to the dorsum of the hand.     

Predicting which children benefit most from parental presence during induction of anesthesia

BACKGROUND: The purpose of this large-scale prospective cohort study (n = 426) was to identify child and parent characteristics that are associated with low anxiety and good compliance during induction of anesthesia when parents are present. METHODS: Outcome variables included child's anxiety and child's compliance during induction of anesthesia. Predictor variables included demographics, temperament, trait (baseline) anxiety, coping style, and locus of control. RESULTS: Results of a linear regression model (overall proportion of variance accounted for equals 39.5%) showed that significant predictors of anxiety during induction of anesthesia while parents are present included: the child's age (DeltaR(2) = 0.315, P = 0.0001), behavior during previous medical visits (DeltaR(2) = 0.025, P = 0.001), child's activity level (DeltaR(2) = 0.016, P = 0.007), parent's state (contextual) anxiety (DeltaR(2) = 0.022, P = 0.001) and parent's locus of control (DeltaR(2) = 0.009, P = 0.036). A linear regression model that was constructed with compliance of the child as the outcome revealed similar findings. CONCLUSIONS: Children who benefit from parental presence are older, had lower levels of activity in their temperament, and had parents who were calmer and who valued preparation and coping skills for medical situations. The practical implications of these findings are discussed.     

EMLA patch for spinal puncture. A comparison of EMLA patch with lignocaine infiltration and placebo patch

We have prospectively assessed pain and anxiety of spinal puncture in 180 adult patients randomly allocated to one of three equal groups. On the morning of surgery group 1 had an EMLA patch, whereas group 2 and 3 had placebo patches. Group 2 also had infiltration analgesia with 2 ml lignocaine 2% with adrenaline, immediately before the block. Spinal anaesthesia was performed with 25 gauge sharp needles without introducer or 25,27 gauge blunt needles with 20,22 gauge introducers. Patients assessed the spinal puncture pain on a 10-cm visual analogue scale immediately after removal of the needle. Pain scores were significantly lower in group 1 (EMLA), median 0.75, than in group 2 (placebo, infiltration analgesia), median 1.75, and group 3 (placebo), median 1.80, p < 0.0001. Pain intensity was less than expected in more patients in the EMLA group than in the other two groups, p = 0.034. However, the decision to accept/reject spinal anaesthesia in the future was not influenced by the pain of lumbar puncture. We conclude that application of an EMLA patch is a simple and effective method to provide adequate analgesia for spinal puncture, which also helps to allay patients' fears of spinal anaesthesia.     

The EMLA patch—a new type of local anaesthetic application for dermal analgesia in children

The skin application of EMLA cream under a Tegaderm dressing was compared in children with a new combined dressing/local anaesthetic patch—the EMLA patch. The analgesic effect during venepuncture was assessed using a visual analogue scale (patients) and a verbal rating scale (investigator). Skin adhesiveness and incidence of local skin reactions with the two types of application were also studied. The study was designed as an open randomised trial with two parallel groups. Sixty children, aged between 5 and 15 years were evaluated. After a minimum application time of 60 min an intravenous cannula was inserted. There was no difference in analgesia as assessed by the patients or the investigators. Mild discomfort at removal of the occlusive dressing/patch was observed in a few patients, but there was no difference in the adhesiveness of the Tegaderm dressing and the EMLA patch. Only mild local skin reactions (with paleness in the anaesthetised skin area) were observed in both groups. It was concluded that both the EMLA patch and the Tegaderm/EMLA cream dressing provide effective dermal analgesia for venepuncture with a 0.8 mm (outer diameter) cannula. The two types of application were indistinguishable but the ease of application of the patch is a distinct advantage.     

Motivation and parental presence during induction of anesthesia: an examination of the role of ethnicity and language

Objectives: To examine the role of ethnicity and language in parental desire and motivation to be present for children’s anesthesia induction. Aim: To compare motivation for parental presence at induction of anesthesia (PPIA) between English‐ and Spanish‐speaking White and Hispanic parents of children undergoing outpatient surgery. Background: The effectiveness of PPIA may depend, in part, on parental motivation and desire to be present at children’s anesthesia induction; however, cultural variables such as ethnicity and language have not previously been explored in this relationship. Methods/Materials: Participants included 258 parents of children undergoing outpatient surgery and general anesthesia. Parents were grouped by self‐reported ethnicity and primary language spoken into English‐speaking White (ESW, n = 55), English‐speaking Hispanic (ESH, n = 108), and Spanish‐speaking Hispanic (SPH, n = 95) groups. Measures included the Motivation for Parental Presence during Induction of Anesthesia (MPPIA) and a 4‐item measure of preference for PPIA. Results: The majority of parents (73%) expressed a preference for PPIA. Analyses controlling for group differences in socioeconomic status and demographic variables revealed that English‐ (P = 0.03) and Spanish‐speaking (P = 0.06) Hispanic parents reported significantly greater levels of desire to be present for their child’s anesthesia induction compared to English‐speaking White parents. English‐speaking Hispanic parents also reported greater levels of beliefs about the impact of anxiety on children’s anesthesia induction compared to English‐speaking White parents (P = 0.07). Conclusions: Parental ethnicity and language may impact desire and motivation for PPIA, which may subsequently impact the effectiveness of PPIA and child anxiety at anesthesia induction. Future research should examine the impact of parental characteristics, including cultural variables, on children’s preoperative anxiety.     

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.     

The safety of atropine premedication in children with Down''s syndrome

Forty-five operative procedures were performed in 32 patients with Down's syndrome at the Royal Alexandra Hospital for Children, Sydney in a single year recently. Atropine premedication was administered to 25 patients with Down's syndrome on 38 occasions. Three dosage regimes of atropine were used: 20 micrograms/kg, 12 micrograms/kg, both intramuscularly, and 10 micrograms/kg intravenously. There was no statistically significant difference in the alteration of heart rate for the three dosage groups of atropine used when children with Down's syndrome were compared with weight-matched control children having similar operative procedures performed.     

Parental presence during induction enhances the effect of oral midazolam on emergence behavior of children undergoing general anesthesia

Background:  Pre-anesthetic anxiety and emergence agitation are major challenges for anesthesiologists in pediatric anesthesia. Thus, sedative premedication and parental presence during induction of anesthesia (PPIA) are used to treat pre-anesthetic anxiety in children. The aim of the present study was to test if a combination of mother presence and midazolam premedication is effective for improving emergence condition in children undergoing general anesthesia.
Methods:  Sixty children were allocated to one of three groups: a sedative group (0.5 mg/kg oral midazolam), a PPIA group or a sedative and PPIA group. When anesthesia was induced with 7% sevoflurane in 100% oxygen, qualities of mask induction were rated. Anesthesia was maintained with sevoflurane (1.5–2.5%) in 60% oxygen and intravenous fentanyl 4 μg/kg. During emergence from anesthesia, the score of the child's emergence behavior was rated.
Results:  The children in the midazolam group showed a better quality of mask induction compared with those in the PPIA group, the addition of parental presence to oral midazolam did not provide additional improvement of mask induction. In contrast, the children in the midazolam + PPIA group were less agitated than those in the other groups at emergence from anesthesia.
Conclusion:  Parental presence during induction of anesthesia enhanced the effect of oral midazolam on emergence behavior of children undergoing general anesthesia.     

Comparison of the effect of EMLA and semicircular subcutaneous anaesthesia in the prevention of tourniquet pain during plexus block anaesthesia of the arm

In 54 patients who were to undergo surgery of the upper extremity in plexus block anaesthesia the effect of 5 g EMLA (group E) on tourniquet pain was examined and compared with the effect of a semicircular subcutaneous anaesthesia using 10 ml 0.25% bupivacaine (group B) or 10 ml 1% mepivacaine (group M). Among the patients with satisfactory brachial plexus analgesia allowing for surgery ( n  = 51), the incidence of tourniquet pain was not significantly different between groups E, M and B. Notably, there was no significant difference in the time of tourniquet application. We conclude that topical application of EMLA is as effective as a semicircular subcutaneous anaesthesia with mepivacaine or bupivacaine in the prevention of tourniquet pain during brachial plexus anaesthesia.     

父母陪伴对患儿七氟醚麻醉诱导时焦虑状态的影响

目的 评价父母陪伴对患儿七氟醚麻醉诱导时焦虑状态的影响.方法 全麻患儿120例,年龄2～12岁,体重12～32kg,ASA分级Ⅰ或Ⅱ级,采用分层随机法,将患儿随机分为2组(n=60):试验组(父母陪伴)和对照组(无父母陪伴).术前1 d分别与患儿及其父母沟通,均详细告知其麻醉诱导步骤和注意事项.术日试验组患儿由父母带人童趣化小儿麻醉诱导间一同玩耍,对照组则由医务人员带入一同玩耍.采用8%七氟醚和纯氧流量6 L/min预充呼吸环路60s后,试验组由父母将水果香味面罩贴于患儿面部并通过语言和动作安抚患儿,试验组则由医务人员进行,吸入8%七氟醚进行麻醉诱导.于术前访视、手术等候、诱导间玩耍15 min和麻醉诱导开始(T1～4)时行改良耶鲁术前焦虑评分(mYPAS),麻醉诱导期间采用麻醉诱导期合作度评分量表评价其麻醉诱导配合程度.记录麻醉诱导期间不良反应的发生情况.结果 与对照组比较,试验组T3,4时mYPAS评分降低(P＜0.05);对照组有3例诱导失败,试验组麻醉诱导均成功,两组麻醉诱导合作程度差异无统计学意义(P＞0.05);试验组2例咳嗽,对照组3例咳嗽、1例呕吐,两组不良反应发生率比较差异无统计学意义(P＞0.05).结论 父母陪伴可减轻患儿七氟醚麻醉诱导时的焦虑状态.

Abstract：

Objective To investigate the effect of parental presence on the anxiety of children during induction of anesthesia with sevoflurane. Methods One hundred and twenty children (ASA Ⅰ or Ⅱ ) aged 2-12 yr weighing 12-32 kg were assigned to one of 2 groups using a random number table ( n = 60 each): control group (group C) and parental presence group (group P). Preoperatiave visit was made the day before surgery in both groups. In group P a parent played with toys with the children for 15 min before induction of anesthesia, while in group C a nurse played with them. Anesthesia was induced with 8% sevoflurane in O2 delivered at 6 L/min through a scented face mask held by the parent or anesthesiologist talking with them in soft words. Modified Yale preoperative anxiety scale (mYPAS) was used to measure anxiety of the children during preoperative visit, before and during induction of anesthesia. Induction compliance checklist (ICC) was used to measure behavioral compliance during induction. ICC score ＞ 5 implied failure of induction of anesthesia with sevoflurane. Adverse events were recorded. Results The mYPAS scores were significantly lower before and during induction of anesthesia in group P than in group C (P ＜ 0.05), but there was no significant difference in ICC scores between the 2 groups ( P ＞0.05). There was no failure of induction in group P while in group C there were 3 failures. Cough occurred in 2 patients in group P but in 3 patients in group C. One patient vomited during induction of anesthesia in group C.Conclusion Parental presence is effective in reducing anxiety of children during induction of anesthesia.     

The effect of a priming epidural injection of adrenaline on epidural blockade with bupivacaine

Twenty-four patients receiving epidural anaesthesia were studied to test the hypothesis that 1:200,000 adrenaline administered into the epidural space 5 minutes before 20 ml bupivacaine 0.5% would improve nerve block and delay systemic absorption of the local anaesthetic. Group A/B received 20 ml adrenaline 1:200,000 5 minutes before 20 ml bupivacaine 0.5%, group S/BA 20 ml saline followed by 20 ml bupivacaine 0.5% with 100 micrograms adrenaline, and group S/B saline 20 ml followed by 20 ml plain bupivacaine 0.5%. Mean maximum plasma concentrations of bupivacaine tended to be lower in the adrenaline groups. A delay in the time to peak plasma concentration of bupivacaine was noted in the A/B group; this indicated that priming with adrenaline may be effective at delaying early systemic uptake of the local anaesthetic. In both adrenaline groups a more prolonged epidural block and increased efficacy were noted, although this was only significant for the duration of block at T6 (p = 0.023) and duration of motor block at Bromage level 1 (p = 0.016) in group A/B. There seems little clinical advantage in administering adrenaline 5 minutes before bupivacaine.     

Parental presence at induction of anesthesia: perceptions of a pediatric surgical department before and after program implementation

Introduction

Parental presence at induction of general anesthesia (PPI) is highly desired by children and parents. However, it often faces resistance from medical personnel. We conducted a survey evaluating the perceptions of surgeons before and after establishment of a PPI program.

Evaluation of intubating conditions with rocuronium and either propofol or etomidate for rapid sequence induction

We have assessed the effect of two induction agents on tracheal intubating conditions after rocuronium 0.6 mgkg⁻¹ in unpremedicated patients undergoing simulated rapid sequence induction. Following pre-oxygenation, anaesthesia was induced with propofol up to 2.5 mgkg⁻¹ ( n  = 35) or etomidate 0.3 mgkg⁻¹ ( n  = 36), and further increments as required. After loss of verbal contact, cricoid pressure was applied and rocuronium was injected. Laryngoscopy was performed at 45 s and intubation attempted at 60 s after rocuronium had been given. Ninety-four per cent of patients in the propofol group had clinically acceptable (good or excellent) intubating conditions compared to only 75% in the etomidate group (p = 0.025). Owing to coughing, one patient in the etomidate group could not be intubated on the first attempt. A greater pressor response also followed intubation after induction with etomidate. We conclude that etomidate and rocuronium alone cannot be recommended for intubation at 60 s under rapid sequence induction conditions.     

The effect of swabs soaked in bupivacaine and epinephrine for pain relief following simple dental extractions in children

We studied 133, ASA I or II children, aged 5-12 years undergoing general anaesthesia for simple dental extractions. Induction and maintenance of anaesthesia were achieved using sevoflurane in nitrous oxide and oxygen. At the end of surgery, patients had swabs soaked in a trial solution placed over the exposed teeth sockets. The bupivacaine group had swabs soaked in bupivacaine 0.25% with epinephrine 1:200 000, the saline group had swabs soaked in saline. Pain scores were recorded on a 4-point scale as follows: 0 = I don't hurt at all; 1 = I hurt a bit; 2 = I hurt a lot; 3 = I hurt the most. Nurse pain assessments and the patient's own scores were recorded at 15 and 30 min following recovery from anaesthesia. The median pain scores (2 at 15 min and 1 at 30 min postoperatively) were the same in both groups.     

Postoperative agitation in preschool children following emergence from sevoflurane or halothane anesthesia: A randomized study on the forestalling effect of midazolam premedication versus parental presence at induction of anesthesia

ObjectiveThe effect of midazolam premedication on forestalling postoperative agitation in children is not yet concluded. The purpose of this study was to compare the effects of midazolam premedication and parental presence during anesthetic induction on the incidence of postoperative agitation in pediatric patients.MethodsOne hundred sixty-seven children between 2 years and 7 years of age, undergoing anesthesia for outpatient surgery, were enrolled and randomly divided into four groups: sevoflurane anesthesia with parental presence without premedication, sevoflurane anesthesia with oral midazolam premedication, halothane anesthesia with parental presence without premeditation, and halothane anesthesia with oral midazolam premedication. The children randomized to the premedication groups took oral midazolam 0.5 mg/kg 20–30 minutes before anesthetic induction. For patients in the groups without premedication, one of the parents was present throughout the induction of anesthesia. One recovery room nurse blinded to the group assignment observed the patients and recorded the agitation scores all through their stay in the postanesthesia care unit.ResultsPostoperative agitation was significantly less in patients who received halothane anesthesia with oral midazolam premedication (p < 0.002).ConclusionBased on our data, the presence of a parent at induction of sevoflurance anesthesia was as effective as midazolam premedication in decreasing the incidence of postoperative agitation. Midazolam premedication, however, decreased postoperative agitation when halothane was used as the anesthetic agent.     

The effects of an educational programme on the anxiety and satisfaction level of parents having parent present induction and visitation in a postanaesthesia care unit

BACKGROUND: In Hong Kong, some hospitals have established the practice of Parental Presence Induction (PPI) and visitation in Postanaesthesia Care Units (PACU) for children receiving surgery. The literature indicates that parents reported extreme anxiety and discomfort after being present at induction of anaesthesia and suggests that it would seem appropriate to devise a programme of education to reduce anxiety for parents. METHODS: A quasi-experimental pretest and post-test design was employed. Parents in the experimental group received an educational programme about the role and expectations of parents having PPI and visitation in PACU together with an information pamphlet. The comparison group received routine (verbal) instructions. The Chinese version of the State and Trait Anxiety Inventory and the Parental Satisfaction with Care Questionnaire were used to assess parents' anxiety and satisfaction with care. RESULTS: A total of 50 parents (mostly mothers) were recruited. Twenty-five were allocated in the intervention group and 25 in the comparison group. The children were aged 1--9 years with a mean age of 2.9 years. There were 46 male and four female children. The results demonstrate that parents who received an education programme reported a decrease in anxiety (P < 0.001) and an increase in their satisfaction with the care provided (P < 0.001). A significant negative relationship (r= -0.61, P < 0.001) between parental anxiety postoperatively and the satisfaction with care score was also obtained, suggesting that lower levels of parental anxiety are associated with higher levels of satisfaction. CONCLUSIONS: The study suggests that an educational programme preparing parents for their child's induction of anaesthesia and visitation to the PACU should be offered, as it can reduce their anxiety with the practice of PPI and visitation in the PACU and increase parents' satisfaction with care.     

A comparison of 1% ropivacaine with a mixture of 0.75% bupivacaine and 2% lignocaine for peribulbar anaesthesia

In a single centre, randomised, double-blind study, 54 patients underwent intraocular surgery under peribulbar anaesthesia with either ropivacaine 1% or a mixture of bupivacaine 0.75% and lignocaine 2%, both with hyaluronidase 7.5 iu.ml-1. There were no significant differences in volume of anaesthetic required, time to onset of block, peri-operative pain scores or frequency of adverse events between the ropivacaine group and the lignocaine and bupivacaine group.