Case Synopsis
A 4-year-old boy presents for inguinal hernia repair. In the preoperative holding area, he appears scared and agitated and refuses to leave his mother’s lap. On separation, he cries and tries to escape from the anesthesiologist. One week after surgery, the mother reports major behavioral changes in the boy since his operation, including nightmares and temper tantrums.
Problem Analysis
Definition
The perioperative period is frequently an extremely traumatic time for both children and parents. Subjective feelings of tension, apprehension, and worry characterize preoperative anxiety in children. Preoperative anxiety stimulates sympathetic, parasympathetic, and endocrine systems, leading to increases in heart rate, blood pressure, and cardiac excitability. These reactions reflect the child’s fear of separation from parents and the home environment, loss of control, and fear of unfamiliar routines, surgical instruments, and hospital procedures. Thus it is no surprise that up to 65% of all children undergoing anesthesia and surgery develop extreme anxiety and fear during the perioperative period.
Of perhaps greater importance than the child’s behavior in the preoperative holding area is the child’s behavior after the surgery. Clinicians and investigators have long recognized postoperative psychological reactions such as general anxiety, nighttime crying, enuresis, separation anxiety, and temper tantrums. These behavioral changes are of particular concern if they persist for an extended period and negatively affect the child’s responses to subsequent medical care or interfere with his or her emotional and cognitive development.
Recognition
Children having anesthesia and surgery express many forms of anxiety. Some explicitly verbalize their fears, whereas others express their anxiety behaviorally. Many children look scared, become agitated, breathe deeply, tremble, stop talking or playing, or begin to cry. Others may wet themselves unexpectedly, have increased motor tone, and actively attempt to escape from medical personnel. The specific maladaptive behaviors in any particular child can vary widely. However, the most common ones are separation anxiety, eating problems, increased fear of doctors and hospitals, bad dreams or nightmares, and temper tantrums.
Perioperative anxiety is associated with increased levels of serum cortisol, epinephrine, growth hormone, and adrenocorticotropic hormone. Reports show a significant correlation between increased heart rate and blood pressure and behavioral ratings of anxiety. Preoperative anxiety is often associated with a relative vagal predominance in sympathovagal-mediated heart rate variability.
Risk Assessment
The incidence of preoperative anxiety in young children is reported to range from 40% to 60%. Children of anxious parents, shy and inhibited children, children with a history of previous surgery, children with a history of previous poor-quality medical encounters, and children ages 4 to 7 years are at increased risk for the development of preoperative anxiety.
Postoperative maladaptive behavioral responses, such as general anxiety, nighttime crying, enuresis, separation anxiety, and temper tantrums, occur in 13% to 40% of children 2 weeks after surgery; 3% to 20% of these children continue to demonstrate maladaptive behaviors 6 months after surgery ( Fig. 68.1 ). More significant behavioral changes, such as new-onset enuresis, are rare and present in only 0.8% of children. It is important to emphasize that although a large number of young children develop negative behavioral responses in the immediate postoperative period, the magnitude of these changes is limited, and only a minority of children have persistent, long-term maladaptive behavioral responses.
The child’s age, baseline temperament, number of siblings, enrollment in day care, and preoperative anxiety are all independent predictors for postoperative maladaptive behaviors in multivariate models ( Tables 68.1 and 68.2 ). Genitourinary surgery is associated with the highest incidence of postoperative behavioral changes. Pressure-equalizing myringotomy and tympanic membrane tube placement have the lowest incidence of postoperative negative behavioral changes.
| Predictor Variables | Outcome | Relative Risk (95% CI) |
|---|---|---|
| 4 vs. 6 years of age | Separation anxiety | 9.4 (1.2–39) |
| General anxiety | 3.3 (1.1–7.8) | |
| Not enrolled vs. enrolled in a day-care facility | Separation anxiety | 6.6 (1.2–29) |
| Very anxious mother vs. calm mother in the holding area a | Apathy and withdrawal | 6.6 (1.6–19.1) |
| Sleep anxiety | 3.9 (1.1–14) | |
| Separation anxiety | 3.4 (1.2–6.7) | |
| Child who is very anxious on separation vs. one who is calm on separation b | Eating anxiety | 4.2 (1.3–8.7) |
| No siblings vs. siblings | Separation anxiety | 3.5 (1.3–9.6) |
| Child who is very impulsive vs. one who is not very impulsive c | General anxiety | 2.7 (1.1–6.8) |
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