Inhalational induction of general anaesthesia for elective caesarean: ethical acceptability in treatment-resistant needle phobia?

We describe the anaesthetic management of a parturient who, due to a severe needle phobia, requested an inhalational induction of general anaesthesia for an elective caesarean section. If general anaesthesia is indicated, conventional practice in the UK is to perform a rapid sequence induction via an intravenous route of drug administration to allow rapid intubation of the trachea. This is because obstetric patients are considered to have a 'full stomach' due to the effects of pregnancy and labour on gastric emptying, and a higher risk of aspiration with consequent maternal and fetal adverse outcomes. Despite a thorough consent process highlighting these significant risks, the patient insisted on an inhalational induction of anaesthesia. We present the case and discuss the ethical dilemma (relating to patient care) in situations in which decisions made by patients deviate from medical recommendations.

Validation of a Simple Tool for Electronic Documentation of Behavioral Responses to Anesthesia Induction.

BACKGROUND: Anxiety and distress behaviors during anesthesia induction are associated with negative postoperative outcomes for pediatric patients. Documenting behavioral responses to induction is useful to evaluate induction quality at hospitals and to optimize future anesthetics for returning patients, but we lack a simple tool for clinical documentation. The Induction Compliance Checklist is a tool for grading induction behaviors that is well validated for research purposes, but it is not practical for routine documentation in busy clinical practice settings. The Child Induction Behavioral Assessment tool was developed to provide a simple and easy to use electronic tool for clinical documentation of induction behaviors. The aim of this study was to test the Child Induction Behavioral Assessment tool's concurrent validity with the Induction Compliance Checklist and the interrater reliability. METHODS: This prospective, observational study included 384 pediatric patients undergoing anesthesia inhalation induction. Concurrent validity with the Induction Compliance Checklist and interrater reliability of the Child Induction Behavioral Assessment were evaluated. Two researchers alternated scoring the Induction Compliance Checklist. The 2 researchers independently scored the Child Induction Behavioral Assessment. The anesthesia clinician caring for the patient also independently scored the Child Induction Behavioral Assessment by completing their routine documentation in the patient's medical record. Two age groups were evaluated (ages 1-3 and 4-12 years old). RESULTS: Clinicians' and researchers' Child Induction Behavioral Assessment scores demonstrated a strong correlation with the Induction Compliance Checklist (P < .0001). There was an excellent agreement between the 2 researchers' Child Induction Behavioral Assessment scores for the younger and older age groups, respectively (Kappa [95% CI] = 0.97 (0.94-0.99); K = 0.94 (0.89-0.99)]. The agreement between the researchers and the 117 clinicians who documented Child Induction Behavioral Assessment assessments in the medical record was good overall (intraclass correlation coefficient = 0.70), with fair agreement with the 1- to 3-year-old patients (intraclass correlation coefficient = 0.56) and good agreement for the 4- to 12-year-old patients (intraclass correlation coefficient = 0.74). CONCLUSIONS: The Child Induction Behavioral Assessment scale is a simple and practical electronic tool used to document pediatric behavioral responses to anesthesia inductions. This study provides evidence of the tool's validity and reliability for inhalation inductions. Future research is needed at other hospitals to confirm validity.

Anxiety during inhalation induction in paediatrics: Sitting versus supine position, a randomised trial.

STUDY OBJECTIVE: We evaluated if the sitting or supine positions affect anxiety levels induced by the application of a facemask in children. DESIGN: Prospective, randomised study. SETTING: Paediatric hospital, operating room. PATIENTS: Two to twelve years old children, 1-3 ASA status, undergoing inhalation anaesthesia for elective surgery. INTERVENTION: Children were randomly assigned to a sitting or supine position. After monitoring equipment was established, inhalation was inducted by the application of the mask. MEASUREMENTS: Child anxiety was then assessed with the modified Yale Preoperative Anxiety Scale (mYPAS) before the application of the facemask and following mask application. MAIN RESULTS: Overall, 99 children in the sitting group and 103 in the supine group were analysed. The mYPAS score was not different in both groups before the application of facemask (40 [28-51] versus 40 [28-53]; P=0.99). It increased (P=0.005) to a similar extent in both groups following mask application without difference between groups (48 [38-60] versus 48 [35-63]; P=0.95). Side effects were not different between both groups. CONCLUSION: In children undergoing inhalation induction, sitting or supine positions did not modify anxiety induced by the application of a facemask, nor adverse effects; therefore, children should be allowed to choose their preferred position.

Effects of different methods of general anesthesia on intraoperative awareness in surgical patients.

The purpose of the study was to investigate the effects of total intravenous anesthesia (TIVA) and combined of intravenous and inhaled anesthesia (CIIA) on intraoperative awareness in surgical patients.A total of 678 patients were recruited in the CIIA group, while TIVA group included 566 patients. The clinical characteristics and the occurrence of intraoperative awareness were compared between the groups. Mini-Mental State Examination, Generalized Anxiety Disorder 7, and Patient Health Questionnaire 9 tests were performed to estimate cognitive and psychological functions of the patients. In addition, logistic regression analysis was applied to identify the risk factors for intraoperative awareness in surgical patients.In CIIA group, 3 patients (0.44%) were confirmed with intraoperative awareness, while 11 patients (1.94%) in TIVA group underwent intraoperative awareness. The occurrence rate of intraoperative awareness was significantly higher in VITA group than that in the CIIA group (P = .029). Awareness classification demonstrated that intraoperative awareness mainly included auditory, tactile, and pain perceptions. Moreover, 4 patients showed distress after operation. Patients with intraoperative awareness exhibited poor performance in cognitive and psychological tests (P < .001 for all). Logistic regression analysis demonstrated that CIIA (odds ratio [OR] = 0.198, 95% confidence interval [CI] = 0.047-0.827), age (OR = 0.951, 95% CI = 0.908-0.997), midazolam application (OR = 0.158, 95% CI = 0.034-0.736), awareness history (OR = 10.131, 95% CI = 2.206-45.517), and duration of surgery (OR = 1.016, 95% CI = 1.001-1.032) were significantly associated with intraoperative awareness.Intraoperative awareness can significantly influence the cognitive and psychological functions of surgical patients. CIIA and midazolam application may lower the risk of intraoperative awareness.

[Case report: patient with needle phobia for caesarean section - not quite as in a textbook ]. / Kasuistik: Patientin mit Nadelphobie zur Sectio caesarea - Nicht ganz wie im Lehrbuch ...

In a 20-year old parturient general anesthesia is induced by inhalation and without venous access because of severe needle phobia. This article discusses risks associated with inhalational induction of anesthesia in this special situation. It deals with needle phobia, an anxiety disorder belonging to the group of blood-injury-injection phobia. This psychic illness can cause severe problems for the anaesthetic management in acute or in elective situations.

Undergraduates' perceptions of the value of practical inhalation sedation experience in a UK dental school.

AIM: This was to establish the level and reported value of paediatric IHS experience from the perspective of final year undergraduates and to evaluate whether those students with more experience expressed feeling better-prepared for future practice and more likely to undertake further postgraduate education in IHS. METHODS: All final year students were invited to complete an anonymous questionnaire designed to elicit undergraduate perceptions of IHS using visual analogue scales and free-text questions. RESULTS: A response rate of 77 % was achieved. Results revealed that only 21 % of participants reported acting as operator sedationist in ten or more IHS cases. Thus, the majority of undergraduates' did not meet the recommended quantity of practical IHS experiences, as outlined by the British Dental Sedation Teachers Group. In general, students felt on the value of IHS in the management of anxious children and expressed a desire to undertake further postgraduate education in conscious sedation. However, those students with more experience of practical IHS expressed feeling better able to describe the IHS experience with patients and parents, and were more satisfied with the quality of teaching. Furthermore free-text comments revealed that, regardless of experience, students wished to gain more experience of the practical administration of IHS. CONCLUSION: There is a need to increase the provision of IHS training within an undergraduate curriculum, in addition to improving the accessibility of postgraduate sedation courses.

Anesthesia induction using video glasses as a distraction tool for the management of preoperative anxiety in children.

BACKGROUND: Distraction technology suitable for the perioperative setting is readily available, but there is little evidence to show how it compares with oral midazolam in managing anxiety. Video glasses, which enable children to view and listen to cartoons and movies, may be used through the completion of inhaled induction. We compared the efficacy of oral midazolam and behavioral distraction with video glasses in managing preoperative anxiety in children. METHODS: In this prospective, randomized study, 96 children aged 4 to 9 years undergoing outpatient surgery were recruited to one of 3 intervention groups receiving midazolam, video glasses, or both. The Modified Yale Preoperative Anxiety Scale was the primary dependent measure used to assess anxiety at baseline before intervention, 20 minutes later at transport to the operating room (OR), and during mask induction. RESULTS: There was no significant increase in anxiety score within any group between baseline and OR transport (P = 0.21, 0.42, and 0.57 for midazolam, video glasses, and combined groups, respectively). An increase in anxiety, though not large enough to be clinically significant, was observed from baseline to induction in the midazolam and combined groups (P = 0.02 and 0.03) but not in the video glasses group (P = 0.38). Confidence intervals for pairwise comparisons in Modified Yale Preoperative Anxiety Scale changes among groups were all within a clinically significant difference of 15 units. CONCLUSIONS: The use of video glasses and midazolam alone or in combination maintains baseline levels of anxiety at time of transport to the OR and prevents significantly increased anxiety during induction of anesthesia in children. Video glasses are not inferior to midazolam for preoperative anxiolysis and provide a safe, noninvasive, nonpharmacologic, and pleasant alternative.

Comparison of buccal and nasal dexmedetomidine premedication for pediatric patients.

BACKGROUND: Alpha-2 adrenergic agonists are used to premedicate pediatric patients to reduce separation anxiety and achieve calm induction. The clinical effects of clonidine are similar whether via the oral or nasal route. However, oral dexmedetomidine is not preferred because of its poor bioavailability. The objective of this study was to evaluate the effects of nasal versus buccal dexmedetomidine used for premedication in children. METHODS: Sixty-two patients, aged 2-6 years, undergoing minor elective surgery were randomly assigned to two groups to receive dexmedetomidine, either 1 µg·kg(-1) buccally (group B) or 1 µg·kg(-1) intranasally (group N) for premedication 45 min before the induction of anesthesia. Heart rate, peripheral oxygen saturation, and respiratory rate were measured before and every 10 min after administering dexmedetomidine in all children. Level of sedation was assessed every 10 min until transport to operating room. Drug acceptance, parental separation, and face mask acceptance scores were recorded. RESULTS: There was no significant difference between the two groups in patient characteristics, nor was there any significant difference between the two groups in heart rate, respiratory rate, or SpO(2) values at all times after premedication. Levels of sedation, parental separation, and mask acceptance scores were significantly higher in group N than in group B at the various times. CONCLUSIONS: These results suggest that intranasal administration of 1 µg·kg(-1) dexmedetomidine is more effective than buccal administration of 1 µg·kg(-1) dexmedetomidine for premedication in children.

[Postanesthetic agitation syndrome after inhalation anesthesia with sevofluorane in children].

The paper analyzes the publications dedicated to the problem of agitation after inhalation anesthesia with sevofluorane. A brief explanation of the conception "agitation" is given in the context of interpretation of explanatory and psychological dictionaries. According to most of the analyzed papers, it is concluded that the incidence of the postanesthetic agitation syndrome occurs after anesthesia with sevofluorane than after that with halothane. The leading risk factors of agitation are preschool age, significant psychoemotional lability in the preoperative period (difficult parting with parents), fear. The efficiency of the preventive measures given in the analyzed paper is disputable. These include opioids (fentanyl), benzodiazepines (midasolam), clonidine, ketamine, dexmedotomidine, nitrous oxide, propofol, etc. The authors conclude that this problem is of no high significance in the aspect of priority, the width and safety of sevofluorane use in the anesthetic maintenance of children although it by far needs further more detailed study.

[Effects of hydroxyzine on tolerance of facial mask during induction in children]. / Effets de l'hydroxyzine sur l'acceptation du masque à l'induction de l'enfant.

OBJECTIVE: To evaluate the effectiveness of hydroxyzine as a premedication agent for the acceptance of facial mask during induction of general anaesthesia in children. STUDY DESIGN: Prospective randomized single-blind study including ASA 1 and 2 children, aged between 1 and 9 years and undergoing outpatient surgery. PATIENTS AND METHODS: Patients were randomly allocated to receive orally either 1mg/kg hydroxyzine (G1) or water 0.1 ml/kg (G2) one hour before induction of standardized inhalational anaesthesia. Tolerance of facial mask was assessed with a 3-points scale (good, moderate or poor). Chi-square and Student's t-test were used in statistical analysis; p values less than 0.05 were considered statistically significant. RESULTS: One hundred patients were included (G1 = 49, G2 = 51). Demographic data were similar in both groups. Acceptance of facial mask was significantly better in G1 than in G2 (p = 0,002). CONCLUSION: Hydroxyzine provided better acceptance of facial mask than placebo during induction of general anaesthesia in children.

Healthcare provider and parent behavior and children's coping and distress at anesthesia induction.

BACKGROUND: To date, no study has evaluated the impact of specific healthcare provider and parent behaviors on children's distress and coping during anesthesia induction. METHOD: Extensive digital video data were collected on 293 two- to ten-yr-old children undergoing anesthesia induction with a parent present. Anesthesiologist, nurse, and parent behavior and children's distress and coping were coded using the Revised Preoperative Child-Adult Medical Procedure Interaction Scale administered using specialized coding software. RESULTS: Anesthesiologists and parents engaged in higher rates of most behaviors than nurses. Overall, adult emotion-focused behavior such as empathy and reassurance was significantly positively related to children's distress and negatively related to children's coping behaviors. Adult distracting behavior such as humor and distracting talk showed the opposite pattern. Medical reinterpretation by anesthesiologists was significantly positively related to children's coping behaviors, but the same behavior by parents was significantly positively related to children's distress. CONCLUSIONS: The data presented here provide evidence for a relation between adult behaviors and children's distress and coping at anesthesia induction. These behaviors are trainable, and hence it is possible to test whether modifying physician behavior can influence child behavior in future studies.

The child who refuses to undergo anesthesia and surgery--a case scenario-based discussion of the ethical and legal issues.

Situations where children refuse to undergo anesthesia and surgery can be challenging for anesthetists. Clear legal guidelines are lacking and decisions often need to be made with a degree of urgency. When a child refuses to cooperate with the induction of anesthesia, it is important to consider the autonomous capacity of the child, the presence of a legally valid consent from a suitable guardian, the urgency with which the surgery needs to proceed and the practical implications of proceeding without the child's cooperation. In this article, case scenarios are used to demonstrate how these considerations can be applied in practice.

Factors predictive of poor behavioral compliance during inhaled induction in children.

BACKGROUND: Preoperative identification of children at risk of emotional distress and poor behavioral compliance during inhaled induction of anesthesia allows targeted interventions to reduce distress, thereby enhancing the quality of the anesthetic experience. We sought to identify patient, procedural, and health care system factors predictive of poor behavioral compliance during induction. METHODS: We studied 861 developmentally appropriate children ages 1-13 yr, The American Society of Anesthesiologists physical status I to III, presenting for inhaled induction of anesthesia. All inductions were performed in an induction room with parent(s) present. Behavioral compliance was assessed using the Induction Compliance Checklist (ICC), an observational scale consisting of 10 behaviors scored as the number of behaviors observed during induction; ICC > or =4 was considered poor behavioral compliance. A multivariable ordinal logistic regression model for behavioral compliance was generated and the performance of the multivariable model was evaluated by the c statistic. RESULTS: Twenty-one percent of children exhibited poor behavioral compliance on induction. Factors increasing the odds of poor behavioral compliance were younger age (< 4 yr, P < 0.0001), shorter preoperative preparation time (P = 0.004), and high anxiety levels in the preoperative clinic (modified-Yale preoperative anxiety scale > 40; P = 0.016). Previous anesthesia experience increased the odds in school-age children (P = 0.046); this effect was ameliorated in children attending the preoperative tour (P = 0.018). The model using these factors demonstrated moderate discrimination between children with poor compliance and those with perfect compliance (ICC = 0) (c statistic = 0.75). CONCLUSIONS: Factors predictive of poor behavioral compliance were age, previous anesthesia, preoperative tour attendance, preoperative preparation time and anxiety levels in the preoperative clinic. These factors, bundled into a predictive algorithm, may help identify children who could benefit from behavioral or pharmacological interventions and avoid use of interventions to those at low risk.

Do not mask the mask: use it as a premedicant.

BACKGROUND: Preoperative anxiety frequently causes resistance to mask application and prolongs induction. Anesthesia masks resembling popular heroes or toys was used to deal with this problem. An anesthesia mask given on a preoperative visit to play with at home, may aid to establish a familiarity with the mask and alleviate mask fear, possibly making a gaseous induction more acceptable. METHODS: After approval of the ethical committee, 50 children were randomly assigned into two groups. Both groups received conventional verbal information about the anesthetists, materials and equipment to be used for the procedure, description of gaseous induction via mask and transportation to the operating room. Additionally transparent anesthesia masks were given to children in the mask group after conventional verbal information. Both groups were premedicated with 0.3 mg.kg(-1) midazolam. Anxiety was assessed during separation from parents and induction of anesthesia by a modified Yale Preoperative Anxiety Scale. Mask acceptance quality and total mask time (TMT; time between the introduction of mask anesthesia and the loss of lid reflex) were also determined. RESULTS: Anxiety levels in the informed group were statistically higher than in the mask group during induction of anesthesia (26 +/- 1.8 vs 30 +/- 2.9, P < 0.05). Mask acceptance quality was better in the mask group than in the informed group (IG). TMTs were 5.1 +/- 1.3 and 7 +/- 0.9 min in the mask group and in the IG, respectively. CONCLUSIONS: Playing with an anesthesia mask given during a preanesthesia visit relieved anxiety, improved mask acceptance quality and shortened the induction period. We believe that this type of premedication would be feasible in gaseous induction of anesthesia in children.