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Intervention for prevention: easing children’s preoperative anxiety
Umeå University, Faculty of Medicine, Department of Diagnostics and Intervention. Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.ORCID iD: 0000-0002-4585-8786
2024 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Intervention för prevention : lindring av barns preoperativa oro (Swedish)
Abstract [en]

Background: Preoperative anxiety in children is associated with several adverse outcomes and consequences that can have a negative impact on the perioperative outcome and delay recovery. Anxiety can cause stress-induced cardiorespiratory instability, increased postoperative pain, nausea, emergence delirium, and long-term behavior changes. The ideal premedication for children is still debated. Only a few studies have examined the use of premedication in relation to total intravenous anesthesia (TIVA), and there is also a lack of studies exploring staff’s experiences of premedication. The aim of this thesis was to compare midazolam (a benzodiazepine), clonidine, and dexmedetomidine (a2-agonists) given as premedication to preschool children, regarding anxiety, cardiorespiratory response to sedation, time to postoperative recovery, posthospital negative behavior changes (NBCs), and staff’s experiences of the interventions.

Methods: In a randomized clinical trial, 90 children aged 2–6 years, scheduled for TIVA and ear, nose, and throat surgery, were randomized to one of three groups, receiving midazolam 0.5 mg/kg, clonidine 4 mg/kg, or dexmedetomidine 2 mg/kg. The children were included at a 200-bed county hospital in northern Sweden and observed with validated tools from the day of surgery until two weeks postoperatively (Studies I–IV). To explore the clinical aspects, we conducted focus group interviews to elicit perioperative staff’s experiences of the studied interventions and analyzed the data with qualitative content analysis (Study V). 

Results: Midazolam reduced preoperative anxiety and provided perioperative cardiorespiratory stability. Clonidine and dexmedetomidine provided deeper sedation along with a minor decrease in heart rate. Some children, mainly from the clonidine group, awoke during the preoperative preparation, triggering anxiety, while the midazolam group remained conscious, calm, and cooperative. Postoperatively, the midazolam group emerged earlier from anesthesia compared to the two a2-agonist groups. However, the midazolam group had more episodes of postoperative anxiety, delirium, and pain compared to both groups receiving a2-agonists, and the overall recovery and discharge time from the post-anesthesia care unit was thus the same for all groups. The posthospital study showed at least one NBC in half of the children during the first two weeks after surgery. The staff’s experiences of premedication could be summarized in three themes: a matter of time, covering the efforts of building trust along with timing the administration and onset; don’t wake the sleeping bear, covering the challenge of maintaining sleep in the sleeping child in order to avoid a backlash if woken; and on responsive tiptoes, covering safety precautions and ethical perspectives on the interventions.

Conclusion: The different premedications varied in their ability to reduce anxiety and to induce sleep, and this manifested itself throughout the perioperative process. Short-acting midazolam reduced preoperative anxiety but did not provide adequate sleep, and early postoperative emergence occasionally caused a rise in adverse symptom intensification. The long-lasting and sleep-inducing a2-agonists showed an unsatisfactory anxiolytic effect in comparison to midazolam. The sleep was superficial, and an awakening risked triggering anxiety. The staff strove to keep the sedated child asleep, and the recovery time was better and more peaceful when the children slept for a long time postoperatively. However, despite a calm perioperative process, one in two children presented with posthospital NBC. At the doses used in this study, all these premedications seem to be safe in cardiorespiratory terms, and the decision of which one to use should be tailored by individual and time.

Place, publisher, year, edition, pages
Umeå: Umeå University, 2024. , p. 84
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2271
Keywords [en]
Premedication, pediatric anesthesia
National Category
Anesthesiology and Intensive Care
Research subject
Anaesthesiology
Identifiers
URN: urn:nbn:se:umu:diva-224425ISBN: 9789180702171 (print)ISBN: 9789180702188 (electronic)OAI: oai:DiVA.org:umu-224425DiVA, id: diva2:1858390
Public defence
2024-06-14, Samlingssalen, Sunderby sjukhus, Luleå, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2024-05-24 Created: 2024-05-16 Last updated: 2024-05-17Bibliographically approved
List of papers
1. Preoperative anxiety in preschool children: A randomized clinical trial comparing midazolam, clonidine, and dexmedetomidine
Open this publication in new window or tab >>Preoperative anxiety in preschool children: A randomized clinical trial comparing midazolam, clonidine, and dexmedetomidine
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2021 (English)In: Pediatric Anaesthesia, ISSN 1155-5645, E-ISSN 1460-9592, Vol. 31, no 11, p. 1225-1233Article in journal (Refereed) Published
Abstract [en]

Introduction: Anxiety in pediatric patients may challenge perioperative anesthesiology management and worsen postoperative outcomes. Sedative drugs aimed to reducing anxiety are available with different pharmacologic profiles, and there is no consensus on their effect or the best option for preschool children. In this study, we aimed to compare the effect of three different premedications on anxiety before anesthesia induction in preschool children aged 2-6 years scheduled for elective surgery. The secondary outcomes comprised distress during peripheral catheter (PVC) insertion, compliance at anesthesia induction, and level of sedation.

Patients and methods: In this double-blinded randomized clinical trial, we enrolled 90 participants aged 2-6 years, who were scheduled for elective ear-, nose-and-throat surgery. The participants were randomly assigned to three groups: those who were administered 0.5 mg/kg oral midazolam, 4 µg/kg oral clonidine, or 2 µg/kg intranasal dexmedetomidine. Anxiety, distress during PVC insertion, compliance with mask during preoxygenation, and sedation were measured using the modified Yale Preoperative Anxiety Scale, Behavioral Distress Scale, Induction Compliance Checklist, and Ramsay Sedation Scale, respectively.

Results: Six children who refused premedication were excluded, leaving 84 enrolled patients. At baseline, all groups had similar levels of preoperative anxiety and distress. During anesthesia preparation, anxiety was increased in the children who received clonidine and dexmedetomidine; however, it remained unaltered in the midazolam group. There were no differences in distress during PVC insertion or compliance at induction between the groups. The children in the clonidine and dexmedetomidine groups developed higher levels of sedation than those in the midazolam group.

Conclusions: In preschool children, midazolam resulted in a more effective anxiolysis and less sedation compared to clonidine and dexmedetomidine.

Place, publisher, year, edition, pages
John Wiley & Sons, 2021
Keywords
anesthesiology, children, clinical trials, clonidine, dexmedetomidine, midazolam, premedication
National Category
Anesthesiology and Intensive Care Nursing Pediatrics
Research subject
Medicine
Identifiers
urn:nbn:se:umu:diva-186941 (URN)10.1111/pan.14279 (DOI)000688432500001 ()34403548 (PubMedID)2-s2.0-85113382900 (Scopus ID)
Funder
Norrbotten County Council, NLL‐485451Norrbotten County Council, NLL‐486841Region Västerbotten, RV-865681Region Västerbotten, RV-932836Region Västerbotten, RV-940554
Available from: 2021-08-26 Created: 2021-08-26 Last updated: 2024-05-16Bibliographically approved
2. Cardiorespiratory response to sedative premedication in preschool children: a randomized controlled trial comparing midazolam, clonidine, and dexmedetomidine
Open this publication in new window or tab >>Cardiorespiratory response to sedative premedication in preschool children: a randomized controlled trial comparing midazolam, clonidine, and dexmedetomidine
2023 (English)In: Journal of Perianesthesia Nursing, ISSN 1089-9472, E-ISSN 1532-8473, Vol. 38, no 3, p. 454-460Article in journal (Refereed) Published
Abstract [en]

Purpose: Sedative premedication in children may negatively impact their cardiorespiratory status during the perioperative course, and no clear consensus exists on the optimal premedication treatment for pediatric patients. The objective was to compare the perioperative cardiorespiratory responses to sedation using three different sedative premedication regimens in preschool children scheduled for surgery with total intravenous anesthesia.

Design: A single-center randomized controlled trial.

Methods: This is a planned secondary analysis of a study conducted at a 200-bed tertiary referral hospital. Ninety children participated in the study. They were aged 2–6 years and scheduled for ear, nose, and throat surgery with propofol/remifentanil anesthesia. Participants were randomly assigned to receive oral midazolam 0.5 mg/kg-1 (MID), oral clonidine 4 mcg/kg–1 (CLO), or intranasal dexmedetomidine 2 mcg/kg-1 (DEX). The main outcome measures were the sedation level, based on the Ramsay Sedation Scale (RSS), and cardiorespiratory status, monitored during the perioperative period.

Findings: The final cohort had 83 children (MID, n=27; CLO, n=26; DEX, n=30), with similar intergroup patient characteristics. RSS scores were lower in the MID group than in the CLO and DEX groups before induction and within 30 min postsurgery (P<0.001 and P=0.006, respectively). A negative correlation existed between the RSS and heart rate (HR) (r=-0.570, P<0.001). Before anesthesia induction, the respiratory rate was lowest in the DEX group (MID 21.5±1.7 min–1, CLO 20.6±2.6 min–1, DEX 20.2±1.7 min–1; P=0.042). The HR was lower in the CLO and DEX groups than in the MID group (MID, 102.8±10.0 min–1; CLO, 87.4±9.6 min–1; DEX, 87.6±7.9 min–1; P<0.001). The HR was lower immediately after induction (P=0.009) and intraoperatively (P=0.025) in the CLO and DEX groups than in the MID group.

Conclusions: When used as premedication before propofol/remifentanil anesthesia, clonidine and dexmedetomidine provided deeper preoperative sedation compared to midazolam. From a clinical perspective, all three study drugs provided essentially stable cardiovascular and respiratory conditions during the entire perioperative period.

Place, publisher, year, edition, pages
Elsevier, 2023
Keywords
cardiorespiratory, clonidine, dexmedetomidine, midazolam, pediatric anesthesia, premedication, sedation
National Category
Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:umu:diva-203567 (URN)10.1016/j.jopan.2022.08.009 (DOI)001001763500001 ()36604221 (PubMedID)2-s2.0-85145714015 (Scopus ID)
Available from: 2023-01-19 Created: 2023-01-19 Last updated: 2024-05-16Bibliographically approved
3. Postoperative recovery in preschool-aged children: A secondary analysis of a randomized controlled trial comparing premedication with midazolam, clonidine, and dexmedetomidine
Open this publication in new window or tab >>Postoperative recovery in preschool-aged children: A secondary analysis of a randomized controlled trial comparing premedication with midazolam, clonidine, and dexmedetomidine
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2023 (English)In: Pediatric Anaesthesia, ISSN 1155-5645, E-ISSN 1460-9592, Vol. 33, no 11, p. 962-972Article in journal (Refereed) Published
Abstract [en]

Background: Preoperative anxiety in pediatric patients can worsen postoperative outcomes and delay discharge. Drugs aimed at reducing preoperative anxiety and facilitating postoperative recovery are available; however, their effects on postoperative recovery from propofol-remifentanil anesthesia have not been studied in preschool-aged children. Thus, we aimed to investigate the effects of three sedative premedications on postoperative recovery from total intravenous anesthesia in children aged 2–6 years.

Methods: In this prespecified secondary analysis of a double-blinded randomized trial, 90 children scheduled for ear, nose, and throat surgery were randomized (1:1:1) to receive sedative premedication: oral midazolam 0.5 mg/kg, oral clonidine 4 μg/kg, or intranasal dexmedetomidine 2 μg/kg. Using validated instruments, outcome measures including time for readiness to discharge from the postoperative care unit, postoperative sedation, emergence delirium, anxiety, pain, and nausea/vomiting were measured.

Results: After excluding eight children due to drug refusal or deviation from the protocol, 82 children were included in this study. No differences were found between the groups in terms of median time [interquartile range] to readiness for discharge (midazolam, 90 min [48]; clonidine, 80 min [46]; dexmedetomidine 100.5 min [42]). Compared to the midazolam group, logistic regression with a mixed model and repeated measures approach found no differences in sedation, less emergence delirium, and less pain in the dexmedetomidine group, and less anxiety in both clonidine and dexmedetomidine groups.

Conclusions: No statistical difference was observed in the postoperative recovery times between the premedication regimens. Compared with midazolam, dexmedetomidine was favorable in reducing both emergence delirium and pain in the postoperative care unit, and both clonidine and dexmedetomidine reduced anxiety in the postoperative care unit. Our results indicated that premedication with α2-agonists had a better recovery profile than short-acting benzodiazepines; although the overall recovery time in the postoperative care unit was not affected.

Place, publisher, year, edition, pages
Wiley, 2023
National Category
Anesthesiology and Intensive Care
Research subject
Anaesthesiology
Identifiers
urn:nbn:se:umu:diva-212532 (URN)10.1111/pan.14740 (DOI)37528645 (PubMedID)2-s2.0-85166673433 (Scopus ID)
Funder
Region Västerbotten, RV-940554Region Västerbotten, RV-865681Norrbotten County Council, NLL-485451Norrbotten County Council, NLL-486841Norrbotten County Council, RN-785981
Available from: 2023-08-02 Created: 2023-08-02 Last updated: 2024-05-16Bibliographically approved
4. Posthospital negative behavioural changes in children: a secondary analysis of a previous randomized clinical trial including a narrative review
Open this publication in new window or tab >>Posthospital negative behavioural changes in children: a secondary analysis of a previous randomized clinical trial including a narrative review
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(English)Manuscript (preprint) (Other academic)
National Category
Anesthesiology and Intensive Care Nursing Pediatrics
Research subject
Anaesthesiology
Identifiers
urn:nbn:se:umu:diva-224422 (URN)
Available from: 2024-05-16 Created: 2024-05-16 Last updated: 2024-05-17
5. Perioperative staff’s experiences of premedication for children
Open this publication in new window or tab >>Perioperative staff’s experiences of premedication for children
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2024 (English)In: Journal of Perianesthesia Nursing, ISSN 1089-9472, E-ISSN 1532-8473Article in journal (Refereed) Accepted
National Category
Anesthesiology and Intensive Care Pediatrics
Research subject
Anaesthesiology
Identifiers
urn:nbn:se:umu:diva-224419 (URN)
Available from: 2024-05-16 Created: 2024-05-16 Last updated: 2024-05-17

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