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Pediatric Anxiety

 

 

Background

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  • Pre-operative anxiety is associated with:

    • ↑ opioid requirements

    • Emergence delirium

    • Sleep disturbances

    • Enuresis

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Considerations

 

  • Risk factors:

    • Age < 4 years

    • Temperament: shy, inhibited, dependent, withdrawn

    • ↓ time for preoperative preparation

    • Accompanied by anxious parents

    • Previous negative experience with anesthesia or hospitalization

    • Multiple previous hospital admissions

  • Separation anxiety develops at 6-8 months old

    • Age < 6 months can be soothed by surrogate (i.e. nurse or physician)

  • Non-pharmacologic techniques should be employed for all children

  • Pharmacologic techniques can be used in carefully selected children

  • Consider avoiding pharmacologic techniques children with:

    • Potential difficult airway

    • OSA or central sleep apnea

    • Renal or hepatic impairment

    • Altered LOC

    • Increased ICP

    • Acute systemic illness

    • URTI

    • New or unexplained O2 desaturations

    • Allergies or adverse reaction to proposed medication

  • If considering pharmacologic techniques:

    • Ensure patient is in monitored setting

    • Resuscitation equipment must be available

    • Transfer to OR on stretcher bed, with portable suction and Ambu bag available, accompanied by nurse or physician

    • ↓ LOC or respiratory depression

      • protect airway, support ventilation

      • consider naloxone (if opioid given) and flumazenil (if midazolam given)

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Non-pharmacologic techniques to reduce anxiety

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  • Providing adequate pre-hospital information (i.e. books, videos, OR tours)

  • Play therapy 

  • Distraction (i.e. cartoons, toys, games)

  • Engaging with anesthetic equipment (i.e. holding the mask, “blowing up the balloon”)

  • Environmental adjustments (i.e. limiting healthcare staff, choosing music)

  • Calm parents accompanying to OR

  • Breathing techniques

  • Communication aids (info about the child’s needs/routines)

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Pharmacologic techniques to reduce anxiety

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  • Benzodiazepines (midazolam)

    • Oral liquid midazolam (0.25-0.5 mg/kg, maximum 20 mg)

    • Buccal midazolam (0.3 mg/kg, max 10mg)

    • Caution: potential for paradoxical reaction, unpleasant taste

  • Alpha-2 Agonists (Dexmedetomidine, clonidine)

    • Intranasal / buccal dexmedetomidine (1-4 mcg/kg, maximum 200 mcg)

    • Oral clonidine (4 mcg/kg, maximum 200mcg)

    • Caution: caution in patients with Grade 2/3 heart block, hypertension, cardiovascular disease, instability, on digoxin

  • Ketamine

    • Oral (3-8 mg/kg + midazolam)

    • IM (4-5 mg/kg)

    • IV (1-2 mg/kg)

    • Caution: ↑ salivation, hallucinations and emergence delirium, PONV

  • Opioids

    • Morphine (0.2 mg/kg, max 10mg)

    • Caution: risk of respiratory depression

 

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References

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  • Heikal S, Stuart G. Anxiolytic premedication for children. BJA Educ. 2020 Jul;20(7):220-225. 

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