Development, Validation, and Results of a Survey of Personal Electronic Device Use Among 299 Anesthesia Providers From a Single Institution.

BACKGROUND: The pattern of perioperative use of personal electronic devices (PEDs) among anesthesia providers in the United States is unknown. METHODS: We developed a 31-question anonymous survey of perioperative PED use that was sent to 813 anesthesiologists, anesthesiology residents, and certified registered nurse anesthetists at 3 sites within one health system. The electronic survey assessed patterns of PED use inside the operating room (OR), outside the OR, and observed in others. Questions were designed to explore the various purposes for PED use, the potential impact of specific hospital policies or awareness of medicolegal risk on PED use, and whether PED was a source of perioperative distraction. RESULTS: The overall survey response rate was 36.8% (n = 299). With regard to often/frequent PED activity inside the OR, 24% reported texting, 5% reported talking on the phone, and 11% reported browsing on the Internet. With regard to often/frequent PED activity outside the OR, 88% reported texting, 26% reported talking on the phone, and 63% reported browsing the Internet. With regard to often/frequent PED activity observed in others, 52% reported others texting, 14% reported others talking on the phone, and 34% reported others browsing the Internet. Two percent of respondents self-reported a distraction compared to 15% who had observed a distraction in others. Eighty percent of respondents recognized PED as a potential distraction for patient safety. CONCLUSIONS: Our data reinforce that PED use is prevalent among anesthesia providers.

The Effects of Coronavirus Disease 2019 on Pediatric Anesthesiologists: A Survey of the Members of the Society for Pediatric Anesthesia.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has affected the personal and professional lives of all health care workers. Anesthesiologists frequently perform virus-aerosolizing procedures (eg, intubation and extubation) that place them at increased risk of infection. We sought to determine how the initial COVID-19 outbreak affected members of the Society for Pediatric Anesthesia (SPA) on both personal and professional levels. Specifically, we examined the potential effects of gender and age on personal stress, burnout, sleep deprivation, anxiety, depression, assessed job satisfaction, and explored financial impact. METHODS: After receiving approval from the SPA Committees for Research and Quality and Safety and the Colorado Multiple Institutional Review Board, we e-mailed a questionnaire to all 3245 SPA members. The survey included 22 questions related to well-being and 13 questions related to effects of COVID-19 on current and future practice, finances, retirement planning, academic time and productivity, and clinical and home responsibilities. To address low initial response rates and quantify nonresponse bias, we sent a shortened follow-up survey to a randomly selected subsample (n = 100) of SPA members who did not respond to the initial survey. Response differences between the 2 cohorts were determined. RESULTS: A total of 561 (17%) members responded to the initial questionnaire. Because of COVID-19, 21.7% of respondents said they would change their clinical responsibilities, and 10.6% would decrease their professional working time. Women were more likely than men to anticipate a future COVID-19-related job change (odds ratio [OR] = 1.92, 95% confidence interval [CI], 1.12-2.63; P = .011), perhaps because of increased home responsibilities (OR = 2.63, 95% CI, 1.74-4.00; P < .001). Additionally, 14.2% of respondents planned to retire early, and 11.9% planned to retire later. Women and non-White respondents had higher likelihoods of burnout on univariate analysis (OR = 1.75, 95% CI, 1.06-2.94, P = .026 and OR = 1.82, 95% CI, 1.08-3.04, P = .017, respectively), and 25.1% of all respondents felt socially isolated. In addition, both changes in retirement planning and future occupational planning were strongly associated with total job satisfaction scores (both P < .001). CONCLUSIONS: The COVID-19 pandemic has affected the personal and professional lives of pediatric anesthesiologists, albeit not equally, as women and non-Whites have been disproportionately impacted. The pandemic has significantly affected personal finances, home responsibilities, and retirement planning; reduced clinical and academic practice time and responsibilities; and increased feelings of social isolation, stress, burnout, and depression/anxiety.

Implications of nocebo in anaesthesia care.

Nocebo refers to non-pharmacological adverse effects of an intervention. Well-intended procedural warnings frequently function as a nocebo. Both nocebo and placebo are integral to the generation of 'real' treatment effects and their associated 'real' side-effects. They are induced or exacerbated by: context; negative expectancy; and negative conditioning surrounding treatment. Since the late 1990s, the neuroscience literature has repeatedly demonstrated that the nocebo effect is mediated by discrete neurobiological mechanisms and specific physiological modulations. Although no single biological mechanism has been found to explain the nocebo effect, nocebo hyperalgesia is thought to initiate from the dorsal lateral prefrontal cortex subsequently triggering the brain's descending pain modulatory system and other pain regulation pathways. Functional magnetic resonance imaging shows that expectation of increased pain is accompanied by increased neural activity in the hippocampus and midcingulate cortex which is not observed when analgesia is expected. Functional magnetic resonance imaging studies have shown that the anterior cingulate cortex is pivotal in the perception of affective pain evoked by nocebo words. Research has also explored neurotransmitters which mediate the nocebo effect. The neuropeptide cholecystokinin appears to play a key role in the modulation of pain by nocebo. Hyperalgesia generated by nocebo also increases the activity of the hypothalamic-pituitary-adrenal axis as indicated by increases in plasma cortisol. The avoidance or mitigation of nocebo needs to be recognised as a core clinical skill in optimising anaesthesia care. Embracing the evidence around nocebo will allow for phrases such as 'bee sting' and 'sharp scratch' to be thought of as clumsy verbal relics of the past. Anaesthesia as a profession has always prided itself on practicing evidence-based medicine, yet for decades anaesthetists and other healthcare staff have communicated in ways counter to the evidence. The premise of every interaction should be 'primum non nocere' (first, do no harm). Whether the context is research or clinical anaesthesia practice, the nocebo can be ignored no longer.

Validation of the Portuguese version of Amsterdam Preoperative Anxiety and Information Scale (APAIS).

BACKGROUND: Preoperative anxiety is common among the oncological surgical population. Due to its psychological and physiological detrimental effects, identifying and addressing it is of uttermost importance to improve anesthetic management and patient's outcomes. The aim of this study is to validate the Portuguese version of Amsterdam Preoperative Anxiety and Information Scale (APAIS) in the oncological population. METHODS: Following forward and backward translation of the original APAIS scale, further adaptation was obtained through cognitive interviewing. The resulting instrument was tested on the day before surgery on a sample of adult cancer surgical patients from a Portuguese oncology centre. Psychometric evaluation was derived from inter-item correlation, confirmatory factor analysis, Cronbach's alpha, correlation with comparative scales, receiver operating characteristic curve and Youden index. RESULTS: 109 patients (58 males, 51 females) were included. A three-dimensional model-anxiety about anesthesia, anxiety about surgery and desire for information, showed the best fit to the data. The questionnaire revealed high internal consistency (Cronbach alpha 0.81) and good inter-item correlation. Also, Portuguese APAIS correlated well with the gold standard anxiety scale. Therefore, the psychometric properties of this scale version make it a valid and reliable instrument. The optimal cutoff to maximize both sensitivity and specificity was 12 for the APAIS global anxiety score. CONCLUSIONS: Portuguese APAIS version is an accurate tool to identify preoperative anxiety among cancer patients and might impact its management, from premedication choice to provision of information and reassurance about either anesthesia or surgery.

A Qualitative Assessment of Factors That Children, Parents, and Clinicians Prioritize in the Setting of Elective Anesthesia and Surgery.

BACKGROUND: Assessing the postoperative recovery of pediatric patients is challenging as there is no validated comprehensive patient-centered recovery assessment tool for this population. A qualitative investigative approach with in-depth stakeholder interviews can provide insight into the recovery process and inform the development of a comprehensive patient-centered postoperative assessment tool for children. METHODS: We conducted open-ended, semistructured interviews with children 6-12 years old undergoing elective surgery (n = 35), their parents (n = 37), and clinicians (n = 23) who commonly care for this population (nurses, anesthesiologists, and surgeons). A codebook was developed and analyzed using NVivo 12 Plus. The codebook was iteratively developed using a qualitative content analysis approach with modifications made throughout to refine codes. We report the results of this thematic analysis of patient, parent, and clinician transcripts. RESULTS: Postoperative recovery priorities/concerns overlapped and also diverged across the 3 groups. Topics prioritized by children included mobility and self-care, as well as access to a strong social support network following surgery. The majority of children reported feeling anxious about the surgery and separating from their parents, as well as sadness about their inability to participate in activities while recovering. Although children highly valued familial support during recovery, there was variable awareness of the impact of surgery on family members and support network. In contrast, parents focused on the importance of clear and open communication among themselves and the health care team and being equipped with appropriate knowledge and resources on discharge. The immediate repercussions of the child's surgery, such as pain, confusion, and nausea, appeared to be a primary focus of both parents and clinicians when describing recovery. Clinicians had a comprehensive awareness of the possible psychological impacts of surgery in children, while parents reported varying degrees of awareness or concern regarding longer-term or more latent impacts of surgery and anesthesia (eg, anxiety and depression). Prior experience with pediatric surgery emerged as a distinguishing characteristic for parents and clinicians as parents without prior experience expressed less understanding of or comfort with managing a child's recovery following surgery. CONCLUSIONS: A patient-centered qualitative investigative approach yielded insights regarding the importance of various aspects of recovery in pediatric patients, their parents, and members of the health care team. Specifically, this investigation highlighted the importance of clear communication providing anticipatory guidance for families presenting for elective surgery in an effort to optimize patient recovery. This information will be used in the development of a patient-centered recovery assessment tool.

Preoperative anxiety in adults - a cross-sectional study on specific fears and risk factors.

BACKGROUND: Preoperative anxiety comprising anesthesia and surgery related anxiety is common and perceived by many patients as the worst aspect of the surgical episode. The aim of this study was to identify independent predictors of these three anxieties dimensions and to quantify the relevance of specific fears particularly associated with anesthesia. METHODS: This study was part of a cross-sectional survey in patients scheduled to undergo elective surgery. Anxiety levels were measured with the Amsterdam Preoperative Anxiety and Information Scale (APAIS). Modified numeric rating scales (mNRS, range 0-10) were used to assess the severity of eight selected specific fears which were predominantly analyzed descriptively. Multivariate stepwise linear regression was applied to determine independent predictors of all three anxiety dimensions (APAIS anxiety subscales). RESULTS: 3087 of the 3200 enrolled patients were analyzed. Mean (SD) total preoperative anxiety (APAIS-A-T, range 4-20) was 9.9 (3.6). High anxiety (APAIS-A-T > 10) was reported by 40.5% of subjects. Mean (SD) levels of concern regarding the eight studied specific fears ranged from 3.9 (3.08) concerning "Anesthesiologist error" to 2.4 (2.29) concerning "Fatigue and drowsiness" with an average of 3.2 (2.84) concerning all specific fears. Ranking of all specific fears according to mean mNRS scores was almost identical in patients with high versus those with low anxiety. Among nine independent predictors of anxiety, only 3 variables (female gender, negative and positive anesthetic experience) independently predicted all three APAIS anxiety subscales. Other variables had a selective impact on one or two APAIS anxiety subscales only. Female gender had the strongest impact on all three APAIS anxiety subscales. Adjusted r2 values of the three models were all below 13%. CONCLUSIONS: The high variability of importance assigned to all specific fears suggests an individualized approach is advisable when support of anxious patients is intended. Considering independent predictors of anxiety to estimate each patient's anxiety level is of limited use given the very low predictive capacity of all three models. The clinical benefit of dividing patients into those with high and low anxiety is questionable. TRIAL REGISTRATION: German Registry of Clinical Trials (DRKS00016725), retrospectively registered.

Randomized-controlled trial of parent-led exposure to anesthetic mask to prevent child preoperative anxiety.

PURPOSE: To examine the efficacy of parent-directed anesthetic mask exposure and shaping practice to prevent child preoperative anxiety, with a specific focus on timing of exposure. METHODS: This randomized-controlled trial included 110 children ages four to seven years undergoing day surgery dental procedures and their parents. Families were randomly assigned to one of three groups: 1) parent-directed mask exposure/shaping practice at least three times in the week prior to surgery (Group 1); 2) parent-directed mask exposure/shaping practice at least once on the day of surgery (Group 2); 3) no exposure prior to induction (Group 3). Child anxiety was observer-rated using the modified Yale Preoperative Anxiety Scale during the day surgery experience, and induction compliance was observer-rated using the Induction Compliance Checklist. RESULTS: Results demonstrated significant differences in observer-rated child anxiety at anesthetic induction across groups. Group 2 demonstrated significantly lower observer-rated anxiety than Group 3 with a medium effect, F(1, 71) = 4.524, P = 0.04, η p 2 = 0.06. A significant interaction was observed between these two groups over time (i.e., admission to anesthesia induction), F(1, 71) = 4.365, P = 0.04, η p 2 = 0.06 (i.e., small to medium effect). Group 2 demonstrated the best anesthesia induction compliance (i.e., significantly lower scores than Group 3, P = 0.04). CONCLUSION: Timing of the delivery of mask exposure (i.e., on the day of surgery) to address child preoperative anxiety and induction compliance in the day surgery setting may be an important consideration. The current results inform the integration of this simple, effective strategy into practice.

RéSUMé: OBJECTIF: Examiner l'efficacité d'une exposition au masque anesthésique menée par un parent et détermination d'une pratique visant à prévenir l'anxiété préopératoire de l'enfant en se concentrant spécifiquement sur le moment de l'exposition. MéTHODES: Cette étude randomisée contrôlée a inclus 110 enfants âges de quatre à sept ans subissant une procédure dentaire en chirurgie d'un jour et leurs parents. Après randomisation, les familles ont été assignées à l'un des trois groupes suivants : 1) exposition au masque/pratique de modelage comportemental dirigée par le parent au moins trois fois dans la semaine précédant l'intervention (Groupe 1); 2) exposition au masque/pratique de modelage comportemental dirigée par le parent au moins une fois le jour de la chirurgie (Groupe 2); 3) aucune exposition avant l'induction (Groupe 3). L'anxiété de l'enfant a été évaluée par un observateur utilisant l'échelle mYPAS (échelle modifiée d'anxiété préopératoire de Yale) au cours de l'expérience le jour de la chirurgie et la conformité de l'induction a été évaluée par un observateur utilisant l'ICC (liste de vérification de la conformité de l'induction). RéSULTATS: Les résultats ont mis en évidence des différences significatives entre les groupes sur l'anxiété de l'enfant évaluée par un observateur au moment de l'induction anesthésique. Le Groupe 2 a présenté une anxiété évaluée par l'observateur significativement inférieure à celle du Groupe 3 avec un effet médian F (1, 71) = 4,524, P = 0,04, η P 2 = 0,06. Une interaction significative a été observée entre ces deux groupes au fil du temps (c'est-à-dire entre l'admission et l'induction de l'anesthésie), F (1, 71) = 4,365, P = 0,04, η P 2 = 0,06 (soit un effet petit à moyen). Le Groupe 2 a manifesté la meilleure conformité de l'induction de l'anesthésie (c'est-à-dire, des scores significativement inférieurs au Groupe 3, P = 0,04). CONCLUSION: Il peut être important de tenir compte du moment de l'exposition au masque (c'est-à-dire le jour de l'intervention) pour répondre à l'anxiété préopératoire de l'enfant et à la conformité de l'induction dans le cadre de la chirurgie d'un jour. Les résultats actuels renseignent sur l'intégration de cette stratégie simple et efficace dans la pratique.

A prospective study on elective surgical inpatient satisfaction with perioperative anaesthesia service at Ayder comprehensive specialized hospital, Mekelle, Ethiopia.

BACKGROUND: Patient satisfaction is a subjective and challenging perception, linking physical, expressive, psychological, societal, and cultural factors. Dissatisfaction arises if the patient feels an inconsistency between expected and delivered care. Usually health care satisfactions are very high and according to many studies levels of satisfaction are above 85% and patient's satisfaction in terms of anesthesia is not very different. The aim of this study was to assess patient's satisfaction with perioperative anesthesia service and associated factors. METHODS: Institution-based cross-sectional study was conducted from December to January, 2017/8 at the Ayder Comprehensive Specialize Hospital. The data were collected using structured interviewer-administered questionnaire prepared to collect data on demographic character of the patients, determinant factors which could affect the patient satisfaction level on anesthesia service. Epi Info version 6 was used to record the data and SPSS version 20 was used for the analysis. Descriptive statistics were used to explore the socio-demographic characteristics of patients; factors possibly related to satisfaction level and overall satisfaction were summarized as frequencies and percentages. RESULTS: One hundred twenty consecutive patients were originally enrolled in the study that took over 1 Month. The overall proportion of patients who satisfied with anaesthesia services was 88.33%. Nausea and vomiting, pain, shortness of breath and cold were factors which affected patient satisfaction negatively. CONCLUSION AND RECOMMENDATION: Compared with the other studies done at home and abroad; the overall proportion of patients, in Ayder comprehensive specialized hospital, who responded for satisfaction with perioperative anesthesia service is low. Patient satisfaction level should be determined regularly and all bodies should work to decrease the factors which decrease the satisfaction level.

Patient satisfaction with peri-operative anesthesia care and associated factors at two National Referral Hospitals: a cross sectional study in Eritrea.

BACKGROUND: Measuring patient satisfaction has become an important parameter of the continuous quality assessment and improvement in anaesthesia services. The aim of this study was to assess the level of patient satisfaction with perioperative anaesthesia care and to determine the factors that influence satisfaction. METHOD: This study is an cross sectional design, conducted on 470 patients who underwent different types of surgeries at two National Referral Hospitals in Asmara, Eritrea between January and March of 2018. Patients were interviewed 24 h after the operation using a Tigrigna translated Leiden Perioperative Care Patient Satisfaction questionnaire (LPPSq). Descriptive and inferential analysis were made using SPSS (version 22). Statistical significance level was set at P < 0.05. RESULTS: The overall satisfaction score was 68.8%. Less fear and concern was observed among patients with satisfaction scores of 87.5%. Staff-patient relationship satisfaction score was 75%. Patients were least satisfied with information provision (45%). Multivariable analysis revealed that satisfaction of patients who did surgery at Halibet hospital is significantly higher (p < 0.001) than those patients who did at Orotta hospital. Moreover, those patients who did elective surgery had higher level of satisfaction that those who did emergency surgery (p < 0.001). CONCLUSION: Moderate level of satisfaction was observed among the patients. Generally, the study emphasized that the information provision about anesthesia and surgery was low. Patients described better staff-patient relationship and low fear and concern related to anesthesia and surgery was observed.

Visual Distraction During Sleep Induction with Propofol in Pediatric Patients - Can Cartoon Watching Influence the Sedative Dose?

BACKGROUND: In general anesthesia, cartoon watching and playing video games reduce anxiety in children. It is unknown whether watching a video in the intervention room has a similar effect, and therefore is able to reduce sedative doses in children undergoing small medical procedures. Aim of this prospective study was to determine the effect of watching a standardized cartoon immediately before and during sleep induction for deep sedation on consumption of propofol in children. PATIENTS AND METHODS: 50 children aged 2-14 years undergoing deep sedation were randomly assigned to 2 groups: (A) watching or (B) not watching a standardized videoclip during sleep induction with propofol. The achievement of predefined sedation depth was objectified by measuring Comfort Score (aim 10-14) and Bispectral Index (aim 50-60). RESULTS: The median sleep induction dose of propofol did not differ in both groups (A: 1.76 (0.62-4.37) mg/kg; B: 1.37 (0.66-5.26) mg/kgKG; p=0.65). Cartoon watching was associated with shorter sleep onset latency (A: 120 (60-480)s; B: 240 (40-600)s; p=0.043). Subgroup analysis reveals this especially for school children and girls. In both groups no complications occurred. CONCLUSION: Children watching a standard cartoon during sleep induction for deep sedation have a shorter sleep onset time but sedative dose is not reduced.

What are the validity and reliability of the modified Yale Preoperative Anxiety Scale-Short Form in children less than 2 years old?

BACKGROUND: Accurate measurement of preoperative anxiety is important for pediatric surgical patients' care as well as for monitoring anxiety-reducing interventions. The modified Yale Preoperative Anxiety Scale-short form is well validated for this purpose in children aged 2 years and above, but not in younger children. AIMS: We aimed to validate the Dutch version of the modified Yale Preoperative Anxiety Scale-short form for measuring preoperative anxiety in children less than 2 years old. METHODS: Two investigators independently assessed infants' anxiety at the holding area and during induction of anesthesia with the modified Yale Preoperative Anxiety Scale-short form and the COMFORT-Behavior scale-live and from video observations. Construct validity and responsiveness of both scales were tested with Pearson correlation coefficient. Internal consistency of the modified Yale Preoperative Anxiety Scale-short form was assessed using Cronbach's α, and inter-rater reliability and intra-rater reliability were tested using the intraclass correlation coefficient and Cohen's linearly weighted kappa. Hypotheses for sufficient inter-rater reliability (r > 0.60) and validity (r > 0.65) had been formulated a priori in line with the COSMIN guidelines. RESULTS: Behavior of 129 infants (89.1% male) with a median age of 6.5 months (range 0.9-16.5 months) was observed. The correlations between the modified Yale Preoperative Anxiety Scale-short form and COMFORT-Behavioral scale were strong at the holding area and at induction of anesthesia, as were the correlation of change scores between the holding area and induction. Internal consistency of the modified Yale Preoperative Anxiety Scale-short form was excellent at both the holding area and at induction of anesthesia. Inter-rater reliability was good to excellent on scale level and moderate to good on item level. CONCLUSION: These findings support the validity and reliability of the Dutch version of the modified Yale Preoperative Anxiety Scale-short form in children less than 2-years-old.

Behavioral training and mirroring techniques to prepare elective anesthesia in severe autistic spectrum disorder patients: An illustrative case and review.

Children with autistic spectrum disorder are more likely to become distressed during induction of anesthesia. Inhalational induction is almost always the preferred route with acceptance of the face mask often presenting a considerable challenge. Tempering measures to facilitate gas induction such as forced premedication and physical restraint are no longer viable options except in extenuating circumstances. Recent research interest has focused on the need for advanced planning in collaboration with the caregiver to tailor an individualized perioperative plan. This plan may include both pharmacological and non-pharmacological interventions. Applied behavior analysis strategies have a well-documented efficacy in this unique population to systematically change an individual's usual behavior. These can be used, as a non-pharmacological strategy, to ensure a smooth perioperative course. We present a successful case of preoperative desensitization of a child with severe autistic spectrum disorder using a mirror demonstration technique associated with positive reinforcement to prepare him for general anesthesia. We discuss the potential application of applied behavior analysis strategies for anesthesia in this unique population. From a practical point of view, early communication with carers is required to establish who may benefit from this behavioral training. Planned individual preparation for general anesthesia must be provided by trained multidisciplinary staff.

Animated video consultation for reducing pre-operative anxiety in dermatologic surgery.

Pre-operative anxiety is common in patients undergoing dermatologic surgery. This pilot study aimed to evaluate whether the addition of an animated educational video to conventional in-person surgery consultation helps to reduce pre-operative anxiety related to anesthesia, surgery, wound care, and post-operative pain in patients undergoing outpatient dermatologic surgery. Patients awaiting dermatologic surgery were randomized into groups with conventional consultation, or video with consultation prior to undergoing their procedure. The conventional consultation group received conventional consultation with the surgeon, whereas the video with consultation group received conventional consultation and a two-minute-long animated educational video. Intra- and inter-individual score differences were assessed based on baseline and subsequent surveys. Although not statistically significant, video with consultation group anxiety scores were lower than conventional consultation group across all categories. After crossing over, conventional consultation group patients reported statistically significant improvement in anxiety related to all areas except wound care, in which anxiety did not change significantly, although a trend toward reduced anxiety was seen. Animated educational videos during surgical consultation can reduce pre-operative anxiety related to anesthesia, surgery, and post-operative pain. Future studies should explore its benefit to clinical outcomes and overall surgical experience.

Development and Psychometric Exploration of the Anesthesia Surrendering Instrument.

PURPOSE: The aim of this study was to develop and test an instrument to measure surrendering at the time of anesthesia induction and to explore the construct validity. DESIGN: An instrumental cross-sectional design was used and construct validity was evaluated via psychometric testing. METHODS: The anesthesia surrendering instrument (ASI) comprised 36 items. A total of 202 adults (older than 18 years) answered the questionnaire. Principal component analysis was used for item reduction and identification of defining constructs. FINDINGS: Surrendering to anesthesia was defined by four constructs: preparation by avoidance, control, preparation by understanding, and acceptance, explaining 43.2% of the variance in the matrix. CONCLUSIONS: The findings show that it is possible to measure the concept of surrendering by means of four dimensions as preparation by avoidance, control, preparation by understanding, and acceptance, although the dimensional variance of 43% could be considered weak. The ASI will constitute context-specific patient-reported experience measures for anesthesia, whereas further item refinement and testing of the ASI are necessary to achieve a better variance.

Results after implementation of a sedoanalgesia protocol for procedures in hospital environment. / Resultados tras implantación de un protocolo de sedoanalgesia para procedimientos en ámbito hospitalario.

INTRODUCTION: We analyze the effectiveness and safety of a specific analgosedation protocol for procedures, and eva luate the satisfaction of the health personnel with each procedure. PATIENTS AND METHOD: Prospective study of an analgosedation protocol for hospital procedures in children under 18 years of age, with an individualized strategy based on the patient's baseline situation, the type of procedure and the experience of the pediatrician responsible for the sedation. The following variables were recorded: diagnosis motivating the procedure, type of procedure, anthropometric data, allergies, medication, ASA status and baseline disease, fasting time, lung auscultation, temperature, oxygen saturation, res piratory rate, heart rate, blood pressure, sedation location, type of drug, dose, route of administra tion, Ramsay sedation scale, duration of sedation, type and treatment of adverse effects, presence of family members throughout the procedure, and patient satisfaction. RESULTS: 279 sedations were performed. The most commonly used drugs were nitrous oxide (62.7%) and midazolam (16.5%); the most commonly used routes of administration were the inhaled one (62.4%) and the intravenous one (15.8%). The satisfaction was high for the pediatrician (92.5%), the nurse (94.3%), the family (96.8%), and patients (93.6%), with a good correlation between them, and it was significantly lower when using midazolam and the nasal and oral routes. The adverse effects rate was 3.2%, and none was severe. CONCLUSIONS: The implementation of a specific analgosedation protocol for procedures in the hospital environment achieves high levels of effectiveness and safety, as well as a high level of satisfaction, both in family members and in health personnel.

Prevalence of Potentially Distracting Noncare Activities and Their Effects on Vigilance, Workload, and Nonroutine Events during Anesthesia Care.

BACKGROUND: When workload is low, anesthesia providers may perform non-patient care activities of a clinical, educational, or personal nature. Data are limited on the incidence or impact of distractions on actual care. We examined the prevalence of self-initiated nonclinical distractions and their effects on anesthesia workload, vigilance, and the occurrence of nonroutine events. METHODS: In 319 qualifying cases in an academic medical center using a Web-based electronic medical chart, a trained observer recorded video and performed behavioral task analysis. Participant workload and response to a vigilance (alarm) light were randomly measured. Postoperatively, participants were interviewed to elicit possible nonroutine events. Two anesthesiologists reviewed each event to evaluate their association with distractions. RESULTS: At least one self-initiated distraction was observed in 171 cases (54%), largely during maintenance. Distractions accounted for 2% of case time and lasted 2.3 s (median). The most common distraction was personal internet use. Distractions were more common in longer cases but were not affected by case type or American Society of Anesthesiologists physical status. Workload ratings were significantly lower during distraction-containing case periods and vigilance latencies were significantly longer in cases without any distractions. Three distractions were temporally associated with, but did not cause, events. CONCLUSIONS: Both nurse anesthetists and residents performed potentially distracting tasks of a personal and/or educational nature in a majority of cases. Self-initiated distractions were rarely associated with events. This study suggests that anesthesia professionals using sound judgment can self-manage nonclinical activities. Future efforts should focus on eliminating more cognitively absorbing and less escapable distractions, as well as training in distraction management.

Recommendations for the nomenclature of cognitive change associated with anaesthesia and surgery-2018.

Cognitive change affecting patients after anaesthesia and surgery has been recognised for more than 100 yr. Research into cognitive change after anaesthesia and surgery accelerated in the 1980s when multiple studies utilised detailed neuropsychological testing for assessment of cognitive change after cardiac surgery. This body of work consistently documented decline in cognitive function in elderly patients after anaesthesia and surgery, and cognitive changes have been identified up to 7.5 yr afterwards. Importantly, other studies have identified that the incidence of cognitive change is similar after non-cardiac surgery. Other than the inclusion of non-surgical control groups to calculate postoperative cognitive dysfunction, research into these cognitive changes in the perioperative period has been undertaken in isolation from cognitive studies in the general population. The aim of this work is to develop similar terminology to that used in cognitive classifications of the general population for use in investigations of cognitive changes after anaesthesia and surgery. A multispecialty working group followed a modified Delphi procedure with no prespecified number of rounds comprised of three face-to-face meetings followed by online editing of draft versions. Two major classification guidelines [Diagnostic and Statistical Manual for Mental Disorders, fifth edition (DSM-5) and National Institute for Aging and the Alzheimer Association (NIA-AA)] are used outside of anaesthesia and surgery, and may be useful for inclusion of biomarkers in research. For clinical purposes, it is recommended to use the DSM-5 nomenclature. The working group recommends that 'perioperative neurocognitive disorders' be used as an overarching term for cognitive impairment identified in the preoperative or postoperative period. This includes cognitive decline diagnosed before operation (described as neurocognitive disorder); any form of acute event (postoperative delirium) and cognitive decline diagnosed up to 30 days after the procedure (delayed neurocognitive recovery) and up to 12 months (postoperative neurocognitive disorder).

Description of typical personality factors and events that lead to anxiety at induction of anesthesia in French children.

BACKGROUND: Preventive strategies are available to reduce preoperative anxiety in children, the ideal time for implementing such strategies remains poorly determined. AIMS: The aim of this study was to determine psychological factors and events involved in the development of preoperative anxiety in children. METHODS: This study consisted of prospective evaluations of anxiety trait and state during the preoperative period. Attendance at a preanesthetic consultation is obligatory for all patients undergoing surgery in France. Anxiety trait and state assessments were quantified in mothers and children before and after the preanesthetic consultation using visual analog and faces numerical scales. Preoperative anxiety in children was assessed immediately before induction of anesthesia using an analog scale. Other data recorded included demographic and medical data and type of hospital stay. Univariate and multivariate logistic regression analyses were used. RESULTS: Overall 111 consecutive patients were included. The following factors emerged leading to anxiety state at induction of anesthesia: maternal anxiety state before the preanesthetic consultation, a feeling of not being reassured by the anesthesiologist, maternal anxiety state after the consultation, and anxiety trait in the child. Logistic regression found this combination of factors (OR = 4 [1.4 -12]) and inpatient stay (OR = 3 [1.4-7]), predicting anxiety with an accuracy of 69%. CONCLUSION: The present study identified a combination of psychological factors and events associated with the development of anxiety at induction of anesthesia in children. Parental anxiety impacts upon children and occurs before the preanesthetic consultation. This result may assist clinicians to prescribe personalized preventive strategies against anxiety.

Patient Satisfaction With Propofol for Outpatient Colonoscopy: A Prospective, Randomized, Double-Blind Study.

BACKGROUND: Previous literature has shown that propofol has ideal anesthetic properties for patients undergoing colonoscopy, a common procedure at outpatient surgery centers. However, there is a paucity of information regarding patient satisfaction with propofol. OBJECTIVE: The aim of this study was to evaluate patient satisfaction with propofol compared with nonpropofol (fentanyl/midazolam) anesthesia for outpatient colonoscopies. Safety and complications were secondary end points. DESIGN: This study was a double-blind, randomized, parallel-group controlled clinical trial (NCT 02937506). SETTING: This study was conducted at a single ambulatory surgery center at an urban teaching community health system. PATIENTS: Patients were scheduled for outpatient colonoscopy. Those with high-risk cardiac or pulmonary disease were excluded. INTERVENTIONS: Anesthesia personnel administered either fentanyl/midazolam (n = 300) or propofol (n = 300) for sedation during outpatient colonoscopy. A single, highly experienced endoscopist performed all colonoscopies. MAIN OUTCOME MEASURES: The primary outcomes measured were patient satisfaction (5-point Likert scale) and procedure complications. Data were collected on the day of endoscopy by the nursing staff of the postanesthesia care unit. A subinvestigator blinded to the randomization called patients 24 to 72 hours after discharge to obtain data on postprocedure problems and status of resumption of normal activities. Analysis was intention-to-treat. RESULTS: Fewer patients who received propofol remembered being awake during the procedure (2% vs 17% for fentanyl, p < 0.0001) and were more likely to rate the amount of anesthesia received as being "just right" (98.7% vs 91.3% for fentanyl, p = 0.0002) and state that they were "very satisfied" with their anesthesia (86.3% vs 74% for fentanyl, p = 0.0005). Twenty-six percent of fentanyl procedures were rated "difficult" compared with 4.3% for propofol (p < 0.0001), and complications were fewer in the propofol group (2.7% vs 11.7%, p < 0.0001). LIMITATIONS: The endoscopist could not be completely blinded to the anesthetic administered. CONCLUSIONS: Patients prefer propofol over a combination of fentanyl/midazolam as their anesthetic for outpatient colonoscopies. From a patient and provider perspective, propofol appears to be superior to fentanyl/midazolam for outpatient colonoscopy. See Video Abstract at http://links.lww.com/DCR/A445.

Validation of a simple tool for anxiety trait screening in children presenting for surgery.

BACKGROUND.: Screening for preoperative anxiety is an important challenge during the preoperative period. The aim of our study was to validate the faces scale used to detect anxiety trait in children. METHODS.: Children aged 8-18 yr were asked to quantify their anxiety trait using the readily available faces scale and to respond to the trait component of the State-Trait Anxiety Inventory (STAI) for children (C) or adults (A) before the anaesthesia consultation. Using receiver operating characteristics analysis, we determined the faces scale optimal value on a construct cohort. A validation cohort was recruited to assess the accuracy of the results. RESULTS.: The construction cohort comprised 207 patients and the validation cohort 91 patients. The receiver operating characteristics analysis found an area under the curve of 0.75 [95% confidence interval (CI) 0.67, 0.83]. The optimal value for faces scale score was 4, with a sensitivity of 0.61 [95% CI 0.59, 0.62] and a specificity of 0.82 [95% CI 0.81, 0.83]. When this threshold was applied to the construction and validation cohorts, 61.3 and 44.4% of positives were true positives in the construction and validation cohorts, respectively; and 82.1 and 81.3% of negatives were true negatives, respectively. CONCLUSIONS.: Our study determined the performance of a simple faces scale to measure the preoperative anxiety trait in children aged 8-18 yr. This tool is potentially helpful for clinicians aiming to identify patients at risk of preoperative anxiety and to assign them to targeted management.