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PERIOPERATIVE BEHAVIORAL STRESS IN CHILDREN

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Andrew Triebwasser, MD Clinical Assistant Professor of Surgery Department of Surgery (Anesthesiology) Warren Alpert School of Medicine of Brown University – PowerPoint PPT presentation

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Title: PERIOPERATIVE BEHAVIORAL STRESS IN CHILDREN


1
PERIOPERATIVE BEHAVIORAL STRESS IN CHILDREN
  • Andrew Triebwasser, MD
  • Clinical Assistant Professor of Surgery
  • Department of Surgery (Anesthesiology)
  • Warren Alpert School of Medicine of Brown
    University
  • atriebwasser_at_lifespan.org

2
Learning ObjectivesAT THE CONCLUSION OF THIS
ACTIVITY, PARTICIPANTS SHOULD BE ABLE TO
  • discuss the risk factors and developmental issues
    associated with perioperative behavioral stress
    in children
  • recognize the potential adverse outcomes
    associated with perioperative anxiety
  • cite specific interventions aimed at alleviating
    perioperative behavioral stress

3
Behavioral Perioperative Stress RISK FACTORS
DEVELOPMENTAL ISSUES
  • age cognitive development
  • prelogical?concrete?logical
  • risk ? with higher IQ (Kain 2001)
  • attachment (risk highest age 1-5)
  • temperament (shy ? risk)
  • environment
  • situational factors, parental coping
  • previous medical experiences

4
Anesthesia Postoperative Personality Changes
in Children
  • 18 month questionnaire data ENT pts
  • personality changes identified include
    bedwetting, apathy, sleep disturbances,
    separation anxiety, fear of subsequent
    procedures, aggression
  • ? younger age, unsatisfactory induction
  • experiences of hospitalization, anesthesia and
    operation not easily separated

5
Postoperative Behavior Changes
Eckenhoff 1953 Am J Dis Child Meyers 1977 Anesth Analg Hannallah 1983 Can Anaesth
Apathy Anxiety Enuresis Sleeping Eating 26 23 19 32 28 45 33 34 33 37 66 5 65
6
Preoperative Anxiety in ChildrenCORRELATION W/
POSTOP BEHAVIOR
  • anxiety measured in HU and separation
  • postoperative behavior changes correlated with
    anxiety of child and parent in HU
  • 54 overall at 2 weeks
  • 20 persisted for 6 months
  • 7.3 persisted for 1 year
  • nightmares, separation anxiety, eating disorders,
    fear of doctors most common

7
Behavioral Perioperative StressA RELATIVELY
RECENT CONCERN
  • preoperative anxiety in up to 40-60 of children
    (? separation induction)
  • stress hormone response and potential adverse
    outcome (Kicolt-Glaser 1998)
  • anxiety one of 5 most important low-morbidity
    outcomes (Marcario 1999) YET
  • apparent wide variability and underutilization of
    preventive modalities noted in pediatrics

8
Behavioral Perioperative Stress OVERVIEW
9
Anxiety the 6th vital sign?
  • tension, apprehension and worry related to
    separation, uncertainty and loss of control
    often accompanied by physical sensations
  • measurement tool validation m-YPAS
  • Kain. Child Neuropsychol. 19951203
  • 27 items in 5 domains of behavior
  • activity, emotional expressivity, arousal,
    vocalization and use of parents

10
Preoperative AnxietySIGNIFICANCE
  • anxiety during induction correlates with PACU
    excitement and postop changes (Kain 1999)
  • preoperative anxiety correlates with PACU
    agitation and postop changes (Kain 2004)
  • preoperative anxiety correlates with increase in
    pain scores and analgesic use (Kain 2006)
  • ?BP, HR neuroendocrine ?s with ? anxiety
  • cortisol, epi, NE (more pronounced pre-school)

11
Preoperative Anxiety and Postoperative Pain and
Behavioral Recovery in Young Children undergoing
Surgery
12
Perioperative AnxietyRISK FACTORS
  • 261 children between 2-12
  • m-YPAS throughout perioperative period
  • peaked at introduction of mask
  • low child sociability
  • high parental anxiety
  • correlated with behavior changes and pain

13
Learning ObjectivesAT THE CONCLUSION OF THIS
ACTIVITY, PARTICIPANTS SHOULD BE ABLE TO
  • discuss the risk factors and developmental issues
    associated with perioperative behavioral stress
    in children
  • recognize the potential adverse outcomes
    associated with perioperative anxiety
  • cite specific interventions aimed at alleviating
    perioperative behavioral stress

14
Preoperative AnxietySTRATEGIES
15
Preoperative AnxietyEDUCATION
  • may allay specific fears
  • fear of needles
  • fear of hunger and thirst
  • fear of separation
  • fear of being awake in OR
  • loss of autonomy
  • evolving methods of delivery
  • Spencer says
  • looking back..would have been much easier
    had I been better informed

16
Preoperative AnxietySTRATEGIES
17
Preoperative AnxietyEDUCATION preoperative
visit
  • individual attention and formulation of a plan
  • informed consent (risk) and assent
  • specific rehearsal for the day of surgery
  • numerous authors improved anxiety scores and
    quality induction
  • Varughese. Anesth Analg 2008 107413
  • Vetter. Anesth Analg 19937796
  • Vernon meta-analysis fewer postoperative
    behavior ?s (Dev Behav Pediatr 19931436)

18
Preanesthetic Videotape for Parental Preparation
experimental group
control group
measure Pre-video Post-video Pre-video Post-video P
SALT ( correct) 75.21.8 84.92.3 73.41.4 75.41.9 lt.02
STAI (anxiety) 40.51.7 36.01.4 39.21.5 37.71.2 lt.03
APAIS (total) 22.01.2 17.00.9 22.00.8 21.60.7 lt.0001
APAIS (anxiety) 12.70.8 9.00.6 12.60.6 12.20.5 lt.0001
APAIS (need info) 9.30.7 8.00.3 9.40.6 9.30.6 lt.0001
19
Education effectiveness of preoperative programs
cost
effectiveness
20
Preoperative AnxietySTRATEGIES
21
Behavioral InterventionsFAMILY-CENTERED ADVANCE
PROGRAM
n Cont 99 Midaz 98 PPIA 94 ADV 96 p
HU Anxiety 36 37 35 31 .001
Mask Anxiety 52 40 50 43 .018
PACU Fentanyl (ug/kg) 1.37 1.23 0.81 0.41 0.16
PACU (m) 120 129 122 108 0.40
  • Anxiety ?
  • Distraction
  • Video model
  • Add parents
  • No excessive reassurance
  • Coach parents
  • Exposure of child (shaping)

Kain. Anesthesiology 2007 10665
22
Preoperative AnxietySTRATEGIES
23
Preoperative AnxietyPREMEDICATION overview
  • classic indications no longer in play
  • oral midazolam most common (80-90)
  • ketamine, fentanyl, a-2 agonists
  • usage varies inversely with PPIA
  • more compliant induction than PPIA (Kain 1998), ?
    satisfaction when used in conjunction with
    (unprepared) PPIA
  • potential downsides efficiency, costs (drug
    personnel), paradoxical rxn

24
Evidence-based clinical update does
premedication with oral midazolam lead to
improved behavioural outcomes in children?
  • literature search for RCT with preoperative
    midazolam (M) with control arm (30)
  • M reduced anxiety at separation and induction
    (grade A) w/minimal effect recovery
  • inconsistent effect on PACU agitation
  • inconsistent effect on behavioral outcomes at
    home (some have had increased ?s)

25
Midazolam vs. Game-boy
  • prospective RCT
  • 78 children 4-12 yrs

26
MidazolamONE DISADVANTAGE
had pre-med
BUSTED!
27
Preoperative AnxietySTRATEGIES
28
Preoperative AnxietyBEHAVIORAL MODALITIES PPIA
  • PPIA increased from 1995-2002 BUT
  • 10 used PPIA gt75 of the time
  • 50 NEVER used it
  • 26 stated against hospital policy

1995
2002
29
An evidence-based review of parental presence
during anesthesia induction and parent/child
anxiety
  • review MEDLINE (1950-2008) and EMBASE (1980-2008)
    for RCT comparative studies
  • 14 studies provided best evidence
  • 9 RCT 4 prospective 1 retrospective
  • parental anxiety not alleviated compared to no
    PPIA, M or PPIA with M (10 studies)
  • child anxiety not alleviated compared to no PPIA,
    M, PPIA with M or PPIA with video game

30
Parental Intervention Choices for Children
Undergoing Repeated Surgeries
  • random assignment at first surgery to PPIA, M,
    PPIA M, no intervention
  • subsequent surgery
  • 70 who had PPIA chose it again
  • 23 who had M chose it again
  • PPIA was preferred in all groups regardless of
    initial intervention

31
PPIA importance of parent selection
  • 568 subjects age 2-12 multiply matched concurrent
    cohort analysis
  • STAI for parents mYPAS for children

child state anxiety during induction
cohort PPIA No PPIA
Calm parent and child 39.9 22 34.7 20
Calm parent, anxious child 51.9 24 64.6 26
Anxious parent, calm child 52.4 28 39.4 21
Anxious parent and child 71.0 23 66.6 27
32
Preoperative AnxietyPPIA the debate
  • PPIA diminishes separation trauma for child and
    need for premedication
  • does increase parent satisfaction but may
    increase stress (Kain 2003 ? HR)
  • numerous medico-legal issues cited
  • effects on induction controversial and depend on
    the child and the parent
  • shift focus on parent selection / preparation

33
Perioperative behavioral stress in children a
conceptual framework
34
P-CAMPISPERIOPERATIVE CHILD-ADULT MEDICAL
PROCEDURE INTERACTION SCALE
  • CAMPIS (Blount 1997) for painful procedures
    prototype for Caldwell-Andrews (2005)
  • interactions between children and adults in HU
    and OR coded via propietary program
  • 44 defined verbal and non-verbal behaviors
  • 6 adult codes / 3 child codes
  • child codes validated with m-YPAS
  • 40 of children age 2-10 displayed distress
    during induction and 17 is severe

35
Healthcare Provider and Parent Behavior and
Childrens Coping and Distress at Anesthesia
InductionBACKGROUND
  • to date, no study has evaluated the impact of
    specific healthcare provider and parent behaviors
    on childrens distress and coping during
    anesthesia induction

36
Healthcare Provider and Parent Behavior and
Childrens Coping and Distress at Anesthesia
Induction HYPOTHESES
  • adult behaviors will impact childs ability to
    cope with the stress of induction
  • emotion-based behaviors will tend to increase
    distress while distraction-based behaviors will
    tend to decrease distress
  • health care professionals and parents will take
    cues from each other

37
Healthcare Provider and Parent Behavior and
Childrens Coping and Distress at Anesthesia
InductionMETHODS
  • n293 (no dev delay, chronic illness, premed)
  • HU and inhalation induction videotaping
  • observer XT software allows differentiation of
    individual behaviors from the interactions of
    many, while linking behavior to initiator
  • state codes (duration) vs. event codes
    (frequency)
  • 4 raters (3 mos training) w/10 overlap each
    analysis taking approximately 4 hours

38
M P-CAMPISCODING SYSTEM
  • ADULT BEHAVIOR CODES
  • CHILD BEHAVIOR CODES
  • Medical reinterpretation
  • Non-procedural talk
  • Humor
  • Reassurance
  • Empathy
  • Empathic touch
  • Acute distress
  • Nonverbal resistance/cry
  • Anticipatory Distress
  • Verbal resistance
  • Request for support
  • Negative verbal emotion
  • Regulating Behavior
  • Non-procedure talk
  • Engaging in medical play
  • Seeking information

39
Medical reinterpretation
40
Results CORRELATION OF ADULT BEHAVIORS
  • interaction ? between nurse (N) parent (P) and
    anesthesiologist (A) parent
  • parents take cues from health providers and/or
  • adults all respond to the same cues from child
  • correlation highest non-procedural talk,
    reassurance, humor
  • A and P engaged in behaviors most frequently
  • A more medical reinterpretation
  • P more empathic touch

41
Results (Chorney et al) RELATION ADULT BEHAVIOR
- CHILDS DISTRESS
CHILD DISTRESS BEHAVIOR CHILD REGULATING BEHAVIOR
emotion-focused behavior (all adults) 0.575 -0.269
distracting behavior (all adults) -0.210 0.286
Reinterpretation
anesthesiologist -0.077 0.370
parent 0.202 0.042
nurse -0.020 0.023
Spearman rank order correlations P lt 0.001
42
Behavioral Perioperative Stress REASONABLE
GUIDELINES
  • encourage evaluation of anxiety (as in pain)
  • proactive role in preoperative assessment
  • MacLaren. Anesth Analg 20091081777
  • consider premedication and/or alternatives to
    inhalation induction in at-risk patients
  • encourage preoperative teaching and risk
    assessment facilitation of natural ? PPIA
  • multidisciplinary approach encouraged
  • evaluation of impact on postoperative endpoints

43
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