Pediatric: Preoperative anxiety

Incidence: 60% Shown to be consistent regardless of country, procedure or health care system

Who is at greatest risk?

  • Age > 7 years
  • Personality: Children who are shy, inhibited, introverted are at increased risk
  • Children who have anxious parents
  • Prior upsetting hospital experience
  • Only children (children without siblings)
  • Children who did not attend pre-school

Why treat it?

  • Anxiety can delay induction of anesthesia
  • Hinder recovery
  • Lasting detriment: Up to 10 % of children can have behavior problems up to 1 year after surgery

5 factors that provoke anxiety:

  • Thoughts of physical harm/injury
  • Separation from parents
  • Fear of unknown
  • Uncertainty about normal behavior
  • Loss of control

Pharmacologic Management
-Route given: oral > nasal> IM > rectal
Medication % usage/ route options & dose:

Midazolam (85%)

PO (0.5 mg/kg), nasal/sublingual (0.2–0.3 mg/kg), rectal (0.5-1 mg/kg)

Ketamine (4%)

PO (5-6 mg/kg), IM (2-5 mg/kg), nasal(3-5 mg/kg), rectal (5-6 mg/kg)

Fentanyl (3%)

PO (10–15 mcg/kg), IV (2 mcg/kg)

Dexmedetomidine (?)

Nasal (3 mcg/kg), IV (0.5-1 mcg/kg)

Clonidine (?)
PO (4-6 mcg/kg)

Non-Pharmacologic Management
Parental presence

  • Pros: Avoids the need for pre-operative sedatives, avoid separation anxiety
  • Cons: Adverse parental reaction and litigation if injury ensues, anxious parents, stress on anesthesiologist/OR staff, less effective than Midazolam

Child life

Work with children pre-op to reduce incidence of anxiety

Pre-op programs

Give parents and children an idea of what to expect on the day of surgery and reduce anxiety


Related Media

Keyword history




  1. Brophy CJ, Erickson MT. Children’s self-statements and adjustment to elective outpatient surgery. J Dev Behav Pediatr. 1990 Feb;11(1):13-6.
  2. Bar-Mor G. Preparation of children for surgery and invasive procedures: milestones on the way to success. J Pediatr Nurs. 1997 Aug;12(4):252-5.
  3. Kain ZN, Mayes LC, O’Connor TZ, Cicchetti DV. Preoperative anxiety in children. Predictors and outcomes. Arch Pediatr Adolesc Med. 1996 Dec;150(12):1238-45.
  4. McCann ME, Kain ZN. The management of preoperative anxiety in children: an update. Anesth Analg. 2001 Jul;93(1):98-105.
  5. Visintainer MA, Wolfer JA. Psychological preparation for surgery pediatric patients: the effects on children’s and parents’ stress responses and adjustment. Pediatrics. 1975 Aug;56(2):187-202.

Defined by:  Catherine Ray, MD