|Year : 2018 | Volume
| Issue : 12 | Page : 958-962
Effect of premedication with oral midazolam on preoperative anxiety in children with history of previous surgery – A prospective study
Pulak Priyadarshi Padhi1, Neerja Bhardwaj2, Sandhya Yaddanapudi2
1 International Training Fellow, Norfolk and Norwich University Hospital, Norwich, United Kingdom
2 Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Web Publication||10-Dec-2018|
Dr. Pulak Priyadarshi Padhi
C-27-G, Rail Vihar, Chandrasekharpur, Bhubaneswar - 751 023, Odisha
Source of Support: None, Conflict of Interest: None
Background and Aims: History of previous surgery may be a risk factor for high preoperative anxiety. The most commonly used technique to reduce preoperative anxiety is oral midazolam premedication because of its safety profile. The aim of this study was to compare the anxiety after premedication in children with a history of previous surgery and those without a history of previous surgery. Methods: A prospective study was conducted in children aged 4–10 years scheduled for surgery under general anaesthesia. Thirty-five children with a history of previous surgery and 35 children without any history of previous surgery were enrolled. Anxiety was assessed using modified Yale Preoperative Anxiety Scale (mYPAS) before and 20 min after premedication with oral midazolam. Anxiety during parental separation and mask acceptance during induction of anaesthesia was assessed using 4-point scale. mYPAS scores were compared using Mann–Whitney U-test, and the incidence of satisfactory parental separation and mask acceptance was compared using χ2 test. Results: The median (interquartile range) anxiety scores after premedication were statistically similar (P = 0.74) in children without a history of previous surgery [31.7 (23.3–40.8)] and in those with a history of previous surgery [33.3 (28.3–47.5)]. Baseline anxiety scores were comparable in the two groups. A high percentage of children in both the groups had a satisfactory parental separation and mask acceptance score. Conclusion: Anxiety scores after premedication with midazolam were similar in children with history of previous anaesthesia exposure and those experiencing anaesthesia for the first time.
Keywords: Anxiety, midazolam, premedication
|How to cite this article:|
Padhi PP, Bhardwaj N, Yaddanapudi S. Effect of premedication with oral midazolam on preoperative anxiety in children with history of previous surgery – A prospective study. Indian J Anaesth 2018;62:958-62
|How to cite this URL:|
Padhi PP, Bhardwaj N, Yaddanapudi S. Effect of premedication with oral midazolam on preoperative anxiety in children with history of previous surgery – A prospective study. Indian J Anaesth [serial online] 2018 [cited 2021 Jan 24];62:958-62. Available from: https://www.ijaweb.org/text.asp?2018/62/12/958/247129
| Introduction|| |
Surgery and anaesthesia are stressful events for children. A large proportion, up to 40%–60%, experience high levels of anxiety in the preoperative period., Increased preoperative anxiety not only causes distress to the child and parents but also delays the induction and recovery from anaesthesia, increases the patient's pain experience and increases the likelihood of emergence delirium and maladaptive behaviour.,
Previous history of surgery has been found to be one of the risk factors for increased preoperative anxiety in some studies.,,,, However, these findings have not been confirmed by other investigators., In our clinical practice, we have observed that children who have undergone surgery in recent past exhibit increased levels of anxiety when rescheduled for surgery and remain anxious even after premedication. We conducted this study to test this observation.
| Methods|| |
After the approval of the Institutional Ethics Committee and written informed consent from the parents/guardians, this prospective study was conducted between December 2013 and June 2014, in children in the age group of 4–10 years, belonging to American Society of Anesthesiologists' physical status I or II, undergoing elective urogenital, abdominal or orthopaedic surgical procedures under general anaesthesia. Thirty-five children who were undergoing surgery for the first time and did not have any history of previous surgery were included in Group A and 35 children with a history of previous surgery within the last 2 years were included in Group B. Children with a decreased level of consciousness, delayed milestones or neurodevelopmental anomalies, those with history of chronic illness, hypersensitivity to benzodiazepines and children who refused mask induction of anaesthesia were excluded from the study.
Patients were asked to fast as per the standard institutional protocol. Baseline anxiety of children was measured in the preoperative holding room using the modified Yale Preoperative Anxiety Scale (mYPAS). It is an observational instrument of anxiety assessment and contains 22 items in five categories, namely, activity, emotional expressivity, state of arousal, vocalisation and use of parents. Children were premedicated with 0.5 mg kg−1 of oral midazolam syrup about 20–30 min prior to induction of general anaesthesia. Anxiety was reassessed using the same scale 20 min after premedication. High anxiety was defined as a score of 30 or more on mYPAS. Anxiety was also evaluated at the time of parental separation on a 4-point scale (1 = crying, very anxious; 2 = anxious, not crying; 3 = calm, but not cooperative; 4 = calm, cooperative or asleep).
Children were transferred to the operating room by the anaesthesiologist without the parents accompanying their wards. Anaesthesia was induced with sevoflurane (8%) in oxygen using a transparent mask. Mask acceptance during induction of anaesthesia was graded on a 4-point scale (1 = combative, crying; 2 = moderate fear of the mask, not easily calmed; 3 = cooperative with reassurance; 4 = calm, cooperative or asleep). Parental separation and mask acceptance scores of 1 or 2 were considered unsatisfactory, while scores of 3 or 4 were considered satisfactory effects of premedication. Assessment of anxiety and scoring was done by another trained staff who did not participate in the anaesthetic management and was not aware of group allocation. The rest of the anaesthetic management was at the discretion of the attending anaesthesiologist.
The primary objective of the study was to compare the anxiety after premedication in children without a history of previous surgery and those with a history of previous surgery and anaesthesia. The secondary objectives were to compare the baseline anxiety, and the incidence of satisfactory parental separation and mask acceptance in these children.
Kain et al. observed that the mean [standard deviation (SD)] anxiety score on mYPAS was 28 when assessed 20 min after midazolam premedication. Using Power and Sample Size Calculations version 3.0.43, we estimated a sample size of 33 per group to detect a difference of 20% in the anxiety scores with a power of 80% and an α error of 0.05. To adjust for any dropouts, 35 patients were recruited in each group.
Statistical analysis was performed using SPSS® version 15 (Statistical Packages for the Social Sciences, Chicago, IL, USA). Normally distributed data are presented as mean ± SD and analysed using Student's t-test. Skewed continuous variables and ordered categorical variables are presented as median (interquartile range) and analysed using Mann–Whitney U-test. Pearson χ2 test was used for analysis of categorical variables. A P value of <0.05 was considered to be statistically significant.
| Results|| |
A total of 70 children were enrolled in the study, 35 in each group. The demographic characteristics such as age, gender, weight and height were similar in the two groups [Table 1]. There was no significant difference in the proportion of children operated on day-care basis in the two groups. The two groups were also similar with respect to the times from premedication to second assessment of anxiety, to parental separation and to mask induction of anaesthesia [Table 1]. Assessment of anxiety 20 min after premedication was possible only in 33 children in each group as two children in each group were asleep.
The median anxiety scores assessed 20 min after premedication were not significantly different in the two groups. The baseline anxiety scores were also statistically similar in the two groups. The number of children with high anxiety was similar in the two groups before and after premedication with midazolam [Table 2].
In post hoc analysis, the mYPAS score of children being operated on a day-care basis [40 (28.3–57.5)) was found to be similar to that of admitted children [35 (28.3–55); P = 0.72]. There was no significant difference in the number of children with satisfactory parental separation and mask acceptance scores in the two groups [Table 3].
|Table 3: Incidence of satisfactory parental separation and mask acceptance|
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| Discussion|| |
A number of risk factors and predictors of preoperative anxiety have been described in children. History of previous surgery and anaesthesia has been reported as one of them. We found that the anxiety scores after midazolam premedication in children with previous history of surgery and anaesthesia are not different from those in children scheduled for surgery for the first time. We also found that the baseline anxiety in these two groups of children was not different. Fortier et al. studied children undergoing day-care surgery and found that history of previous surgery or hospitalisation was not a predictor of increased perioperative anxiety. Fortier et al. studied adolescents in another investigation and found similar results. On the other hand, Vetter et al. showed that having undergone previous surgery was a significant predictor of problematic preoperative behaviour. Previous surgery or anaesthesia exposure was shown as a predictor of increased anxiety in children coming for subsequent procedures in few other studies also.,,,
We postulate that this difference in the effect of previous surgery on preoperative anxiety in various studies may be due to the difference in the quality of previous experience during the hospital stay. A negative experience is expected to give rise to increased anxiety levels on subsequent admissions, whereas a positive experience during the past anaesthetic exposure may not have any significant effect on the anxiety levels or may result in less anxiety during subsequent anaesthetic exposure. Thus, qualitative evaluation of the child's experience of previous surgery may help in planning appropriate psychological preparation and anxiolytic premedication.
We used mYPAS to assess anxiety as it has been validated for this purpose in children in the perioperative settings. It is an observational instrument which can be easily applied to assess the anxiety in less than 2 min. The other widely used self-reported measure of anxiety State-Trait Anxiety Inventory for Children (STAIC), which is also considered the gold standard for assessment of anxiety, was not used as it takes longer to be completed and it can be used only in older children. Another limitation of STAIC is that it cannot assess state anxiety in a dynamic or rapidly changing environment such as in the perioperative period.
We included children who had experienced an anaesthetic within the past 2 years, as an exposure earlier than that was unlikely to be remembered and be a cause of anxiety during subsequent procedures. Also, children younger than 2 years will probably not retain the memory of their previous anaesthetic. Hence, we selected the minimum age for the study to be 4 years.
Kain et al. found that a score of 30 or more on mYPAS identified high anxiety. The same cutoff score was validated in a previous study conducted by Mathew et al. Using this cut-off value of mYPAS score, we observed that the incidence of high anxiety was similar in children with or without previous history of anaesthetic exposure, before and after premedication. Although there was a reduction in the anxiety scores after premedication with midazolam in both the groups, the scores were still more than 30 indicating that premedication was only partially effective in reducing anxiety.
We found that the anxiety scores in children operated as day-care or as admitted patients were similar. Davidson et al. observed that hospital admission via the day-stay ward was associated with less anxiety. This may be due to the fact that day-care patients stay in a familiar environment and with people they know right till the time of surgery as opposed to admitted patients who are exposed to an unfamiliar environment and unknown people the night before surgery. Children in our study did not show any difference in anxiety levels based on the type of hospital admission probably because in our hospital, one or more family members always stay with the child during admission. Also, the number of children included in Davidson's study was much higher compared with our study which included only 70 patients and was thus not adequately powered to make a conclusion regarding this parameter.
The number of children with satisfactory parental separation and mask acceptance was similar in the two groups in our study. Also, a high percentage of children in both the groups had a satisfactory parental separation and mask acceptance scores, despite high anxiety scores at baseline and after premedication. Premedication with oral midazolam has been seen earlier to be associated with satisfactory mask acceptance in more than 80% of children.
Some of the limitations of the study are as follows. The quality of experience during the previous induction of anaesthesia can affect the anxiety of the children at the time of subsequent surgeries. We could not obtain this information as most of the parents were usually not present during induction of anaesthesia, and many of the children did not remember these details. Other factors, such as parental anxiety and temperament of the child, which could have an effect on child's anxiety were not evaluated in this study.
The effect of the child's experience during previous anaesthesia and surgery on preoperative anxiety can be the subject of future studies. The interaction of this factor with other predictors of anxiety can also be evaluated.
| Conclusion|| |
In this study, we found that the anxiety scores after premedication with midazolam were similar in children with history of previous anaesthesia exposure and those experiencing anaesthesia for the first time.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Corman H, Hornick E, Kritchman M, Terestman N., Emotional reactions of surgical patients to hospitalization, anesthesia and surgery. Am J Surg 1958;96:646-53.
Melamed BG, Siegel LJ. Reduction of anxiety in children facing hospitalization and surgery by use of filmed modeling. J Consult Clin Psychol 1975;43:511-21.
Johnston M. Preoperative emotional states and post-operative recovery. Adv Psychosom Med 1986;15:1-22.
Vernon DT, Schulman JL, Foley JM. Changes in children's behavior after hospitalization: Some dimensions of response and their correlates. Am J Dis Child 1966;111:581-93.
Vetter TR. The epidemiology and selective identification of children at risk for preoperative anxiety reactions. Anesth Analg 1993;77:96-9.
Kain ZN, Mayes LC, O'Connor TZ, Cicchetti DV. Preoperative anxiety in children: Predictors and outcomes. Arch Pediatr Adolesc Med 1996;150:1238-45.
Davidson AJ, Shrivastava PP, Jamsen K, Huang GH, Czarnecki C, Gibson MA, et al
. Risk factors for anxiety at induction of anesthesia in children: A prospective cohort study. Pediatr Anesth 2006;16:919-27.
Mathew PJ, Malik RH, Yaddanapudi S, Kohli A, Panda NB. Assessment of factors affecting pre-operative anxiety and compliance in school-going children. Arch Dis Child 2014;99(Suppl. 2):A137-8.
Wollin SR, Plummer JL, Owen H, Hawkins RM, Materazzo F. Predictors of preoperative anxiety in children. Anaesth Intensive Care 2003;31:69-74.
Fortier MA, Del Rosario AM, Martin SR, Kain ZN. Perioperative anxiety in children. Pediatr Anesth 2010;20:318-22.
Fortier MA, Martin SR, Chorney JM, Mayes LC, Kain ZN. Preoperative anxiety in adolescents undergoing surgery: A pilot study. Pediatr Anesth 2011;21:969-73.
Kain ZN, Mayes LC, Cicchetti DV, Bagnall AL, Finley JD, Hofstadter MB. The Yale Preoperative Anxiety Scale: How does it compare with a ‘Gold Standard’? Anesth Analg 1997;85:783-8.
Almenrader N, Passariello M, Coccetti B. Premedication in children: A comparison of oral midazolam and oral clonidine. Pediatr Anesth 2007;17:1143-9.
Kogan A, Katz J, Efrat R, Eidelman LA. Premedication with midazolam in young children: A comparison of four routes of administration. Pediatr Anesth 2002;12:685-9.
Kain ZN, Hofstadter MB, Mayes LC, Krivutza DM, Alexander G, Wang SM, et al
. Midazolam: Effects on amnesia and anxiety in children. Anesthesiology 2000;93:676-84.
[Table 1], [Table 2], [Table 3]