PREMEDICATION AND INDUCTION OF ANESTHESIA IN PEDIATRIC SURGICAL PATIENTS

Abstract

Patients scheduled for surgery may look forward to the outcome of an operation, but they are unlikely to be happy with the process involved. Regardless of age, the patient relinquishes normal routines and, willingly or not, accepts the unpredictable and the unknown to be cured. The results of well-intentioned medical decisions made by parents on behalf of their children can be accompanied by stress, anxiety, frustration, and physical and emotional pain. Planning and carrying out a smooth transition from the child's awake “normal” state to a condition of surgical anesthesia is one of the anesthesiologist's ongoing challenges. Preoperative anxiety does little to enhance a child's subjective appreciation of the surgical experience and can have negative physiologic and psychologic effects. Unwillingness to undress, tearfulness, and difficulty in separating from parents may be followed by autonomic hyperactivity and dysrhythmias, hypersalivation, breath holding, and laryngospasm under the initial effects of anesthesia. Pediatric surgical patients may recall being held down and struggling against an inhalation induction as particularly traumatic. Moreover, parents and caregivers (nurses, anesthesiologists, surgeons) find that the child's struggle evokes feelings of anxiety and possibly guilt in themselves. This can be so stressful to the parent that he or she may feel the need to rescue the child from the surgical team. The grandmother of a 7-year-old girl about to undergo an umbilical hernia repair was so distressed by the child's perceived “struggling” during stage 2 of an inhalation induction that she scooped up the child and fled the operating room (OR).11 Children and adolescents themselves may strike out physically and verbally at those who are trying to help them, thereby creating a dangerous environment for all. Because of the anthropometric and developmental heterogeneity of the pediatric surgical population, the anesthesia care team must adapt to the specific needs of each child, tailor its approach to the emotional and pharmacologic preparation of the patient, and develop a strategy for addressing parental concerns.60 This article discusses how the child perceives the events surrounding anesthesia and surgery, and reviews strategies for minimizing anxiety and stress before and during anesthetic induction so that a more positive outcome may be achieved.