To be a pediatric anesthesiologist one has to be able to manage the fear and anxiety that children and their parents experience perioperatively. Regardless of age, infants, children, and adolescents know that the “jig is up”, that something just isn’t right from the moment they awaken. Their parents appear apprehensive and may have taken a day from work, they aren’t allowed to eat and drink even though they are hungry and thirsty, the people they meet in the hospital are dressed in unusual clothing, the hospital itself smells weird, and depending on their age they are often afraid of getting stuck with needles or being separated from their parents. In older children and adolescents, they are anxious and don’t want to give up their autonomy and may fear the outcomes of surgery.
How to minimize this anxiety has been a primary focus of how we practice pediatric anesthesia from its earliest days. A pioneer who revolutionized our thinking and management of perioperative anxiety is Dr. Zeev Kain. His research and writing are must reads for anyone practicing pediatric anesthesia.1-5
In today’s PAAD, Yun and Caruso6 review “research-based anxiety scales and their relationship to clinically efficient scales, followed by an evidence-based summary of traditional and non-traditional anxiolytics.”
Just like when assessing pain, validated assessment tools now exist to Identify and measure pediatric perioperative anxiety.6,7 A thorough discussion of these tools is beyond the scope of today’s PAAD. For those of you who want to know more, please read both referenced articles by Yun in their entirety. Additionally, I’ve asked Dr. Yun to write another PAAD specifically on assessment tools that I will hopefully post in the next few weeks. In today’s PAAD, I will concentrate on treatment alternatives concentrating on “what’s beyond benzodiazepines and parental presence at the induction of anesthesia.” Myron Yaster MD
Original article
Yun R, Caruso TJ. Identification and Treatment of Pediatric Perioperative Anxiety. Anesthesiology. 2024 Nov 1;141(5):973-983. doi: 10.1097/ALN.0000000000005105. PMID: 39163600.
Benzodiazepines
The most commonly used perioperative anxiolytic is midazolam which can be effectively administered orally, nasally, intramuscularly, and rectally. The new kid on the block is remimazolam. As discussed in a recent PAAD (Sep 23, 2024 https://ronlitman.substack.com/p/remimazolam-and-emergence-delirium ) think of what you know about remifentanil and substitute the benzodiazepine midazolam for the opioid fentanyl and voila you have remimazolam. Like midazolam, it will not sting on injection. Like midazolam, it can be reversed by flumazenil. Like midazolam, it will cause only modest hypotension, if any. Like remifentanil, it is a “soft drug” that rapidly splits into metabolites through ester hydrolysis. Like remifentanil, it will not accumulate during long infusions, delaying recovery. And unlike propofol, It cannot cause propofol infusion syndrome because it is not propofol. (A similar syndrome has not been reported for benzodiazepines).
The FDA approved label for remimazolam states that “Safety and effectiveness in pediatric patients have not been established. No studies are available in any pediatric population and extrapolation of adult effectiveness data to the pediatric population is not possible.” And it also states “BYFAVO (remimazolam) should not be used in patients less than 18 years of age.” As pediatric clinical trials are completed and submitted to the FDA for pediatric approval, remimazolam will almost certainly find its way into our pediatric anesthesia toolbox.
Alpha-2-agonists
“Dexmedetomidine, a potent, selective alpha two receptor agonist, is a popular benzodiazepine alternative due to its mild analgesic, anti-emetic properties, maintenance of respiratory drive, and decreased risk of perioperative respiratory adverse events in patients with URIs. Disadvantages include a long onset time, inconsistent sedation, and poor oral bioavailability, necessitating intranasal or nebulized administration.”6 Clonidine, a less selective and much less expensive alpha=2 agonist can be used as an alternative but rarely is.
Ketamine
Although ketamine can be given orally (10 times the IV/IM dose) it is almost always used as the IM “dart”, usually in the most uncooperative, combative patients. In my view the dart is a better alternative to physical restraint and a “brutane” mask induction.
Augmented/virtual reality
The most commonly used non-pharmacologic approach to reduce perioperative anxiety is parental presence at induction. This minimizes separation anxiety but has only variable success. In his seminal research, Kain found that despite the hype surrounding parental presence, it simply wasn’t as effective as midazolam. In my own experience, having the parent in the OR was often better for the parent than the child and sometimes worse. It is a tool just like distraction, non-procedure-related conversation, humor, magic tricks, perioperative clowning, acupuncture, hypnotherapy, and music therapy.
Our dental colleagues have long used streamed video clips to reduce anxiety in their practices while their patients were in the dental chair. More recently anesthesiologists have begun to regularly use video and music on smart phones and/or tablets to facilitate the mask induction of anesthesia.8 The new kid on the block is augmented and virtual reality. “Virtual reality provides a completely immersive experience for the patient by utilizing an enclosed head-mounted display. Using computer-generated imagery to create a digital world, a combination of commercially available and custom software is available for pediatric patients. Due to decreasing costs and increasing commercial availability, virtual reality has expanded within healthcare specifically in the pre-, intra- and post-procedural care areas.”9 Indeed, some minor pediatric procedures traditionally requiring general anesthetics have been converted to virtual reality alone.,10 Using these headsets to start IVs preoperatively is in our near future. “Contraindications to virtual reality use include history of seizures, claustrophobia, migraines, motion sickness, and facial wounds. Also, patients less than six years are not ideal candidates due to size of the headsets, eye strain, and ethical concerns.”6
Are you using augmented/virtual reality in your practice? If you are can you pass along some tips and traps? Send your responses to Myron who will post in a Friday reader response.
References
1. Kain ZN. Parental presence during induction of anaesthesia. PaediatrAnaesth 1995;5(4):209-212.
2. Kain ZN, Mayes LC, Caramico LA, et al. Parental presence during induction of anesthesia. A randomized controlled trial. Anesthesiology 1996;84(5):1060-1067.
3. Kain ZN, Mayes LC, O'Connor TZ, Cicchetti DV. Preoperative anxiety in children. Predictors and outcomes. ArchPediatrAdolescMed 1996;150(12):1238-1245.
4. Kain ZN, Mayes LC, Cicchetti DV, Bagnall AL, Finley JD, Hofstadter MB. The Yale Preoperative Anxiety Scale: how does it compare with a "gold standard"? AnesthAnalg 1997;85(4):783-788.
5. Kain ZN, Mayes LC, Wang SM, Caramico LA, Hofstadter MB. Parental presence during induction of anesthesia versus sedative premedication: which intervention is more effective? Anesthesiology 1998;89(5):1147-56; discussion 9A-10A. (In eng). DOI: 10.1097/00000542-199811000-00015.
6. Yun R, Caruso TJ. Identification and Treatment of Pediatric Perioperative Anxiety. Anesthesiology 2024;141(5):973-983. (In eng). DOI: 10.1097/aln.0000000000005105.
7. Yun R, Hess O, Kennedy K, Stricker PA, Blake L, Caruso TJ. Assessing pediatric perioperative affect: A concise review of research and clinically relevant scales. Paediatric anaesthesia 2023;33(3):243-249. (In eng). DOI: 10.1111/pan.14568.
8. Patel A, Schieble T, Davidson M, et al. Distraction with a hand-held video game reduces pediatric preoperative anxiety. Paediatric anaesthesia 2006;16(10):1019-27. (In eng). DOI: 10.1111/j.1460-9592.2006.01914.x.
9. Wang E, Thomas JJ, Rodriguez ST, Kennedy KM, Caruso TJ. Virtual reality for pediatric periprocedural care. Current opinion in anaesthesiology 2021;34(3):284-291. (In eng). DOI: 10.1097/aco.0000000000000983.
10. Salimi-Jazi F, Sabapaty A, Santos Dalusag K, et al. Let Kids Play: Using Virtual Reality as a Substitute for General Anesthesia for Minor Procedures in Pediatric Population. J Pediatr Surg 2024;59(5):992-996. (In eng). DOI: 10.1016/j.jpedsurg.2024.01.002.