1. Andrew S Triebwasser, MD January 20, 2010

2. Jill Maclaren Chorney, Ph.D., Carrie Torrey, B.A., Ronald Blount, Ph.D., Christine McLaren, Ph.D., Wen-Pin Chen, M.S., Zeev Kain, M.D., M.B.A. Anesthesiolog y 2009;111:1290-6

3. To date, no study has evaluated the impact of specific healthcare provider and parent behaviors on children’s distress and coping during anesthesia induction Anesthesiology 2009;111:1290-6

5.  18 month questionnaire data ENT pts  Personality changes identified include bedwetting, apathy, sleep disturbances (nightmares), withdrawal, separation anxiety, fear of subsequent procedures, aggression  ↑ younger age, unsatisfactory induction  “experiences of hospitalization, anesthesia and operation not easily separated” AMA Am J Dis Child. 1953;86:587

6. Eckenhoff Am J Dis Child 1953 Meyers Anesth Analg 1977 Hannallah Can Anaesth 1983 Apathy Anxiety Enuresis Sleeping Eating 26% 23% 19% 32% 28% 45% 33% 34% 33% 37% 66% 5% 65%

7.  Prospective study 163 children ages 2-10  Measured anxiety in HU and at separation  Postoperative behavior changes correlated with anxiety of child and parent in HU ◦ 54% overall at 2 weeks ◦ 20% persisted for 6 months ◦ 7.3% persisted for 1 year  Nightmares, separation anxiety, eating disorders, fear of doctors most common Arch Pediatr Adolesc Med. 1996;150:1238

8.  Tension, apprehension and worry  Measurement tool validation – m-YPAS (Kain)* ◦ 27 items in 5 domains of behavior ◦ activity, emotional expressivity, arousal, vocalization and use of parents  ↑ “vulnerability” – age < 5 (Kain 1999); high IQ, shy, ↓ adaptive abilities (Kain 2001); prior hospitalizations and poor interactions with health professionals in past; parental anxiety * Anesth Analg 1997;85:783

9.  Anxiety during induction correlates with PACU excitement and postop changes (Kain 1999)  Preoperative anxiety correlates with PACU agitation and postop changes (Kain 2004)  Preoperative anxiety correlates with increase in pain scores and analgesic use (Kain 2006)  Additional detrimental outcomes may be related to activation of the “stress” response

10.  Behavioral modalities ◦ Coping strategies ◦ Preoperative program (POP) ◦ Parental presence Induction (PPIA)  Pharmacologic modality (premed)

11.  Classically described by Waters in 1938  Oral premed Nicolson 1989  Oral midazolam most common today  Most commonly utilized age < 3 yrs

12.  Effect on outcome unclear, even with more compliant induction ◦ Kain – reduced regressive behavior POD 1-7, but not POD 14 (1999) ◦ McGraw – increased changes at POD 7, all resolved by 4 wks (1998)  Potential downsides: efficiency, costs (drug & personnel), paradoxical rxn

13.  Behavioral modalities ◦ Coping strategies ◦ Preoperative program (POP) ◦ Parental presence Induction (PPIA)  Pharmacologic modality (premed)

14.  Coping strategies w/large body of literature and experience with painful procedures in chronic illness  Preoperative programs  PPIA

17.  Numerous authors: improved anxiety scores and quality induction ◦ Varughese Anesth Analg 2008; 107:413 ◦ Vetter Anesth Analg 1993:77:96  Kain (ADVANCE)* ◦ Improved anxiety in HU / induction ◦ Decreased emergence agitation ◦ Decreased analgesic requirement in PACU *Anesthesiology 2007;106:65

18.  PPIA increased from 1995-2002 BUT  10% used PPIA >75% of the time  50% NEVER used it  26% stated “against hospital policy” Anesth Analg 2004;98:1252

19.  Separation anxiety “trauma” reflective of developmental age, genetics, parenting  PPIA diminishes separation trauma for child and need for premedication  Does increase overall parent satisfaction  Effects on induction controversial and depend on the child and the parent ◦ shift focus on parent selection / preparation

20.  Adult behaviors will impact child’s ability to cope with the stress of induction  Emotion-based behaviors will tend to increase distress while distraction-based behaviors will tend to decrease distress  Health care professionals and parents will take cues from each other Anesthesiology 2009;111:1290-6

21.  ASA I-II undergoing outpatient surgery  Ages 2-10 ◦ Part of large-scale multicenter NIH-funded Behavioral Interactions-Perioperative Study (BIPS)  Inhalation induction  Exclusion – chronic illness, developmental delay, non-English speaking parents Anesthesiology 2009;111:1290-6

22.  Revised peri-operative child-adult medical procedure interaction scale (R-PCAMIS) ◦ Behavioral collection computer system utilized ◦ 44 defined verbal and non-verbal behavior codes  State (duration) vs. Event (frequency) codes  Six adult behavior codes ◦ 3 “distractions” and 3 “emotional support”  Three child behavior codes ◦ Previously validated with m-YPAS (Anesth Analg 2009;109:1434) Anesthesiology 2009;111:1290-6

23. ADULT BEHAVIOR CODESCHILD BEHAVIOR CODES  Medical reinterpretation  Non-procedural talk  Humor  Reassurance  Empathy  Empathic touch  Acute distress ◦ Nonverbal resistance & cry  Anticipatory Distress ◦ Verbal resistance ◦ Request for support ◦ Negative verbal emotion  Regulating Behavior ◦ Non-procedure talk ◦ Engaging in medical play ◦ Seeking information Anesthesiology 2009;111:1290-6

25.  JMC trained 3 additional raters over 3 months ◦ familiarized with coding interface ◦ met at least 0.80 agreement training tapes  Observer® XT software allows differentiation of individual behaviors from the interactions of many, while linking behavior to initiator  Raters watched videos – coding ~ 4⁰ / subject  10% overlap to assure interrater reliability Anesthesiology 2009;111:1290-6

26.  Power – based on prior studies and allowing 5% for age variability, an n of 264 was chosen for appropriate statistical significance  Spearman rank order utilized to compare relations among adult behaviors as well as the relationship of adult behavior to child distress Anesthesiology 2009;111:1290-6

27.  338 enrolled / final sample 293  48% female  85.7% non-Hispanic white  35% prior surgery  82% mother accompanied to the OR  No differences noted in behavior across 14 anesthesiologists Anesthesiology 2009;111:1290-6

28. ANESTHESIA NURSE PARENT reassurance 0.74 A 0.14 B 0.81 A empathy 0.04 A 0.01 B 0.02 A,B non-procedure talk 0.67 A 0.07 C 0.35 B humor 0.75 A 0.23 B 0.67 A reinterpretation 2.74 A 0.39 C 0.98 B Empathic touch 0.11 B 0.04 C 0.52 A Anesthesiology 2009;111:1290-6 A > B > C P < 0.001

29. ANESTHESIA PARENT NURSE PARENT ANESTHESIA NURSE reassurance 0.358* 0.216* 0.13 empathy 0.126 0.072 0.026 non-procedure talk 0.432* 0.194* 0.056 humor 0.327* 0.199* 0.200* reinterpretation 0.133 0.079 -0.083 empathic touch -0.064 0.042 0.039 Anesthesiology 2009;111:1290-6 Spearman rank order correlation * P < 0.001

30. CHILD DISTRESS BEHAVIOR CHILD REGULATING BEHAVIOR emotion-focused behavior (all adults) 0.575* -0.269* distracting behavior (all adults) -0.210* 0.286* Reinterpretation: anesthesiologist -0.077 0.370* parent 0.202* 0.042 nurse -0.020 0.023 Anesthesiology 2009;111:1290-6 Spearman rank order correlations * P < 0.001

31.  Interaction ↑ between nurse (N) – parent (P) and anesthesiologist (A) – parent ◦ Parents tend to take cues from health providers ◦ Adults all respond to the same cues from child  A and P engaged in behaviors most frequently ◦ A more medical reinterpretation ◦ P more empathic touch Anesthesiology 2009;111:1290-6

32.  Non-procedural talk and humor positively correlated with reducing child stress  Empathy tends to increase distress ◦ agreement with several prior studies  Reinterpretation by A tends to decrease child distress; by P tends to increase distress Anesthesiology 2009;111:1290-6

33.  Effects of age could be better stratified  Effects of behavior leading up to induction  Potential moderators of effect ◦ Child temperament ◦ Premedication ◦ Prior experiences ◦ Preoperative teaching program  Correlation with multiple endpoints (emergence, behavior ∆’s, satisfaction) Anesthesiology 2009;111:1290-6