Reader response
Myron Yaster MD
From David Polaner MD, Professor University of Washington, Seattle Children’s Hospital
A quick comment regarding Matt Careskey’s response about ultrasound and radial artery placement.
I, too use ultrasound for almost every radial artery cannulation, but would add one suggestion to Dr. Caresky’s post. I scan both the radial and ulnar arteries before performing the puncture. It is surprising how many kids are “ulnar dominant”- their ulnar artery is substantially larger than the radial. When I see that I will preferentially cannulate the ulnar.
The only arterial cannulation that I can recall resulting in a problem was a femoral line in an infant for a craniosynostosis repair, placed because radial and ulnar pulses were difficult to detect and the vessels were so small on US. The actual catheter placement was easy, but when the drapes were removed the leg was as white and cold as a sheet, with no detectable perfusion. All the usual tricks did not result in perfusion returning to the leg, and we were forced to cancel the procedure, infuse a vasodilator, which eventually (and thankfully!) resulted in reperfusion.
From David Liston MD MPH, Lynn Martin MD MBA
We enjoyed reading the PAAD on November 5, 2024 in which Yun and Caruso reviewed their original article on the “Identification and Treatment of Pediatric Perioperative Anxiety”.1 While several approaches on the reduction of anxiety were discussed, one important one was missing – the use of parental presence during induction with or without induction rooms. Parental presence during induction of anesthesia has been repeatedly shown to be an effective strategy to reduce the child’s anxiety.2,3 This has been the primary intervention and a critical component of our family centered care efforts at Seattle Children’s since the 1990s.
We suspect induction rooms were not part of the conversation because most institutions simply don’t have them in their perioperative settings. However, the benefit of induction rooms should not be overlooked. Induction rooms facilitates the presence of not one but both parents or guardians during anesthetic induction in an environment that is less intimidating to the child. Operative rooms are anxiety provoking due to their inherent qualities of being cold, sterile environments with many types of tools and equipment on display. On the other hand, induction rooms can be designed to look like clinic rooms which are more familiar and less threatening to patients and allow parents to accompany their child in non-sterile attire during induction.
Given the paucity of literature on the subject, we conducted a study to determine if there was a difference between utilization of an induction room vs the operating room on child and parent perioperative anxiety.4 A single institution multi-site prospective observational study was conducted with a cohort of 51 healthy children aged 6-12 years old, receiving an outpatient tonsillectomy and/or adenoidectomy with their parent present at induction. Two psychological measures of anxiety, (a) momentary and (b) environmental, and one physiological measure of anxiety (i.e., electrodermal activity) were used. Additionally, child and parent trait anxiety was collected to provide a control for differences in trait anxiety between participants.
Our study found that children who underwent anesthetic induction in the induction room exhibited significantly less anxiety for all anxiety measures assessed compared to children who were induced in the operating room. Given these results, we believe that induction rooms deserve a place in this conversation as a viable design intervention to help mitigate pediatric perioperative anxiety. While we believe the benefits of induction rooms go well beyond anxiety prevention, such as the efficiency of performing non-operative tasks outside of the operating room (i.e. lines, airway management, regional anesthesia, etc.), we will leave that discussion for another time!
References
1. 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.
2. Li X, Qiao XF, Ren PX, et al. Parental presence during induction of anesthesia in children undergoing tonsillectomy and adenoidectomy. Eur Arch Oto Rhino Laryng 2023;280(12): 5475-82. PMID: 37707617.
3. Shih MC, Elvis PR, Nguyen SA, et al. Parental Presence at Induction of Anesthesia to Reduce Anxiety: A Systematic Research and Meta-Analysis. J PeriAnesth Nursing 2023;38(1): 12-20. PMID: 35896422.
4. Wingler D, Liston D, Joseph A, et al. Paediatr Anaesth. 2021 Apr;31(4):465-473. doi:10.1111/pan.14098. Epub 2021 Feb 28. PMID: 33278852.