Non-pharmacological interventions for assisting the induction of anaesthesia in children

64 Pages·2010·0.58 MB·English

Non-pharmacological interventions for assisting the induction
of anaesthesia in children (Review)
Yip P, MiddletonP, Cyna AM, Carlyle AV
ThisisareprintofaCochranereview,preparedandmaintainedbyTheCochraneCollaborationandpublishedinTheCochraneLibrary
2010,Issue11
http://www.thecochranelibrary.com
Non-pharmacologicalinterventionsforassistingtheinductionofanaesthesiainchildren(Review)
Copyright©2010TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAINLANGUAGESUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
AUTHORS’CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
CHARACTERISTICSOFSTUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
DATAANDANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Analysis1.2.Comparison1parentalpresenceversusnoparentalpresence,Outcome2Anxietyduringinduction. . . 33
Analysis1.4.Comparison1parentalpresenceversusnoparentalpresence,Outcome4Cooperationduringinduction(poor
complianceICC>6)c. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Analysis1.6.Comparison1parentalpresenceversusnoparentalpresence,Outcome6Parentalanxiety. . . . . . 35
Analysis1.7.Comparison1parentalpresenceversusnoparentalpresence,Outcome7Parentalanxiety. . . . . . 37
Analysis1.9.Comparison1parentalpresenceversusnoparentalpresence,Outcome9Emergencedelirium. . . . 38
Analysis1.11.Comparison1parentalpresenceversusnoparentalpresence,Outcome11Timetakenforinduction
(minutes). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Analysis1.12.Comparison1parentalpresenceversusnoparentalpresence,Outcome12Negativebehaviourpostop. 39
Analysis1.13.Comparison1parentalpresenceversusnoparentalpresence,Outcome13Negativebehaviourpostop. 40
Analysis1.15.Comparison1parentalpresenceversusnoparentalpresence,Outcome15Parentalsatisfaction. . . . 41
Analysis1.16.Comparison1parentalpresenceversusnoparentalpresence,Outcome16Parentalsatisfaction. . . . 42
Analysis2.1.Comparison2parentalpresenceversusmidazolam,Outcome1anxietyduringinduction. . . . . . 44
Analysis2.2.Comparison2parentalpresenceversusmidazolam,Outcome2cooperationduringinduction. . . . 44
Analysis2.4.Comparison2parentalpresenceversusmidazolam,Outcome4parentalanxiety. . . . . . . . . 45
Analysis2.5.Comparison2parentalpresenceversusmidazolam,Outcome5timetakenforinduction(minutes). . . 45
Analysis2.6.Comparison2parentalpresenceversusmidazolam,Outcome6negativebehaviourpostop. . . . . . 46
Analysis2.7.Comparison2parentalpresenceversusmidazolam,Outcome7emergencedelirium. . . . . . . . 46
Analysis2.9.Comparison2parentalpresenceversusmidazolam,Outcome9parentalsatisfaction. . . . . . . . 47
Analysis3.1.Comparison3parentalpresence+midazolamversusnoparentalpresence,Outcome1parentalanxiety. . 48
Analysis3.2.Comparison3parentalpresence+midazolamversusnoparentalpresence,Outcome2parentalanxiety. . 49
Analysis7.1.Comparison7videogameversuscontrol,Outcome1Anxietyduringinduction. . . . . . . . . 51
Analysis7.2.Comparison7videogameversuscontrol,Outcome2Negativebehaviourpostop. . . . . . . . . 51
Analysis8.1.Comparison8videogameversusmidazolam,Outcome1Anxietyduringinduction. . . . . . . . 52
Analysis8.2.Comparison8videogameversusmidazolam,Outcome2Negativebehaviourpostop. . . . . . . 52
Analysis9.1.Comparison9clowndoctors,Outcome1anxietyduringinduction. . . . . . . . . . . . . 53
Analysis9.2.Comparison9clowndoctors,Outcome2parentalanxiety. . . . . . . . . . . . . . . . . 53
Analysis10.1.Comparison10hypnosisversusmidazolam,Outcome1anxietyduringinduction. . . . . . . . 54
Analysis10.2.Comparison10hypnosisversusmidazolam,Outcome2negativebehaviourpostop. . . . . . . . 54
Analysis11.1.Comparison11lowsensorystimulationversuscontrol,Outcome1cooperationatinduction. . . . 55
Analysis11.2.Comparison11lowsensorystimulationversuscontrol,Outcome2parentalanxiety. . . . . . . 55
Analysis12.1.Comparison12acupunctureforparents,Outcome1anxietyduringinduction. . . . . . . . . 56
Analysis12.2.Comparison12acupunctureforparents,Outcome2cooperationduringinduction. . . . . . . 56
Analysis12.3.Comparison12acupunctureforparents,Outcome3parentalanxiety. . . . . . . . . . . . 57
Analysis12.4.Comparison12acupunctureforparents,Outcome4anxietyonenteringinductionarea. . . . . . 58
Analysis13.1.Comparison13videosforparents,Outcome1parentalanxiety. . . . . . . . . . . . . . . 58
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
WHAT’SNEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Non-pharmacologicalinterventionsforassistingtheinductionofanaesthesiainchildren(Review) i
Copyright©2010TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
CONTRIBUTIONSOFAUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
DECLARATIONSOFINTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
SOURCESOFSUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
DIFFERENCESBETWEENPROTOCOLANDREVIEW . . . . . . . . . . . . . . . . . . . . . 61
INDEXTERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Non-pharmacologicalinterventionsforassistingtheinductionofanaesthesiainchildren(Review) ii
Copyright©2010TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
[InterventionReview]
Non-pharmacological interventions for assisting the induction
of anaesthesia in children
PeggyYip2,PhilippaMiddleton3,AllanMCyna1,AlisonVCarlyle4
1DepartmentofWomen’sAnaesthesia,Women’sandChildren’sHospital,Adelaide,Australia.2DepartmentofPaediatricAnaesthesia,
StarshipChildren’sHospital,Auckland,NewZealand.3ARCH:AustralianResearchCentreforHealthofWomenandBabies,Discipline
of Obstetrics and Gynaecology, The University of Adelaide, Adelaide, Australia. 4Department of Anaesthesia, Princess Margaret
Hospital,Subiaco,Australia
Contact address: AllanM Cyna, Department of Women’s Anaesthesia, Women’s and Children’sHospital, 72 King William Road,
Adelaide,SouthAustralia,5006,[email protected].
Editorialgroup:CochraneAnaesthesiaGroup.
Publicationstatusanddate:Edited(nochangetoconclusions),publishedinIssue11,2010.
Reviewcontentassessedasup-to-date: 13December2008.
Citation: YipP,MiddletonP,CynaAM,CarlyleAV.Non-pharmacologicalinterventionsforassistingtheinductionofanaesthesiain
children.CochraneDatabaseofSystematicReviews2009,Issue3.Art.No.:CD006447.DOI:10.1002/14651858.CD006447.pub2.
Copyright©2010TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
ABSTRACT
Background
Inductionofgeneralanaesthesiacanbedistressingforchildren.Non-pharmacologicalmethodsforreducinganxietyandimproving
co-operationmayavoidtheadverseeffectsofpreoperativesedation.
Objectives
Toassesstheeffectsofnon-pharmacologicalinterventionsinassistinginductionofanaesthesiainchildrenbyreducingtheiranxiety,
distressorincreasingtheirco-operation.
Searchstrategy
WesearchedCENTRAL(TheCochraneLibrary2009,Issue1).Wesearchedthefollowingdatabasesfrominceptionto14thDecember
2008:MEDLINE,PsycINFO,CINAHL,DISSERTATIONABSTRACTS,WebofScienceandEMBASE.
Selectioncriteria
Weincludedrandomizedcontrolledtrialsofanon-pharmacologicalinterventionimplementedonthedayofsurgeryoranaesthesia.
Datacollectionandanalysis
Twoauthorsindependentlyextracteddataandassessedriskofbiasintrials.
Mainresults
We included 17 trials, all from developed countries, involving 1796 children, their parents or both. Eight trials assessed parental
presence.Noneshowedsignificantdifferencesinanxietyorco-operationofchildrenduringinduction,exceptforonewhereparental
presencewassignificantlylesseffectivethanmidazolaminreducingchildren’sanxietyatinduction.Sixtrialsassessedinterventionsfor
children.Preparationwithacomputerpackageimprovedco-operationcomparedwithparentalpresence(onetrial).Childrenplaying
hand-heldvideogamesbeforeinductionweresignificantlylessanxiousthancontrolsorpremedicatedchildren(onetrial).Compared
withcontrols,clowndoctorsreducedanxietyinchildren(modifiedYalePreoperativeAnxietyScale(mYPAS):meandifference(MD)
Non-pharmacologicalinterventionsforassistingtheinductionofanaesthesiainchildren(Review) 1
Copyright©2010TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
30.7595%CI15.14to46.36;onetrial).Inchildrenundergoinghypnosis,therewasanonsignificanttrendtowardsreducedanxiety
duringinduction(mYPAS<24:riskratio(RR)0.5995%CI0.33to1.04-39%versus68%:onetrial)comparedwithmidazolam.
Alowsensoryenvironmentimprovedchildren’sco-operationatinduction(RR0.66,95%CI0.45to0.95;onetrial)andnoeffecton
children’sanxietywasfoundformusictherapy(onetrial).
Parentalinterventionswereassessedinthreetrials.Childrenofparentshavingacupuncturecomparedwithparentalsham-acupuncture
werelessanxiousduringinduction(mYPASMD17,95%CI3.49to30.51)andmorechildrenwereco-operative(RR0.63,95%CI
0.4to0.99).Parentalanxietywasalsosignificantlyreducedinthistrial.Intwotrials,avideoviewedpreoperativelydidnotshoweffects
onchildorparentaloutcomes.
Authors’conclusions
Thisreviewshowsthatthepresenceofparentsduringinductionofgeneralanaesthesiadoesnotreducetheirchild’sanxiety.Promising
non-pharmacologicalinterventionssuchasparentalacupuncture;clowndoctors;hypnotherapy;lowsensorystimulation;andhand-
heldvideogamesneedstobeinvestigatedfurther.
PLAIN LANGUAGE SUMMARY
Non-pharmacologicalinterventionsforassistingtheinductionofanaesthesiainchildren
Theinitial processofgiving generalanaesthesia(i.e.induction of anaesthesia)tochildren,canbe distressing forthemandalsofor
their parents. Childrencan be given drugs to sedate themwhenanaesthesia is being induced, but these drugs can have unwanted
harmfuleffects,suchaspossibleairwayobstructionandbehaviourchangesaftertheoperation.Somenon-drugalternativeshavebeen
testedtoseeiftheycouldbeusedinsteadofsedativedrugswhenanaesthesiaisbeinginducedinchildren.Thepresenceofparentsat
inductionofthechild’sanaesthesia,hasbeenthemostcommonlyinvestigated(eighttrials),buthasnotbeenshowntoreduceanxiety
ordistressinchildren,orincreasetheirco-operationduringinductionofanaesthesia.Aninterventioncanbegiventoachildortoa
parent.Onestudyofacupunctureforparentsfoundthattheparentwaslessanxious,andthechildwasmoreco-operative,atinduction
ofanaesthesia.Anotherstudyofgiving parentsinformation, intheformofpamphletsorvideos, failedtoshowaneffect.Insingle
studies,clowndoctors,aquietenvironment,videogamesandcomputerpackages(butnotmusictherapy)eachshowedbenefitssuch
asimprovedco-operationinchildren.Thesepromisinginterventionsneedtobetestedinadditionaltrials.
BACKGROUND
2005a;vandenBerg2005b).Inhalationalanaesthesiaisinduced
Theinitialintroductionofageneralanaestheticisknownas“the withavolatileagentinairornitrousoxidemixedwithsupplemen-
inductionofanaesthesia”andcanbedistressingforchildren.Dis- taloxygen,usuallythroughabreathingcircuit(tubingattachedto
ruptedroutines,unfamiliarfaces,separationfromfamily,hospi- afacemask).
talproceduresanduncertainty about anaesthesiaor surgery can
Distressandanxietyinchildrenundergoinganaesthesia
betraumaticforpatients(Brennan1994;Feldman1998).Min-
imizing anxiety and distress at the time of anaesthetic induc- Mostchildrenfindinductionofgeneralanaesthesiabeforesurgery
tionmayreduceadversepsychologicalandphysiologicaloutcomes verystressful(Kain2005;Wollin2003);andparentalstresscanbe
(Greenberg1996;Holm-Knudsen1998). easilytransmittedindirectlytoachild(Bevan1990).Thelevelof
achild’sanxietyvarieswithage,maturity,temperamentandpre-
Inductionofanaesthesia
viousanaestheticexperiences(Davidson2006;Stargatt2006).A
General anaesthesia may be induced by inhaled or intravenous previouslyco-operativechildmaybecomeapprehensiveandresist
routes,thoughtheformerismostoftenusedforchildren.Many theapplicationofthemaskontheirfaceorbecomeupsetwhenthe
anaesthetistsbelievethatamaskorinhalationalinductionisless anaestheticcircuitisbroughtclosetothem.Childrenmayprotest,
psychologicallytraumatictochildren(Aguilera2003),sincechil- fightortryandescapeduringthisperiod(Greenberg1996),which
drenaregenerallythoughttohaveafearofneedles(vandenBerg mayprolongtheinductionandbeemotionallytraumaticforthe
Non-pharmacologicalinterventionsforassistingtheinductionofanaesthesiainchildren(Review) 2
Copyright©2010TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
child,parentsandtheatrestaff(Holm-Knudsen1998;Iacobucci OBJECTIVES
2005;Kain1999b).Preoperativedistressmaybeassociatedwith
Toassesstheeffectsofnon-pharmacological interventionsinas-
postoperativeagitation andnegativebehaviours(Stargatt2006).
sisting induction of general anaesthesia in children by reducing
Theconsequencesofpreoperativeanxietyanddistressmayextend
theiranxiety,distressorincreasingtheirco-operation.
beyondtheperioperativeperiod(Kain1996;Kotiniemi1997).
Prosandconsofpremedication
METHODS
Sedativemedicationscanalleviatepreoperativeanxiety;facilitate
separationfromrelativesorfriends;andreducedistressatinduc-
tion (Kain 1999a). However, childrenmay refuse the drug, the
Criteriaforconsideringstudiesforthisreview
drugmayfailorevencauseparadoxicalreactionssuchasdisinhi-
bitionanddysphoria,postoperativebehaviouralchangesandpro-
longedrecoverytimes(Ullyot1999).Otherdrawbacksincludesa-
Typesofstudies
fetyconcerns(airwayobstructionorrespiratorydepressioninun-
monitoredsituations);costsofpharmacy;additionalnursingstaff Weincludedrandomizedorquasi-randomizedcontrolledtrials.
and equipment; list delays; and delayeddischarge (Cray 1996);
andsonon-pharmacologicalmethodshavebeensought.
Typesofparticipants
Weincludedchildrenoradolescentsagedlessthan18yearspre-
sentingforinductionofgeneralanaesthesia,exceptwherethein-
Interventions
tentissolelyintravenousinduction.
A wide range of non-pharmacological interventions have been
usedtoreduceperioperativedistressandencourageco-operation
Typesofinterventions
inchildren.Thesecanbebroadlycategorizedas:
Weincludedanynon-pharmacologicalinterventionimplemented
onthedayofsurgerycomparedwithanyotherintervention,such
• psychological(cognitiveorbehavioural);
asamidazolampremedication,ornotreatment.Studiesmayas-
• environmental; sessasingleinterventionoracombinationofinterventions,and
may compare them with other non-pharmacological interven-
• equipmentmodification; tions;pharmacologicalinterventions(e.g.midazolamorketamine
premedication);orwithusualcare.
• socialinterventions,includingcommunication.
Weincludedthefollowingtypesofinterventions:
• psychological(cognitiveorbehavioural)interventions:such
Rationaleforthereview asdistraction,cognitivetasks,hypnosis,virtualreality;
• environmentalinterventions:useofinductionroom,
Previoussystematicreviewshaveexaminedtheeffectsofpatient
patientretainsownclothing;
educationonpreoperativeanxiety(Lee2003;Lee2005)andthe • equipmentmodification:disguisedanaesthesiadelivery
effect of preoperative fasting on perioperative complications in
system;
children (Brady 2005). A Cochrane review in progress (Prictor • socialinterventions:parentalorsupportpersonpresence,
2004) will address non-pharmacological interventions for chil-
numberofmedicalstaffintheroomatinduction;
drenandadolescentspriortohospitalization.ACochranereview • anaesthetistcommunication:toneofvoice,language
(Uman2006)hasevaluatedpsychologicalinterventionsfornee-
(neutralorpositive).
dle-relatedproceduresinchildrenandadolescentswhichincludes
patientspresentingforintravenousinductionofanaesthesia.Also Weconsideredinterventionswithparentsoraccompanyingper-
PillaiRiddell2006hasinvestigatednonpharmacologicalinterven- sons if the child’s anxiety, distress or co-operation at induction
tionsforneedle-relatedproceduralpaininneonatesandinfants. wereoutcomemeasures.
Therehasbeennocomprehensive,systematicreviewoftheeffects
ofnon-pharmacologicalinterventionsadministeredinhospitalto Typesofoutcomemeasures
assisttheinductionofanaesthesiainchildren.Inaddition,infor-
mationaboutwhichparticularinterventionsorcombinationsof
interventions are most effective in this setting has not been as- Primaryoutcomes
sessed.
Non-pharmacologicalinterventionsforassistingtheinductionofanaesthesiainchildren(Review) 3
Copyright©2010TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
1. thenumberofchildrenwithdistressoranxiety,orthe (1995 to 14th December 2008), CINAHL (1982 to 14th De-
extentofpresenceorabsenceofdistressoranxiety(asdefined cember 2008), DISSERTATION ABSTRACTS (1988 to 14th
andmeasuredbytheauthorsofthestudy)duringinductionof December2008),andWebofScience(1990to14thDecember
generalanaesthesia; 2008).
2. thenumberofchildrenwhoco-operate,ortheextentof WesearchedMEDLINEusingtheMeSHheadingsandtextwords
presenceorabsenceofco-operation(asdefinedandmeasuredby shown in Appendix 1. We adapted this strategy for the other
theauthorsofthestudy)duringinductionofgeneralanaesthesia. databasesasappropriate.
Afterpilotingvarioussearchstrategies,welargelyomittedterms
todescribethepossibleinterventions,sinceourpilotingrevealed
Secondaryoutcomes
thatsuchinterventionswerenotalwaysindexed,orindexedcon-
1. thenumberofcaregiverswithanxiety(asdefinedand
sistently.
measuredbytheauthorsofthestudy);
WesearchedregistersofongoingtrialssuchastheMeta-Register
2. thetimetakenforanaestheticinduction;
ofTrials(www.controlled-trials.com).
3. changefromplannedinhalationaltointravenous(iv)
induction;
4. thenumberofpatientswithincreasedanaesthetic Searchingotherresources
requirements;
We locatedadditional referencesby searchingthe referenceand
5. riskofemergencedelirium;
citation lists of relevantpapersand adjusted our searchstrategy
6. thenumberofpatientswithnegativebehaviouralchanges
accordingly.
(asdefinedandmeasuredbytheauthorsofthestudy)inthe
Wesearchedforunpublishedstudiesanddissertationsforpossible
immediatepostoperativeperiod(whilepatientisinrecovery)e.g.
inclusioninthisreviewbycontactingresearchersthroughemail
distressinrecovery;
list-serverssuchasthePaediatricAnaesthesiaConference(PAC)
7. thenumberofpatientsco-operatingorwithoutdistresson
list-server;theSocietyofPediatricPsychologylist-server;andby
enteringtheroom,orarea,whereanaesthesiainductionistotake
contactingexpertsandtrialiststhroughe-mailanddirectcommu-
place(asdefinedandmeasuredbytheauthorsofthestudy);
nication.
8. thenumberofpatientsorcaregiverssatisfiedwithcare(as
Wedidnotlimitthesearchbylanguageorpublicationstatus.
definedandmeasuredbytheauthorsofthestudy).
Whenpresentedascontinuousvariables;outcomessuchasanxiety,
distress and co-operation were analysed using mean differences
Datacollectionandanalysis
wherepossible.
OutcomeMeasures
Selectionofstudies
Wedefinedtheseasanytypeofnegativeaffectorbehaviourasso-
We reviewed the titles and abstracts of studies identified from
ciatedwiththeinductionofanaesthesia(e.g.anxiety,stress,fear,
thesearch.Fromthefulltextofpotentiallyrelevantarticles,two
unco-operativebehaviour)whichcanbeassessedbypsychological
authors(PY,AvC)independentlyassessedeachtrialforinclusionin
measuresofbehaviour,anxietyordistresssuchastheYalePreoper-
termsofpopulation,intervention,outcome,andstudydesign.We
ativeAnxietyScaleformeasuringanxietyinyoungchildren(Kain
resolveddisagreementsregardinginclusionofpotentiallyeligible
1997);theInductionComplianceChecklistforassessingco-op-
studiesbyconsensusorthirdauthorarbitration(AMC).
erationduringinduction(Kain1998);andtheVernonPostHos-
Weexcludedstudies:
pitalizationBehaviorQuestionnaire(Stargatt2006).Thesescales
• wherepatientoutcomesrelevanttothisreviewwerenot
mayprovideameasureoftheextentofanxietyordistress.
measuredorreported;
• ofprehospitalpreparationprogrammes(hospitaltours,
Searchmethodsforidentificationofstudies
modelling,stress-pointpreparation)whicharethesubjectofa
Cochranereviewinprogress(Prictor2004);
Electronicsearches • ofnon-hospitalsettings;
WesearchedtheCochraneCentralRegisterofControlledTrials • ofpatienteducationormedia-basedinterventionspriorto
(CENTRAL)(TheCochraneLibrary2009, Issue1).Wealsowe
thedayofsurgerywhichhasbeenaddressedelsewhere(Lee
searched the following complementary medicine, nursing, psy-
2003;Lee2005);
chologyandmedicaldatabases:MEDLINE(1966to14thDecem-
ber2008),EMBASE(1974to14thDecember2008),PsycINFO
Non-pharmacologicalinterventionsforassistingtheinductionofanaesthesiainchildren(Review) 4
Copyright©2010TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
• assessingtheeffectsofnon-pharmacologicalinterventions Wehadplannedtoconductsubgroupanalysestocompare:
toassistwithintravenousinductionofanaesthesia,asthisis • differentagegroupssuchas:infantortoddler(0to2years),
beingconsideredelsewhere(Uman2006;PillaiRiddell2006); children(3to12years)andadolescent(3to17years);
• inhalationalandintravenousmethodsofinduction(for
• assessingtheeffectsoffastingpreoperativelyasthisisbeing
studieswherebothmethodshavebeenused);
consideredelsewhere(Brady2005).
• whethertheoutcomesweremeasuredatthetimeof
induction,beforeinductionorafterinduction.
Howevertherewereinsufficientdatatodothis.
Dataextractionandmanagement We intended to perform the following sensitivity analyses, but
Twoauthorsindependentlyextractedthefollowingdata(usinga againtherewereinsufficientdatatocompletethis:
formdesignedforthisspecificreview): • forrandomizedandquasi-randomizedtrials;
• studyparticipants:age,gender,previousanaesthetics, • fortrialswithandwithoutclearallocationconcealment;
inclusionandexclusioncriteria; • intrialswhereanaestheticagentsatinductionarecontrolled
andnotcontrolledfor.
• studymethods:objective,design,randomization,
recruitment,blinding(participant,assessor,otherstaff, Weattemptedtoassesspossiblepublicationbiasbyvisualinspec-
statistician),methodsofanalysis,follow-up; tionoffunnelplots,withasymmetryofthefunnelplotsindicating
• interventions:interventiontype,timing(whenintervention possiblepublicationbias.
used),co-interventions,control(usualcaredescription);
• outcomes:outcometype,author’sdefinitionofoutcome,
measurementtool(includingvalidity),timingofassessment;
• results:means,standarddeviations,numbersofevents,
RESULTS
proportions;
• studywithdrawalsorlossestofollow-up,withreasons.
Wecontactedonestudyauthortoclarifyinformationandprovide Descriptionofstudies
additionaldata.Whenthedataextractionformswerecompleted,
tworeviewauthors(PM,PY)enteredthedataintoReviewMan- See:Characteristicsofincludedstudies;Characteristicsofexcluded
agersoftware(RevMan5.0)andthiswascheckedbyathirdreview studies.
author(AVC). We included17 trialsand excludednine. Thereasons for these
exclusionswerethatthreetrialswereofinterventionsappliedprior
tothedayofsurgery;twodidnotclearlystatethatoutcomeswere
Assessmentofriskofbiasinincludedstudies measuredatinduction;twoweretrialsinadults,onetrialtested
Twoauthors(PY,AVC)independentlyexaminedthemethodolog- apharmacologicalinterventionandonetrialwasacomparisonof
icalqualityoftrialsinrelationtorandomization;allocationcon- parentalpresenceatinductionwithparentalpresencebothatin-
cealment;outcomeassessment;blindingofoutcomeassessments; ductionandatemergence(seeCharacteristicsofexcludedstudies).
lossestofollow-upandtreatmentofwithdrawals.Wegradedeach Includedstudies
itemas’adequate’,’inadequate’or’unclear’;orgaveactualnum- The17includedtrialsinvestigated13comparisonsinvolving1796
bersinthecaseoflossestofollow-up.Duetothenature ofthe childrenortheirparents.SeeCharacteristicsofincludedstudies
interventions,suchasparentalpresence,blindingoftheinterven- fordetaileddescriptions.
tions was not possible. Therefore, we included studies without Settings
blindingofindividualsadministeringandreceivinginterventions ElevenofthetrialswereconductedintheUnitedStatesofAmerica;
forinclusion. threewereconductedinEurope;twowereconductedintheUK
andonewasconductedinJapan.
Interventions
Datasynthesis Weincludedeighttrialsofparentalpresence;andsixchildinter-
We synthesized and analysed data using RevMan 5.0. In stud- ventiontrialsandthreeparentalinterventiontrials:
iesthatreporteddichotomousdata,wecalculatedriskratioswith Parentalpresence
95% confidence intervals (CI). For continuous outcomes (such • parentalpresenceversusnoparentalpresence(Arai2007;
asanxiety)wecalculatedmeandifferences(MD)and95%confi- Bevan1990;Kain1996;Kain1998;Kain2000;Kain2003;
denceintervals.WeestimatedheterogeneityusingtheI2 statistic Kain2007;Palermo2000);
(Higgins 2002). Where there was moderate heterogeneity (I2 > • parentalpresenceversusmidazolam(Arai2007;Kain1998;
50%)wepresenteddatawitharandom-effectsmodel. Kain2007);
Non-pharmacologicalinterventionsforassistingtheinductionofanaesthesiainchildren(Review) 5
Copyright©2010TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
• parentalpresenceversusparentalpresenceplusmidazolam Dataonimmediatepostoperativebehaviouralchangesinchildren
(Kain2003). weredescribedinthreestudiesemployingtwodifferentscales:ex-
citement scale (Kain 1996; Kain 2000) and the emergence be-
Childinterventions
haviourscale(Kain2007).Otherscollecteddataonbehavioural
• cartoonandinteractivecomputerpackagepreparation
changesbeyonddayonefrompost-hospitalbehaviouralquestion-
(Campbell2005);
naires.Parentalsatisfactionwasmeasuredbya100mmvisualana-
• videogames(Patel2006);
logue scale (Kain 1996) and Likert scales (Kain 1998; Palermo
• clowndoctors(Vagnoli2005);
2000).
• hypnosis(Calipel2005);
Dataonotheroutcomesofinterestcollectedwere:riskofadverse
• lowsensorystimulation(Kain2001);
effects;timetodischarge;andanalgesiarequirements.
• musictherapy(Kain2004).
Parentinterventions
• parentalacupuncture(Wang2004);
• parentalvideo(McEwen2007;Zuwala2001). Riskofbiasinincludedstudies
Sometrialsinwhichparentalpresencewasnottheprimaryfocus
of theintervention, controlledfor thisfactor by having parents
present (Campbell 2005; McEwen 2007; Patel 2006; Vagnoli
Randomization
2005; Wang 2004; Wang 2005; Zuwala 2001); or not present
(Kain 2004; Kain 2001; Wang 2008) during the induction of
anaesthesia.Onetrialdidnotcontrolforparentalpresence(Calipel
2005)andonetrialusedparentsasarescueinterventionforanxiety
Sequencegeneration
inthecontrolgroup(Kain2003).
Participants Mosttrials(n=9)usedcomputer-generatedrandomization;five
Theincludedtrialsinvestigatedchildrenagedupto17yearsand did not reporttheir methodof sequence generation; threeused
downto10months(inZuwala2001).MosttrialsexcludedASA randomnumbertables;oneusedpermutedblocks;andonetrial
III&IVchildrenandthosewithahistoryofchronicillness,pre- wasquasi-randomized,usingdaysoftheweek(Bevan1990).
maturityanddevelopmentaldelay.Fourtrialsexcludedchildren
whohadreceivedprevious surgery (Arai2007;Campbell2005;
Kain1996;Zuwala2001).Calipel2005excludedthosewhohad
Allocationconcealment
beenhospitalizedsixmonthspriortothestudy.Mostreceivedin-
halationalanaesthesiawithoxygen,nitrousoxideandsevoflurane. Notrialcouldbeclassifiedashavingreportedadequateallocation
Halothanewasusedintwostudies(Kain1996;Kain1998).Three concealment.Mosttrials(n=14)didnotreportthemethodof
trials failed to describe the induction technique (Bevan 1990; allocationconcealmentandtwotrialsusedsealedenvelopes,and
McEwen2007;Palermo2000). so16ofthe17trialswereratedashavingunclearallocationcon-
Outcomeassessments cealment.Bevan1990hadinadequateallocationconcealment,as
VersionsoftheYalePreoperativeAnxietyScale(YPAS,mYPAS) daysoftheweekswereusedtoallocateparticipantstogroups.
were used by most studies to assess anxiety of children. Other
scalesusedwere:hospitalfearinventory;globalmoodscale;visual
analoguescale;clinicalanxietyratingscale;proceduralbehavioural
Blinding
rating scale;; and the child behaviour scale. Serum cortisol was
measuredbyonestudyasaphysiologicalindicator foranxiety( Blindingwasnotalwayspossiblebecausemostinterventionswere
Kain1996).Complianceofchildrenwasratedusingtheinduction visibletoinvestigatorsandparticipants.Fourtrialsreportedthat
compliancechecklist(ICC)infivetrials(Kain1998;Kain2000; assessments of outcomes were blinded and the rest of the trials
Kain2001;Kain2004;Wang2004). either had partial or no blinding; or they did not describe any
Parental anxiety was assessed using state trait anxiety inventory methodsofblinding.
(STAI)inmoststudies.Othermethodsofassessmentwere:anx-
ietyvisual analogue scale(VAS);anxietyquestionnaire; monitor
blunterstylescale(MBSS);andtheAmsterdamPreoperativeAnx-
Lossestofollow-up
ietyandInformationScale(APAIS).Inthreestudies(Kain1996;
Kain2003;Zuwala2001)bloodpressure,heartrate,skinconduc- Losses to follow up were generally small, as would be expected
tanceweremeasuredasphysiologicalindicatorsofparentalanxi- wheremostoutcomeswereabletobeassessedsoonafterthein-
ety. tervention.
Non-pharmacologicalinterventionsforassistingtheinductionofanaesthesiainchildren(Review) 6
Copyright©2010TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Effectsofinterventions 1.3Parentalpresenceversusparentalpresenceplus
midazolam(comparison3)
Childrenweresignificantlylessanxiousduringinductionifthey
1.Parentalpresence receivedmidazolamaspremedicationandwereaccompaniedby
Eighttrialsinvestigatedtheusefulnessofparentalpresenceinreduc- theirparents,comparedwithparentalpresencealone;P=0.023
ingdistressassociated withinduction inchildreninseveraltypes of (nofurtherdetailsreported)(Kain2003)(Analysis3.1;Analysis
comparisons(Arai2007;Bevan1990;Kain1996;Kain1998;Kain 3.2).However,theadditionofpremedicationforthechildhadno
2000;Kain2003;Kain2007;Palermo2000). impactonparentalanxiety.
1.1Parentalpresenceversusnoparentalpresence 2.Childinterventions
(comparison1) Sevendifferentinterventionsforchildrenundergoinganaesthesiawere
Noneofthestudiesshowedanydifferenceinanxietyorcoopera- assessedinsixtrials.
tionofchildrenonenteringtheinductionareaorduringinduc-
tion (Bevan 1990;Kain 1996; Kain 1998; Kain2007; Palermo
2.1Cartoonandinteractivecomputerpackagepreparation
2000)(Analysis1.2;Analysis1.4)
(comparisons4,5and6)
Kain2003alsoreportednosignificantdifferenceinchildren’sanx-
iety between parental presence or no parental presence, but no Preparation with interactive computer packages (in addition to
furtherdetailsweregiven.Inasubgroupof49anxiousparentsin parentalpresence)wasmoreeffectiveinmakingchildrenmoreco-
onetrial(Bevan1990),childrenof’anxious’parentsweresignifi- operativeduringinductioncomparedtoparentalpresencealone
cantlymoreupsetbyhavingaparentpresentatinductionthanif (Campbell2005).Childrenwhowerepreparedbyinteractivecom-
theywereseparatedasmeasuredbytheGlobalMoodScale(GMS) puterpackageorwithcartoonsshowedsimilarlevelsofcoopera-
(meandifference1.1095%CI0.26to1.94). tionatinduction,butthecomputerpreparedgroupshowedfewer
Parental presence had no significant effects overall on parental negativebehaviouralchangesintherecoveryareacomparedwith
anxiety (Analysis 1.7) or satisfaction (Analysis 1.15); children’s thecartoongroup.
cooperationduringinduction;emergencedelirium(Analysis1.9);
ortimetakenforinduction(Analysis1.11);ornegativebehaviour
2.2Videogames(comparisons7and8)
postoperativelyafterdischarge(atoneweek;twoweeks;andsix
months)(Analysis1.12). Childreninthevideogamegroupweresignificantlylessanxious
Inonetrial,whenallchildrenwerepremedicatedwithmidazolam, thanthoseinthecontrolgroup(Patel2006; mYPASMD-9.8,
parents were significantly less anxious and more satisfied when 95%CI-19.42to-0.18;n=74;Analysis7.1);andalsocompared
theywerepresentduringinduction(Kain2000)comparedwith withthechildrenwhowerepremedicatedwithmidazolam(mY-
thoseparentsnotpresent.Inanothertrialwithallchildrenpre- PASMD-12.2,95%CI-21.82to-2.58;n=76).Nodifferences
medicatedwithmidazolam,neitherthequalityofmaskinduction inpostoperativebehaviourscoreswereseen,comparedwitheither
nor emergencebehaviours wasimprovedwhenthemotherheld controlsorthemidazolamgroup.
herchildcomparedwithinductionwithoutaparentpresent(Arai
2007).
2.3Clowndoctors(comparison9)
Clown doctors significantly reduced children’s anxiety (mYPAS
1.2Parentalpresenceversusmidazolam(comparison2) MD30.7595%CI15.14to46.36;40children;Analysis9.1)but
Midazolamwassuperiorinreducinganxietyofchildrenduringin- hadnoapparenteffectonparentalanxiety(STAIMD4.75,95%
ductioncomparedwithparentalpresence-MD10pointsmYPAS CI-9.05to18.55;Analysis9.2)comparedwithparentalpresence
95%CI2.91to17.09(Kain2007)andcooperation(Kain1998) (Vagnoli2005).
(Analysis2.1;Analysis2.2).Italsoshortenedthetimetakenfor
inductionby0.6minutes(95%CI0.36minutesto0.84minutes)
inonetrialof62children(Kain1998)(Analysis2.5).Therewere 2.4Hypnosis(comparison10)
nosignificantdifferencesinparentalanxiety,parentalsatisfaction, Compared with midazolam premedication, fewer children were
emergence delirium in the recovery area or negative behaviour anxious (mYPAS > 24) during induction of anaesthesia in the
twoweekspostoperatively.Inanothertrial,midazolamwassignif- hypnotherapy group but this did not reach statistical signifi-
icantlybetterthanparentalpresencealoneinqualityofthemask cance(RR0.5995%CI0.33to1.04;50children,Calipel2005;
induction, but no difference was seen for emergence behaviour Analysis10.1).Significantlyfewerchildrendemonstratednegative
(Arai2007). behaviourpostoperativelyinthehypnotherapygroup(duringday
Non-pharmacologicalinterventionsforassistingtheinductionofanaesthesiainchildren(Review) 7
Copyright©2010TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.