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

Subspecialty

Related Media

Keyword history

Sources

PubMed

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