Description of typical personality factors and events that lead to anxiety at induction of anesthesia in French children. Honorine Delivet

According to the authors, the psychological and situational factors that contribute to pre-operative anxiety have not been studied. The ability to identify factors associated with anxiety would allow targeted prev
entive strategies. This prospective observational study aims to identify factors that predict anxiety at induction of anaesthesia in children. Children between the ages of 8 and 18 years classified as ASA 1-3 and scheduled for surgery within 48 hours were enrolled. By law, all patients scheduled for surgery in France must be seen by an anaesthetist no less than 48 hours prior to surgery (emergencies excepted). This means that there is always an opportunity to screen patients for potential anxiety at a time when preventive strategies can still be implemented.

Anxiety trait (measure of baseline anxiety) in the children was assessed using the faces scale. Maternal anxiety state was measured before and after the pre-anaesthetic consultation. Anxiety state in the children was measured immediately after the pre-anaesthetic consultation and just prior to induction of anaesthesia. The visual analogue scale for anxiety was used to measure state anxiety for both adults and children. Two trained nurse anaesthetists performed all anxiety measurements under the supervision of a psychologist. All patients received sedative premedication, 2mg/kg hydroxyzine, 1 hour prior to induction of anaesthesia and anxiety state was assessed 5 minutes prior to induction of anaesthesia.

33% of patients met the criteria for anxiety trait. The percentage of children who met the criteria for anxiety state increased from 37% at the pre-anaesthetic consultation to 61 % just prior to induction of anaesthesia. The following factors were found to be independently associated with anxiety: Age ≥ 10, inpatient stay and anxiety state after the pre-anaesthetic consultation. Maternal anxiety and trait anxiety in the child were in turn predictive of anxiety state in the child after the pre-anaesthetic consultation. The authors went further, looking at factors that predicted maternal anxiety after the consultation and found that maternal anxiety before the consultation as well as a feeling of not being reassured by the anaesthetist about the perioperative course (assessed using a questionnaire) was associated with maternal anxiety after the consultation. The interaction of these factors is summarised in a flow diagram within the article. Using their results, the authors outlined a combination of psychological factors predictive of anxiety at induction of anaesthesia. This was combined with age and inpatient status to define a model for predicting anxiety in children at induction of anaesthesia. The authors state that the model predicts state anxiety at induction of anaesthesia with satisfactory accuracy but acknowledge that the specificity was low (60%) indicating that the absence of the factors did not predict the absence of anxiety.

Take Home Message
Non-pharmacological preventive strategies, such as pre-operative preparation can reduce anxiety in children but many of these are time consuming, costly and impractical to implement as a routine.
This combination of psychological and situational factors is said by the authors to predict anxiety with satisfactory accuracy. However, the model does not appear to have been tested outside of the study. I would question the timing of the sedative pre-medication and its efficacy at reducing anxiety as well as the impact this may have had on anxiety measurement. Important points to note were that in this study, child anxiety trait alone did not predict anxiety just prior to induction of anaesthesia although it did predict child anxiety after the anaesthesia consultation. Secondly, the importance of maternal anxiety as a predictive factor was confirmed in this study. The authors also found that ‘reassuring’ parents during the pre-anaesthetic assessment was important. What exactly this involves is difficult to pin down but it does show something that the experienced paediatric anaesthetist already knows; conveying accurate information and obtaining informed consent must be balanced with efforts to reassure parents about the safety of anaesthesia in general and the safety of their child specifically.

Reviewed by: Dr Catherine Olweny