Sunday, August 22, 2010

Parent presence at induction: An anesthesiologist speaks

After my last post supporting the option of parent presence when a child is anesthetized for surgery, many parents and a reader with a disability shared their experiences and opinions.

I wanted to hear the perspective of an anesthesiologist, so I posted a query on the pediatric anesthesia forum run through SickKids in Toronto. This online forum draws questions and insights from children's anesthesiologists from around the world.

I was delighted to hear from Dr. Matthias Konig of Cincinnati Children's Hospital Medical Center. Our correspondence appears below (my initial message has been shortened to omit an explanation about BLOOM). Dr. Konig directed me to an excellent review of the literature, but I need to obtain permission to post its findings. However, you'll get the gist of the results from my response to his message. Louise

Pediatric Anesthesia Forum

General Pediatric Anesthesia => General discussion => Topic started by: LouiseKinross on August 17, 2010, 06:09:31 PM

Title: Parent presence at induction
Post by: LouiseKinross on August 17, 2010, 06:09:31 PM

Given a CAPHC report showing parents overwhelmingly want to be present when their child is anesthetized in the OR, but wide variation in 16 Canadian hospitals surveyed as to when they do or don't allow parent presence, I would be grateful to hear comments from anesthetists as to whether you support, or don't support, parent presence, and why.

In addition, I am interested in knowing if any hospitals have a separate, "safe" ante-room where children are put under before being taken to the OR.

Operating rooms are horrifying places (massive lights, boxes of technology, frightening tools, people in masks). When so much effort is expended on making other experiences in the hospital child-friendly, I'm surprised that so little has been done to reduce the trauma of being taken to the OR and having a stranger put a mask over your face.

I am communications manager at Holland Bloorview Kids Rehabilitation Hospital here in Toronto, and write a blog on parenting kids with disabilities. I wrote a blog related to the new report re parent presence and my own personal experience with my son, who has had multiple surgeries. We've had a number of parent replies but I want to hear from anesthetists!

Why do you, or don't you, support parent presence? Does anyone have positive experience with a safe ante-room where kids are anesthetized before being taken to the OR? Or with other initiatives to make the operating room or induction less traumatic?

Many thanks! Louise

Title: Re: Parent presence at induction
Post by: mwkonig on August 20, 2010, 01:57:41 PM

Certainly a controversial topic and there probably isn't a single "right" answer to all aspects of this. One of the problems when discussing this topic is that we need to differentiate between what the parents want and what is beneficial for the child. It is easy to show that parental satisfaction increases when they are allowed to be present during induction of anesthesia. Despite the parental perception that they "help" their child during this phase, it is actually not at all proven that parental presence in fact benefits the child. This issue has just recently been reviewed in a Cochrane study and the author's conclusion was that parental presence is not superior to induction without parents, and likely less effective than premedication (see Yip et al.: Non-pharmacological interventions for assisting the induction of anaesthesia in children" Cochrane Database Syst Rev 2009: CD006447).

That being said, ultimately a lot of other factors come into play, many of them simply concern the logistics involved in providing the "parental presence option". Depending on OR layout, number and type of cases, available personal, additional expense, etc., bringing all parents into the actual OR for induction may be difficult and impractical and therefore parental presence may not be offered routinely at some places.

At my hospital we have induction rooms for most of our OR' so bringing parents in for induction is relatively easy since they dont have to change into a "bunny suit" or scrubs. As a consequence of this culture, parents here ususally expect to be able to accompany their child, even in cases where theit would certainly not make much sense, such as in the case of a small infant or an immature and tearful teenage parent. So many of us would like to sometimes limit this practice a bit, particularly when it seems unlikely that the child will get any benefit from it or when oral premedication with midazoloam seems more effective.

Matthias Konig

Title: Re: Parent presence at induction
Post by: LouiseKinross on August 22, 2010, 11:31:02 AM

Dear Dr. Konig: I'm immensely grateful for your message and insights.

Thank you for referring me to the Cochrane review, which I read. I was surprised that in the eight studies assessing parental presence not one showed parent presence reduced child's anxiety (vs induction without parents).

I did have a few thoughts. The review notes that most studies excluded children with a history of chronic illness or developmental delay. Some excluded children who had received previous surgery.

I think this is precisely the population in which parents are most insistent that they be present: children with chronic conditions who endure repeated surgeries (going to the OR is not a discreet/one-time, quickly forgotten event in the life of the child/family, but occurs multiple times a year, over years) and who may have developmental disability/be non-verbal (unable to advocate/parent is their only voice).

Perhaps it would be useful to study this specific population by tracking physiological indicators of anxiety at time of induction when parents are present vs. non-present. I think we also need to look at long-term impact of parental presence for this population.

The studies are telling me loud and clear that my presence is not reducing my son's fear in the moments of induction. What they are not gauging is the long-term psychological impact of him knowing that I am there. Yes, he went through hell, but mom was there. What does that mean for the level of trust between a vulnerable child and parent over time? What does it mean for the parent to be able to say: I couldn't take away the fear, but at least I was witness to it. He didn't do it alone.

(of course this may be irrelevant for the healthy, verbal child going in for the one minor surgery he'll have in his entire childhood).

The Cochrane review notes that most children find induction very stressful. My son has had more than a dozen surgeries and it was only recently that I learned he could be given a sedative in advance (and you note that premedication was shown to be superior to parent presence in one of the reviewed studies).

A parent wants full information that puts them in the best position to choose a course of action that will reduce their child's stress.

The review is positive in noting that child-focused interventions (therapeutic clowns, hypnosis, a quiet, low-sensory environment, and hand-held video games) can reduce anxiety. I hope we see more studies of these interventions with the most vulnerable children -- those who have repeated surgeries and those with delays who may not be able to speak for themselves.

How was the rationale made at your hospital for separate induction rooms that accommodate parent presence (given studies suggest it does not benefit the child)?

Again, thank you very much for taking the time to educate me about the Cochrane review and shed light from the perspective of an anesthesiologist. I will share our correspondence with the parent readers of BLOOM who I know will find it invaluable. Cheers. Louise


I commented on your last post and it struck me that the doctor mentioned that there is no conclusive evidence that the parent being there "helps" the child.

When I was reviewing the procedure for my son, and preparing to blog about it, it struck me that as terrified as he was, the last person that he saw when he went under was MY face...and while it certainly made me feel better to be there to comfort him, I started to wonder if Corrigan found it comforting at all, or rather was his last fleeting thought that, hey! My MOM is the only person I see when this is all going my MOM doing this to me?"

Which then, of course, really switched things up in my head.

Thank you for searching for more answers about all of this. I really appreciate it!