Impact of preanesthetic information on anxiety of parents and children

Abstracts

JUSTIFICATIVA E OBJETIVOS: Ansiedade pré-operatória é um fator negativo na experiência anestésico-cirúrgica. Dentre as estratégias para redução da ansiedade em crianças, as não farmacológicas são tão importantes quanto as farmacológicas, porém sua validade ainda é controversa. Verificar se a informação oferecida aos responsáveis interfere na ansiedade da criança. MÉTODOS: 72 crianças de 4 a 8 anos, ASA I e II, submetidas a procedimentos cirúrgicos eletivos e seus responsáveis, divididos aleatoriamente em: Grupo Controle (GC) = responsável recebeu informação anestésica convencional; e Grupo Informativo (GI) = responsável recebeu folheto sobre a anestesia. Foi avaliada ansiedade das crianças pela escala de ansiedade pré-operatória de Yale modificada (EAPY-m), em dois momentos, na sala de espera do centro cirúrgico (SE) e na sala de operação (SO), e dos pais, pela Escala de ansiedade de Hamilton (HAM-A) em SE. RESULTADOS: Não houve diferença nos dados sociodemográficos entre os grupos. O nível de ansiedade nas crianças não apresentou diferença entre os grupos nos dois momentos. Houve diferença estatística significativa nos níveis de ansiedade entre SE e SO nos dois grupos, p = 0,0019 no GC e p < 0,0001 no GI, assim como na prevalência de ansiedade em GC (SE 38,9% e SO 69,4%, p = 0,0174) e em GI (SE 19,4% e SO 83,3%, p< 0,0001). O nível de ansiedade dos responsáveis não apresentou diferença entre os grupos. CONCLUSÃO: Independentemente da qualidade de informação oferecida aos responsáveis, o nível e a prevalência de ansiedade das crianças foram baixos no momento SE e aumentaram significativamente no momento SO.

Ansiedade; Anestesia; Avaliação; Cuidados pré-operatórios; Criança

JUSTIFICATIVA Y OBJETIVOS: La ansiedad preoperatoria es un factor negativo en la experiencia anestésico-quirúrgica. Entre las estrategias para la reducción de la ansiedad en niños, las no farmacológicas son tan importantes como las farmacológicas, pero su caducidad todavía es algo controversial. Verificar si la información ofrecida a los responsables interfiere en la ansiedad del niño. MÉTODOS: Setenta y dos (72) niños de 4 a 8 años, con ASA I y II, sometidos a procedimientos quirúrgicos electivos y sus responsables, divididos aleatoriamente en: Grupo Control (GC) = responsable recibió una información anestésica convencional; y el Grupo Informativo (GI) = responsable recibió un folleto sobre la anestesia. Se evaluó la ansiedad de los niños por la escala de ansiedad preoperatoria de Yale modificada (EAPY-m), en dos momentos, en la sala de espera del centro quirúrgico (SE) y en el quirófano (Q), y de los padres, por la escala de Hamilton (HAM-A) en SE. RESULTADOS: No hubo diferencia en los datos sociodemográficos entre los grupos. El nivel de ansiedad en los niños no presentó ninguna diferencia entre los grupos en los dos momentos. Hubo una diferencia estadística significativa en los niveles de ansiedad entre SE y Q en los dos grupos, p = 0,0019 en el GC y p < 0,0001 en el GI, como también en la prevalencia de ansiedad en GC (SE 38,9% y Q 69,4%, p = 0,0174) y en GI (SE 19,4% y Q 83,3%, p< 0,0001). El nivel de ansiedad de los responsables no presentó diferencia entre los grupos. CONCLUSIONES: Independientemente de la calidad de la información ofrecida a los responsables, el nivel y la prevalencia de ansiedad de los niños fueron bajos en el momento SE aumentando significativamente en el momento Q.

Ansiedad; Anestesia; Evaluación; Cuidados preoperatorios; Niño

SCIENTIFIC ARTICLE

Impact of preanesthetic information on anxiety of parents and children^*

Débora de Oliveira Cumino^I,II,III; Guilherme Cagno^IV; Vinícius Francisco Zacarias Gonçalves^V; Denis Schapira Wajman^V; Lígia Andrade da Silva Telles Mathias^IV,V

^IPediatric Anesthesia Committee, Sociedade Brasileira de Anestesiologia, São Paulo, SP, Brazil

^IIIrmandade Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil

^IIIDepartment of Pediatric Anesthesiology, Hospital Infantil Sabará, São Paulo, SP, Brazil

^IVDepartment of Anesthesiology, Irmandade Santa Casa de São Paulo, São Paulo, SP, Brazil

^VCollege of Medical Sciences, Irmandade Santa Casa de São Paulo, São Paulo, SP, Brazil

Corresponding author

ABSTRACT

BACKGROUND AND OBJECTIVES: Preoperative Anxiety is a negative factor in anesthetic and surgical experience. Among the strategies for reducing children's anxiety, non-pharmacological strategies are as important as the pharmacological ones, but its validity is still controversial.

OBJECTIVES: The aim of this study was to verify if the information provided to guardians interferes with child anxiety.

METHODS: 72 children, 4-8 years old, ASA I and II, undergoing elective surgical procedures and their guardians were randomly divided into two groups: control group (CG) = guardian received conventional information about anesthesia; informative group (IG) = guardian received an information leaflet about anesthesia. Children's anxiety was assessed using the modified Yale Preoperative Anxiety Scale (m-YPAS) on two occasions: at the surgical theater waiting room (WR) and at the operating room (OR). Parents' anxiety was assessed using the Hamilton Anxiety Scale (HAM-A) at the CT.

RESULTS: There was no difference in demographic data between groups. The level of anxiety in children showed no difference between groups at two measured times. There was statistically significant difference in anxiety levels between WR and OR in both groups, p = 0.0019 for CG and p < 0.0001 for GI, as well as the prevalence of anxiety for CG (38.9% WR and 69.4 % OR, p = 0.0174) and GI (19.4% WR and 83.3% OR, p < 0.0001). The anxiety level of guardians did not differ between groups.

CONCLUSION: Regardless of the quality of information provided to the guardians, the level and prevalence of anxiety in children were low at WR time and significantly increased at OR time.

Keywords: Anxiety; Anesthesia; Evaluation; Preoperative care; Child

Introduction

Perioperative anxiety is a major factor in the negative impact on surgical and anesthetic experience and also an additional risk factor for postoperative complications in pediatric patients.^1,2 It is estimated that 40% to 75% of children undergoing surgery experience significant fear and anxiety during the preoperative period.^3-5 Several authors suggest that children under 4 years of age are at greater risk for developing anxiety preoperatively.^6,7 Bevan et al.⁸ report that anxiety of relatives is a factor of great importance and influence on the preoperative anxiety levels of children and effectively contributes to the development of behavioral changes in postoperative pediatric patients. Among the strategies for reducing the pediatric population anxiety, the non-pharmacological approaches through alternative therapies that act on the psychological aspects are as important as the pharmacological ones.⁹ Currently, there is great motivation towards non-pharmacological interventions aimed at anxiety relief for children and their families, such as parental presence during induction of anesthesia (PPIA), educational programs to prepare the family, and written information on anesthetic procedure provided to relatives and/or children. This is due in part to the large growth in outpatient practice and increased participation and presence of parents during children's hospitalization, but also to the new institutional strategies that motivate a more humane medical practice.^7,10-13 The aim of this study was to determine whether the quality of information provided to guardians at the operating theatre waiting room (WR) has an impact on the child's anxiety in the operating room (OR).

Method

After approval by the Research Ethics Committee of Irmandade da Santa Casa de São Paulo and Research Center of Hospital Infantil Sabará (No 108/11), an open randomized clinical trial was conducted at the surgical centers of both hospitals to compare the level of anxiety of children and their guardians, according to the quality of information received in the preanesthetic period.

Seventy-four children were randomly selected through the List Randomizer program (www.random.org) and divided into two groups: informative group (IG), in which the guardian received in the waiting room of the surgical center (SC), in addition to conventional verbal information, a leaflet containing information about the anesthetic procedure; and control group (CG), in which the guardian received only conventional verbal information in the waiting room of the SC.

Developed by the author, the leaflet consists of 17 brief items, such as questions and answers, and provides information regarding the most frequently asked questions by the guardians, as observed in clinical practice. The contents of this informative leaflet covers aspects of the specialty and practice of anesthesiology, such as suspension and use of medications, fasting, full stomach and refeeding after anesthesia, laboratory tests, anesthesia in children, types of anesthesia, risks, induction and recovery room, presence of parents, and how to contribute to a peaceful anesthesia in children (Fig. 1).

Inclusion criteria were ASA physical status I and II, according to the classification of the American Society of Anesthesiologists (ASA), aged between 4 and 8 years, undergoing minor-medium elective surgical procedures, with an indication of general anesthesia, who did no receive premedication and whose parents were illiterate.

The exclusion criteria for children were psychomotor deficits, use of psychoactive drugs, hearing and visual impairment, previous surgery; and for guardians, the exclusion criteria were illness or mental disorder clinically recognized, lack of condition to decide on the child's participation in the study, decline to participate.

Before starting the study, training sessions on how to use the modified Yale Preoperative Anxiety Scale (m-YPAS) were conducted with researchers at the same site where the research took place.

The study began always in the waiting room of the surgical centers, after preanesthetic assessment and provision of information on conventional anesthesia. One of the researchers applied the m-YPAS scale and then the guardians were fully informed about the character of the study and method to be used and asked to sign the consent form. At the end of the preanesthetic evaluation (APA), at least 30 minutes before entering the OR, the guardians of both groups (CG and IG) received conventional verbal information and the guardians of the IG also received an information leaflet. Before the child was taken to the OR, still at the SC waiting room, the guardian anxiety was assessed using the Hamilton Anxiety Scale (HAM-A) in both groups, and then, regardless of group, the collection of sociodemographic data was performed and satisfaction with the information received subsequently evaluated. The children remained always accompanied by the guardians until the end of induction. In the OR, all children underwent standard monitoring and, immediately before induction of anesthesia (intravenous or inhaled) through conventional technique, they were re-evaluated using m-YPAS (OR time).

Analyzed variables:

• Level and prevalence of children's anxiety (m-YPAS), measured at two times [waiting room (WR) and operating room (OR)] immediately before induction. The observational m-YPAS (Fig. 2) was used as originally proposed by Kain et al.¹⁴ A partial score was given for each domain, based on the score observed by the researcher, divided by the number of categories in that domain. The score for each domain is added to the others and then multiplied by 20 (Fig. 3). Cut-off scores to classify patients with or without anxiety were: without anxiety (23.4-30), with anxiety (< 30).

• Level and prevalence of guardians' anxiety¹⁵ (HAM-A) (Fig. 4), which scores quantitatively related symptoms of anxiety and includes 14 symptoms (seven mental and seven physical), using scores from 0-4 that quantify the intensity of each symptom, in which 0 = absence of any symptom; 1 = mild intensity; 2 = medium intensity; 3 = strong intensity; 4 = maximum intensity - disabling. The sum of these values was used to quantify the total anxiety score of the person responsible for the patient, according to the scale original recommendations. The cut-off points considered for this scale met the following criteria^15-17: normal anxiety (0-17); mild anxiety (18-24); moderate anxiety (25-29); severe anxiety (< 30).

For sample size calculation, it was considered that the prevalence of children's anxiety in the operating room is 50%³ and that the proposed intervention is able to reduce it by 30%. Thus, we propose to use a-error of 5%, b-error of 20%, and confidence interval of 95%, totaling 72 patients, 36 in each group.

Results are shown in descriptive tables containing means, standard deviations, minimum and maximum values, median, 25th and 75th percentiles, total values and percentages. The following tests were used: unpaired Student t-test, Fisher exact, Mann-Whitney, Kruskal-Wallis, and qui-square. Differences were considered statistically significant when p < 0.05.

Results

Seventy-four individuals were invited to participate in the study, two guardians refused; therefore, 72 children were included.

Data comparison of age and gender of children and guardians, as well as guardian/child bonding, showed no statistically significant difference between the two groups (Table 1). Surgical procedures had the following distribution: pediatric general surgery, n = 24 (36.0% CG vs. 33.3% IG); ear surgery, n = 5 (8.4% CG vs. 2.8% IG); and ENT surgery, n = 43 (55.6% CG vs. 63.9% IG). There was no statistical difference between groups (p = 0.7498).

Table 2 shows the m-YPAS median and 24-27^th percentile scores of patients in CG and IG at WR and OR times. The children's level of anxiety measured by the median scores showed no significant difference between groups at both times. However, when comparing times in each group, there was a statistically significant difference between the levels of anxiety at WR and OR in both groups, p = 0.0019 for CG and p < 0.0001 for IG (Table 2).

Regarding the prevalence of anxiety in children (child considered anxious when the final score of m-YPAS was greater than 30), there was no difference between groups at any time (WR and OR). In contrast, there was significant increase in the prevalence of anxiety in both groups according to the time: 38.9% and 69.4% for CG at WR and OR times, respectively (p = 0.0174), and 19.4% and 83.3% for IG at WR and OR times, respectively (p < 0.0001) (Table 3).

The guardians' level of anxiety, measured preoperatively by the median scores (25-75^th percentile) of the HAM-A scale, was not significantly different between groups, CG 8 (5.25-16) vs. IG 9 (3.25-17.75), p = 0.8435.

Regarding the guardian's prevalence and anxiety score, there was no statistical difference in the prevalence of anxiety in both groups (qui-square test, p = 0.7002). According to HAM-A scores, the prevalence, total number, and percentage of guardians with anxiety were normal: CG = 29 (80.5%) vs. IG = 27 (75%); mild: CG = 4 (11.1 %) vs. IG = 3 (8.3%); moderate: CG = 2 (5.6%) vs. IG = 3 (8.3%); and severe: CG = 1 (2.8%) vs. IG = 3 (8.3%).

As for the relationship between guardians and children's anxiety, the analysis of both groups was made separately. According to HAM-A, we considered "no anxiety" those guardians with normal anxiety scores (< 18) and "anxious" those with mild, moderate, and severe anxiety scores (≥ 18). There was no statistical significance (Table 4).

Discussion

Anxiety measurement with the use of scales is not routine during the preanesthetic evaluation of children in Brazil.^18-20 However, the current role of anesthesiologists encompasses the entire perioperative period and, in that broad spectrum of activity, anxiety identification is critical to guide the pharmacological and non-pharmacological strategies during the preoperative approach, in an effort to avoid anxiety and achieve better results in the induction of anesthesia and postoperative period of pediatric patients.^5,9,14,21,22

We chose to evaluate preoperative anxiety of children and guardians at the waiting room of the surgical center because this is the time when the anesthesiologist, at both institutions involved in the study, provides information about the anesthetic procedure to the guardian and explains how induction of anesthesia is done to the child.

In the present study, the timing and location for assessing preoperative anxiety was motivated by Kain et al.⁷ clinical trial, which assessed the binomial parent-child and predictors of temperament (calm and anxious) influencing the benefit of the PPIA on the child's anxiety at that time. In this trial, the assessment of preoperative anxiety is made in the SC waiting room and the evaluation of anxiety at induction immediately before placing the facial mask.⁷

In the last decade, there has been greater tolerance for the presence of relatives during hospitalization and procedures under anesthesia. At the two institutions in which this study was conducted, it has been some time that the institutional routine allows the PPIA. However, in daily practice, we observe that not only always the parents' presence was enough to control or reduce children's anxiety in the OR at the time of induction.

The use of informative leaflet with the purpose of increasing knowledge and satisfaction and reduce the anxiety of guardians was proposed in this study as a non-pharmacological strategy, with the main objective of reducing child's anxiety at induction of anesthesia, in accordance with a multicenter analysis reporting that the provision of information and PPIA are factors that affect the satisfaction levels of children and their families regarding anesthesia.²¹ Moreover Padda et al.²² report that the use of teaching or reading materials, even with basic information, is efficient to provide education and knowledge to parents about the perioperative care of their children.

In the present study, the informative leaflet was given to the guardian at the waiting room at least 30 minutes in advance, so he/she had enough time to read the information and guide the child on the anesthetic procedure before entering the OR, assuming that the reading time was approximately 10 minutes. There is no consensus in the current literature about the ideal time to pass the information to those responsible for the child.

A study by Chan and Molassiotis²³ proposes an educational program consisting of verbal information on the entire process of hospital admission and stay, as well as written information on the importance of parental presence during the perioperative period, both provided to relatives the day before the surgical procedure, and compares this strategy with conventional information. The authors report decreased anxiety and increased satisfaction in the group of relatives receiving the educational program.

A clinical trial using informative leaflet on anesthesia, given to parents on admission to hospital outpatient unit, even before the first contact with the anesthesiologist, reports decreased anxiety in 56% of the parents; however, it does not evaluate the time elapsed between the leaflet delivery and surgical procedure or the impact of this strategy on children's anxiety.²⁴

Other authors evaluating the strategy of written information given to guardians reported that there is increased knowledge and decreased anxiety, but these studies have different characteristics, such as time and manner of informative leaflet delivery, existence of educational program, and own ethnicity of guardians, which interfere with the desire for information. Thus, it is difficult to compare with the current study.^10,25-29

The use of HAM-A scale to measure guardian's anxiety was determined because this instrument is easy and quick to apply by researchers and includes psychological and physical symptoms. This scale is used in anesthesia.³⁰ Recently, Rangel Avila et al.³¹ used this tool in an observational study to assess anxiety in relatives of children undergoing general anesthesia.

The choice of the m-YPAS to measure children's anxiety was due to several factors, particularly because it is an observational instrument that avoids stress interaction between researcher and child, allows assessment of preschool age children, has a high sensitivity (85%) and specificity (92%) for m-YPAS score greater than 30 and validation for Portuguese, in addition to being quick and easy to apply.^5,14,20

The age group of 4 to 8 years was chosen to homogenize the sample from the cognitive standpoint. M-YPAS has been used in broad age groups from 2 to 12 years. Our choice was based on studies showing that children over 2 years old benefit more from the presence of parents⁷ and children under 7 years old are more likely to develop high anxiety conditions.⁵

In this study, m-YPAS was always applied by one of the four investigators involved, similarly to the study by Davidson et al.⁵ in which the scale was applied by a single investigator among the 15 technicians involved with anxiety evaluation. In our study, all investigators were instructed and trained on how to apply the scale in order to achieve equalization of values measured before starting data collection. In the primary description of the scale, for validation purposes, we used two independent observers to measure anxiety. In the original study, Kain et al.¹⁴ reported a high level of interobserver agreement in the m-YPAS application, later confirmed by Guaratini et al.²⁰ M-YPAS application at the OR followed the method originally proposed by Kain et al.¹⁴ and used later in several other studies.^5,7,10,32-34

As for outcomes, there were no differences between groups regarding sociodemographic data. It is worth noting that there was a predominance of female among those responsible for the children in both groups, as well as parental bonding. This fact is commonplace in pediatric patients, but this observation was necessary because the difference in the frequency of gender or parental bonding in a group could create a bias in the analysis of children's anxiety, justified by some authors who suggest that mothers are more anxious and influence the children's anxiety at the time of anesthesia,^35,36 as well as the presence of a non-parental guardian could be an additional factor of anxiety for the child.

We report low prevalence of anxiety at the WR of the SC in both groups; most children were calm at WR time (61.1% CG and 80.9% IG). We also noted low levels of anxiety in children at that time, (median scores of m-YPAS: CG 26.7 and IG 25.0); these data are comparable to those found by Kain et al.¹⁴ in the original study that validated the m-YPAS. These results may reflect the benefit of parent's presence in the WR of the SC, and demonstrate that this environment is suited to children and their relatives because it has TV and toys, in addition to the information provided by anesthesiologists, witch yields positive results at that time. Other authors reported different prevalence or level of anxiety, but the adopted strategies for reducing anxiety are not comparable because either the scale used is different or age group is larger.^10,29,37,38

In contrast, there was a higher prevalence of anxious children at OR time in both groups (69.4% CG and 83.3% IG), which was statistically significant compared to WR time. This high prevalence of anxiety at OR corroborates the literature data, which show the prevalence of anxiety in children ranging from 40% to 75% at the time immediately before induction of anesthesia.^4,5

Regarding prevalence of children's anxiety at different times, it is noteworthy that at WR time, although without statistical difference between groups (p = 0.1187), the prevalence of anxiety was 50% lower in IG (n = 7) compared to CG (n = 15). However, at OR time, this prevalence was not observed. Although the IG had a lower prevalence of anxiety, there is no relationship with the intervention used, as the measurement of children's anxiety at WR time was performed before the informative leaflet delivery.

However, although not analyzed in this study, it can be assumed, corroborating the literature data,^{7,8,13,22,33,39} that the entry in the OR has a negative emotional impact on the guardians and influence children's anxiety, in addition to the direct negative emotional impact on them.

Most parents in both groups appeared calm at the time of the HAM-A scale application (80.5% CG and 75% IG), with anxiety levels considered normal according to HAM-A scores. It is important to mention that the scale was used at WR time and literature is scarce regarding assessment of parental anxiety with this tool at that time. Only the study by Rangel Avila et al.,³¹ which also used the scale at the WR of the SC, reported low prevalence of anxiety. The other studies surveyed,^14,25,26,40 which assessed parental anxiety, use STAI scale or visual scale of anxiety at different times; thus, making it difficult to compare with the present study. The study by Kain et al.,¹⁰ despite using STAI to evaluate the anxiety of relatives, reports that parents who attend educational programs on anesthesia have lower levels of anxiety in the preoperative period.

In this study, we sought to evaluate the relationship between children and guardians' anxiety in an attempt to assess if guardians who received written information influenced the anxiety behavior of children compared with guardians who received only conventional verbal information. However, most guardians presenting with normal anxiety (HAM-A) had a greater percentage of non-anxious children in both groups. Still, anxious parents (mild, moderate and severe HAM-A) had the same behavior and also a greater percentage of non-anxious children. Therefore, it was not possible to conclude in this study if there is a relationship between parental anxiety and children's anxiety.

After a critical review of the study, we found that the Hamilton scale was applied after transmission of conventional information, associated or not with the leaflet, which prevented the knowledge of guardians' baseline anxiety. However, most children in both groups were calm. Moreover, the leaflet delivery and initial evaluation of anxiety in children and their guardians could occur outside the surgical environment. However, both the leaflet delivery and first assessment of anxiety could not be done before the patient entered the surgical environment due to institutional routines. Otherwise, it would be possible to assess baseline anxiety out of the SC, guardians would have more time to absorb the information received and, perhaps, influence effectively on children's anxiety at induction of anesthesia.

Conclusion

This prospective study, which assessed children's preoperative anxiety, found that, regardless of the quality of information offered to guardians at the surgical center waiting room, the level and prevalence of anxiety in children increased significantly when they entered the operating room. Thus, the quality of information (conventional + leaflet) offered to those responsible for the children was not superior to the conventional verbal information.

Conflicts of interest

The authors declare no conflicts of interest.

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*

Trabalho realizado na Irmandade Santa Casa de Misericórdia de São Paulo e no Hospital Infantil Sabará, São Paulo, SP, Brasil.

Publication Dates

• Publication in this collection
  18 Dec 2013
• Date of issue
  Dec 2013

History

• Received
  04 Mar 2013
• Accepted
  29 Apr 2013