The impact of psychological factors on the management of intraoperative haemodynamic events in children.

INTRODUCTION: Paediatric anaesthesia requires specific theoretical knowledge and practical training. Non-technical skills and psychological factors might influence learning and practice. The aim of this study was to assess personality type and decision-making styles of paediatric anaesthesiology residents during the management of simulated intraoperative life-threatening cases. METHOD: Residents in anaesthesiology (between 4 and 5 years of training) participated in a simulated hypoxic cardiac arrest in the operating theatre. Their performance was evaluated using a score derived from international recommended management algorithm. They were asked to answer self-assessment questionnaires regarding both their personality (the five personality factors) and their decision-making style. Correlations between performance and personality were investigated. RESULTS: Thirty-eight residents participated in the simulation session and 36 accepted to answer the questionnaires. Good management scoring was positively correlated with agreeableness and conscientiousness personality traits but was negatively correlated with avoidance and spontaneous decision-making styles. DISCUSSION: The current study identified personality traits and decision-making styles that might influence the management of critical situations during paediatric anaesthesia. The proper identification of these factors might allow targeted personalised training to improve knowledge mobilisation and translation in the clinical context.

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.

Efficacy of Self-hypnosis on Quality of Life For Children with Chronic Pain Syndrome.

The aim of this study was to assess the efficacy of self-hypnosis in a therapeutic education program (TEP) for the management of chronic pain in 26 children aged 7 to 17 years. Outcomes of the study were a total or a partial (at least 1) achievement of the therapeutic goals (pain, quality of sleeping, schooling, and functional activity). Sixteen patients decreased their pain intensity, 10 reached all of their therapeutic goals, and 9 reached them partially. Self-hypnosis was the only component of the TEP associated with these improvements. The current study supports the efficacy of self-hypnosis in our TEP program for chronic pain management in children.

Preoperative preparation workshop reduces postoperative maladaptive behavior in children.

INTRODUCTION: Postoperative maladaptive behaviors (POMBs) are common following pediatric anesthesia, and preoperative anxiety is associated with POMBs. A family-centered preoperative preparation workshop was instituted with the aim of reducing the incidence of POMB and preoperative anxiety, and the study was constructed to evaluate its effectiveness. MATERIAL AND METHODS: A prospective cohort study was constructed, comparing patients who attended the workshop (workshop group) with patients who did not attend and who were matched for age and type of surgery (comparison group). Preoperative anxiety was measured using the mYPAS score, postoperative emergence agitation (EA) was measured using the PAED score, POMBs were assessed with the Post-Hospital Behavior Questionnaire (PHBQ) on postoperative day 7, and PACU morphine consumption and PACU length of stay were recorded. Statistical analysis was performed employing the X² test, the Fisher's exact test, and the Mann-Whitney test as appropriate. Data were expressed as median [minimum, maximum]. RESULTS: Fifty-six patients from 3 to 18 years of age were recruited. Twenty-seven patients in the workshop group were compared to 26 in the comparison group, after exclusions for missing data. Significant differences were demonstrated between groups for POMBs intensity (PHBQ score 2 [0; 9] vs 5 [0; 10], P = 0.008) and incidence (PHBQ score >6: 3.6% vs 35.7%, P = 0.003), and for mYPAS score (28 [23; 87] vs 37 [23;100], P = 0.015). No difference was found for EA, PACU morphine consumption, or PACU length of stay. CONCLUSION: The workshop appears to result in reduced preoperative anxiety and POMBs.

Predictive factors for homologous transfusion during paediatric scoliosis surgery.

INTRODUCTION: Blood saving strategies during paediatric spinal surgery often include recombinant erythropoietin (rEPO) and antifibrinolytic therapy (AFT). The goal of this study was to investigate additional preventive factors involved in the risk of blood transfusion. METHODS: This prospective study was designed with the aim of identifying factors associated with the perioperative (defined as the intraoperative and the first postoperative day) probability of homologous red cell transfusion during scoliosis surgery in children operated during a one year period in our institution. The predictors analysed were: age, weight less than the 3rd percentile (W<3P), indication for spinal surgery (idiopathic or neuromuscular), Cobb's angle, ASA status, preoperative haemoglobin, number of levels fused, duration of surgery, intraoperative fluid intakes, sacral fusion and thoracoplasty. Statistical analyses were performed using a multivariate logistic regression model. RESULTS: One hundred and forty-seven patients were included in the analysis. Multivariate analysis found the following variables to be independent predictors for an increased risk of homologous blood transfusion: W<3P, neuromuscular scoliosis and duration of surgery > 255 minutes. ROC analysis for the latter model found an area under the curve of 0.9 (95% confidence interval: 0.8-0.97). The accuracy of the model was 92.3% (97.4% for non-transfusion and 69.2% for transfusion). Multivariate sensitivity analysis excluding patients with no preoperative administration of EPO found similar results. CONCLUSION: The current results indicate that optimising nutritional status might prevent allogenic blood transfusion and requires further investigation.

Emergence delirium in children: an update.

PURPOSE OF REVIEW: Emergence delirium in children is still considered as a mysterious complication occurring after pediatric anesthesia. Although the pharmacology of fast-acting volatile agent is highly suspected in the genesis of this complication, no strong evidence has been published to support this hypothesis. This review summarizes the recent findings concerning this complication. RECENT FINDINGS: Emergence delirium occurs typically in preschool children, with a high intensity of anxiety, after sevoflurane or desflurane anesthesia. In addition, although pain has been suspected in the genesis of this complication, emergence delirium has also been described after nonpainful procedure (imaging). Prevention of this complication relies on preventing preoperative anxiety (using premedication and psychological approaches), providing a sufficient analgesia (either systemically or by regional analgesia) and administering intraoperative sedative agents such as ketamine, clonidine, dexmedetomidine, gabapentine, midazolam, magnesium, hydroxyzine, midazolam and dexamethasone. Treatment of emergence delirium should be pharmacological when facing intense agitation with self-injury risks. This could be achieved using propofol, opioid agents or dexmedetomidine. As a result of the delayed discharge from a postoperative care unit associated with these agents, dexmedetomidine should be favored because of its analgesic and postoperative nausea and vomiting preventive effects. As emergence delirium shares many risk factors with long-lasting cognitive complications such as postoperative maladaptative behavioral changes, letting parents know about these complications is requested. SUMMARY: Emergence delirium in children is a frequent but preventable complication. Strategies for prevention and therapy include particularly pain management and medication with alpha-2 agonists.