PSYCHOLOGICAL ASPECTS OF ANESTHESIA FOR CHILDREN
Hospitalization and/or medical procedures can have profound emotional consequences for infants and children. Some children demonstrate behavior disturbances that persist long after the event. The extent of the upset is determined by several factors, the most important of which is the child’s age.
Infants younger than six months of age are not upset by separation from parents and readily accept a nurse as a substitute mother. From a psychological viewpoint, this is probably a good age for major surgery, although prolonged separation may impair parent-child bonding.
Older infants and young children (six months to five years) are much more upset by a hospital stay, especially with separation from family and home; ambulatory surgery is much less upsetting. Separation of a preschool age child from their parents at the time of surgery, even ambulatory surgery, is a stress that requires consideration. Explanations of procedures and the need for them are difficult at this age, and not surprisingly, these children show the most severe behavior regression after hospitalization.
School-age children are usually less upset by separation and more concerned with the surgical procedure and its possible mutilating effect. They often have the wildest misconceptions of what their operation involves. In contrast, adolescents fear the process of narcosis, the loss of control, waking up during the surgery and the possibility of not being able to face the process calmly. It is for these reasons that providing as much information as possible is essential along with assuring them that they will not awaken during anesthesia and feel the pain of surgery, and that they will awaken at the end.
The type and extent of the surgery is an important factor. Major surgery, craniofacial surgery, and amputation of a limb are especially distressing, and appropriate psychiatric support is encouraged. Surgery of the genitalia in particular may have important psychological implications in children over 18 months of age.
Factors other than age also influence the child’s emotional response. For example, a prolonged hospitalization is much more disturbing than a brief admission, although the former has been mitigated in part by having parents “live-in” with their children during hospital stays. Ambulatory surgery usually has a negligible emotional effect on most children whereas repeated hospitalizations and surgeries may cause significant psychological disturbance; a previous bad experience may be long remembered.
Children vary in their responses to impending hospitalization or medical intervention. Some seek information and participate keenly in preparation programs; they have an active coping style. These children are likely to benefit from psychological preparation and can be expected to cooperate. Others maintain an air of disinterest; they have an avoidant coping style (the “silent child”). Children in the latter group may not benefit and indeed may be further sensitized by efforts at psychological preparation. They may benefit more from an effective anxiolytic premedication (see later discussion).
Preoperative psychological preparation is very important and has been clearly demonstrated to be beneficial to many children. Usually this is accomplished by the parents, although the extent of preparation possible is determined by the child’s age. The basic objective is to explain to the child in simple, understandable, and reassuring terms what will happen at the hospital. Older children and adolescents should be prepared well in advance, as soon as hospitalization is arranged. Younger children should not be prepared too far in advance—it is unnecessary and will be a continuing source of worry for them. Rather, they should be prepared a day or so beforehand.
Hospital tours, puppet shows, and/or audiovisual presentations should be available, as all have been shown to be beneficial. Videotapes are most useful and may be loaned to parents. In some cities, prehospital preparation programs for children have been televised via community television stations on a weekly basis. In this way, a whole population of children can be prepared for the possibility of hospitalization, rather than just those scheduled for surgery.
Meeting with the Parents
“Being unable to choose parents for your patients, you must make do with those who come with the child … ; it would be abnormal if they showed no anxiety” Mellish, 1969
Parents are playing an increasingly active role in the perioperative care of their children; many expect to be present at induction of anesthesia and in the recovery room. However, some parents are more anxious than others, and this is readily perceived and may further upset the child. Good preparation of the parents reduces parental anxiety and indirectly helps the child.
There are many factors that influence the extent of parental anxiety when a child requires surgery. Even parents of children with only minor problems may initially be very anxious. Complete explanations and good communication with the medical and nursing teams usually do much to reduce their anxiety level. In particular, it is important to describe to parents how their child could respond during induction of anesthesia (eyes rolling up, movements of the arms and legs and turning of the head) and to reassure them that these are normal and expected responses.
The anesthesiologist is placed in a difficult situation when obtaining informed consent for general anesthesia; providing information on all the potential risks before a minor surgical procedure might well be expected to increase the level of anxiety of the parents. However, parents appear to benefit from an appropriate discussion of the risks of anesthesia in that this fulfills their own needs of responsibility and understanding. The parents should be permitted to dictate the extent of the information they wish to be given. Most parents of children having minor procedures accept that there are risks, including death, and prefer to have the opportunity for discussion of these risks. Such discussions should, of course, be outside the earshot of the young child.
In general, the anesthesiologist should rely on some well-established general principles in dealing with anxious parents. An approach that has been found most helpful in decreasing parental anxiety is one built on genuine warmth and friendliness, empathy, and understanding. Parents like to be listened to; discussions should allow ample time for questions and for the parents to express their concerns and ideas about the child and the proposed anesthesia process. Parents particularly wish to know about premedication, how their child will be anesthetized, monitored, and provided with postoperative pain relief. A videotaped explanation may be helpful, but should be augmented by a personal interview. An overall discussion of risks, in particular those specific to their child, helps to place risk in perspective. Assurance that their child’s anesthesia will be specifically designed with their child’s safety and the surgeon’s needs in mind also helps to relieve anxiety. Every parent will be pleased if you communicate the message, “We will take very good care and will be with your child all the time!”
Parental Presence at Induction
The question of the parents’ accompanying the child during induction of anesthesia requires special consideration. Many parents express a strong wish to be present, and many facilities routinely allow them to stay with their child. Studies are inconclusive as to the extent to which a parent’s presence can positively influence the emotional outcome for the child, but it may help the parent achieve satisfaction. Certainly many parents of handicapped children can often be of great assistance to the anesthesiologist. Many parents are calm and supportive of their child and appear to benefit from participating in the induction process.
The overanxious parent requires special consideration. Excessive anxiety is often of multifactorial origin and may not be entirely related to the child’s present surgical condition. These parents may not gain much reduction in their anxiety levels from additional information about the forthcoming procedure. An anxious parent who insists on remaining with the child may do more harm than good and may increase the child’s anxiety level. Such anxious parents should be counseled and excluded if possible. Adequate preoperative sedation of the child may help them to agree to this course. Certainly there is no benefit for parental presence for a neonate or infant who is not fearful of strangers due to their young developmental level or for the child in need of a rapid sequence induction. It must be clear that parental presence during induction for older children is a privilege given at your discretion in what you deem to be for the best interests of the child and the child’s safety.
The Anesthesiologist and the Child
Anesthesia, and particularly the induction period, is recognized to have the potential to cause psychological trauma. Studies indicate that anesthesiologists vary in their ability to relate to children and minimize this upset. An empathic approach to the child before and during medical procedures is preferred (e.g., “This may be a little uncomfortable and I know you are scared, but we are going to do all we can to help and it will soon be over. We don’t mind if you cry.” ) . The alternative directive approach ( “Hold still and be big and brave.” ) is generally condemned.
Premedication with an oral anxiolytic is beneficial in decreasing anxiety during separation, increasing cooperation during induction, and decreasing posthospitalization behavior disturbance.
Caution should be exercised in caring for the silent child who has an avoidant coping style, especially the child who must undergo repeat procedures because such a child may not respond as well to routine preparation methods. Some may respond more favorably if they are allowed to continue with their avoidant coping pattern but are given a well-chosen preoperative medication.
Preparing Infants and Children for an Operation
Try to meet the young child with the parents so that the child can see them accept you.
Direct most of your attention at all times to the child, even if he or she is developmentally delayed. Try to maintain eye contact; it helps to sit alongside the child, on the floor if necessary.
Talk to the child in simple terms that the child can understand.
Pay special attention to the silent child and recognize that he or she may be very upset. Consider the use of a suitable sedative premedication if not otherwise contraindicated.
Truthfully explain all the procedures to be undertaken in clear and simple terms, but avoid unnecessary alarming details. Some children may ask about the operation: try to help them understand what is to be done, using drawings if necessary. In many cases children grossly overestimate the extent of the procedure and must be reassured, for instance, about the small size of the incision.
Do not use the phrase “put you to sleep”—this may worry some children if they recall a family pet that never came back! It may also cause them to worry that they might wake up from their “sleep” when the operation starts or while it is still in progress.
Do not present the child with unpleasant and difficult choices. For example, avoid questions such as, “Do you want the needle or the mask?” Tell the child what you intend to do and then try to meet any special requests (e.g., “I do not want a needle, I want to go to sleep with the mask” or “I’d like to hold the mask myself”).
Avoid uncovering the child more than is necessary to complete the physical examination; many children get upset at being disrobed.
Television and especially hand-held computer games are wonderful distractions for the older child waiting in the preoperative area.
Allow the young child to bring a favorite toy or other security object to the operating room (OR). Label the toy with the child’s name; if it is a doll, suggest that perhaps the doll should also get a cast or a dressing applied during the operation. If the child is able, let him or her walk to the OR rather than be carried or wheeled: children are quite independent and feel more at ease walking.
If possible, allow those parents who are judged to be calm and supportive to accompany their child during the induction. If this is not possible, both the child and the parents may be helped by premedicating the child (e.g., oral midazolam, see page 88 ). The parents are much happier seeing their child leave them if he or she is very well sedated. It is sometimes useful to start an intravenous infusion away from the OR with the parents present, especially for handicapped or developmentally delayed children. The intravenous route can then be used for induction as soon as the child is taken to the OR. Always use local analgesia to insert the intravenous cannula; topical anesthetic cream is ideal if it can be applied well in advance (see page 634 ).
An empathic approach should be used to prepare the child. Small children who are crying during venipuncture can often be calmed by telling them, “We will put on a Band-Aid in a minute.”
Reassure older children and adolescents and provide them with careful explanations. They may be quite scared and have many questions. It is important to reassure them of the safety of the procedure and to emphasize that they will not wake up during the operation but will definitely wake up when it is over. Older children may also benefit from premedication (see page 87 ).
Use premedicant drugs whenever indicated; most young children will benefit.
Select the most appropriate induction technique for each child and proceed without delay. Cooperative children may be given a choice of one of three flavors to apply to the facemask to flavor the “magic laughing gas.” Do not allow a child to wait on the OR table longer than is absolutely necessary for the application of basic monitors. A pulse oximeter may be the only monitor that can be maintained during induction of anesthesia in a combative child.
Talk to the child throughout the induction period to explain or distract him or her from the procedures that are required. Ensure that all extraneous noises and conversations are excluded during this time. Only one person should be talking to the child. Quiet soothing music may help.
Tell the child what to expect during the recovery, where recovery will take place, and what discomfort they may experience. Carefully explain such items as eye patches, nasogastric tubes, and catheters as necessary and that they will be inserted while the child is anesthetized. A urinary catheter may look like a giant worm to an unprepared child! Assure the child that any pain will be treated.
Discuss in advance with the family and child the plan for optimal postoperative pain relief.
The parents should be allowed to be with their child as soon as it is practical—before the child awakens, if possible. Every effort should be made to provide good, but safe, analgesia. Regional nerve blocks, opioid infusions, patient-controlled analgesia, epidural opioids, and all ancillary techniques used for adults should be considered, discussed with the parents, and provided for infants and children when appropriate.
In the intensive care unit (ICU), the child’s problems are similar to those for adults: pain, lack of sleep, and later, boredom. In addition, children have their own special concerns, such as separation from the family. Special attention should be directed to pain relief, regular visitation by the parents, and provision of toys, games, and other distractions (e.g., television) as the child’s condition improves. Parents of children in the ICU benefit by being kept very well informed of their child’s condition and progress, and they must also be continuously updated on the treatment plans for their child.