Pediatric Anesthesia ISSN 1155-5645
ORIGINAL ARTICLE
Observational study of perioperative behavior changes in children having teeth extracted under general anesthesia Richard M. Beringer1, Philip Segar1, Annabel Pearson1, Mala Greamspet1 & Nicky Kilpatrick2 1 Department of Paediatric Anaesthesia, Bristol Royal Hospital for Children, Bristol, UK 2 Murdoch Children’s Research Institute, Melbourne, Australia
Keywords child; child behavior; anesthesia; anesthesia, dental; anesthesia recovery period; anxiety Correspondence Richard M. Beringer, Department of Paediatric Anaesthesia, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol BS2 8BJ, UK Email: [email protected] Section Editor: Brian Anderson Accepted 6 January 2014 doi:10.1111/pan.12362
Summary Background: Perioperative behavioral disturbance is common in children. Negative behavior changes may be seen during induction of anesthesia, during recovery and following discharge home. There has been little research on this subject in the UK. Objectives: The aim of this study was to determine the incidence of behavioral changes within our institution and identify which children are at increased risk. Methods: A prospective observational study of healthy children aged two to 12 undergoing elective dental extractions under general anesthesia. Assessments included: the child’s and parent’s state anxiety; anxiety and behavior during induction of anesthesia (modified Yale preoperative anxiety scale and the pediatric anesthesia behavior score); behavior in PACU (pediatric anesthesia emergence delirium [PAED] scale); behavior at home on postoperative days 1 and 7 (post hospitalization behavior questionnaire). Data were examined for associations and correlations. Results: One hundred and two children with a median age of 6 years were recruited. Sixty-seven per cent exhibited high anxiety during induction of anesthesia, although only 3% demonstrated significant vocal or physical resistance. Thirteen per cent had a PAED score of 10 or more. Post-hospitalization behavior changes were demonstrated by 52% of children on day 1 and 22% on day 7; and were associated with: a previous traumatic healthcare experience, male sex, and distress during induction of anesthesia. Conclusions: Perioperative behavioral disturbance is common in children undergoing anesthesia. Predicting which children are at increased risk may allow us to adapt the management of these children in order to minimize adverse behavior changes.
Background Undergoing general anesthesia is a distressing experience for children and may lead to adverse behavior changes during induction of anesthesia, emergence or following discharge home. A number of studies have reported a clinically significant incidence of perioperative behavioral problems (1–5). Adverse behavior changes have a complex and multifactorial etiology, and may be influenced by © 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 499–504
anesthetic technique (6–9). Most research has focused on behavior during induction and emergence from anesthesia, whereas less is known about post hospitalization behavior changes. Despite the likelihood of significant regional variation, little research of this type has been performed in the United Kingdom. This study was designed to answer two questions: 1. What is the incidence of perioperative behavioral disturbance in children undergoing dental extractions under general anesthesia in a UK hospital? 499
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2. Is it possible to identify which children are at risk of developing behavioral problems after discharge home? The study focuses on three time points: anesthetic induction; emergence; and following discharge home.
Methods The National Research Ethics Service committee (South West Bristol) approved this study. Written informed consent was obtained from the parents of all children. This was a prospective observational study. Healthy (ASA 1 or 2) children aged 2–12 years attending the Bristol Dental hospital for day case (same day) extraction of teeth under general anesthesia were eligible to participate. The only exclusion criterion was the inability of the parent(s) to understand the study or consent process. Standard anesthetic management for dental extractions at the Bristol Dental Hospital includes: attendance at the preoperative assessment clinic; preoperative application of Ametop© local anesthetic cream to the dorsum of both hands; preoperative oral paracetamol and a non-steroidal anti-inflammatory drug (either ibuprofen or diclofenac depending upon age and weight); sedative premedication when a child exhibits signs of high anxiety or has a history suggesting that induction of anesthesia may be difficult; parents accompany the child into the operating room for induction; intravenous induction with fentanyl and propofol (inhalational induction is occasionally performed for child preference or failed venous cannulation); a flexible laryngeal mask airway is inserted; anesthesia is maintained with sevoflurane or isoflurane with or without nitrous oxide; local anesthesia is used by the dentist for extraction of permanent teeth, but not primary teeth; the child emerges in the PACU and is discharged home approximately an hour after the procedure, once discharge criteria are met. As well as the validated behavior scores described below, the following data were collected: age; sex; number of teeth extracted; number of previous general anesthetics; whether the child had experienced a significant event within the last month; whether the child had suffered a traumatic experience with doctors or dentists; whether the parent felt the child suffered from behavioral problems; pain or nausea in the PACU; pain or nausea at home. Validated behavior/anxiety scores The linear analogue scale for self-assessment of state anxiety has been validated in adults (10) and children 500
aged 7 years and older (11,12). There is no validated scale for younger children. The scale was used approximately 1 h prior to anesthesia to measure: the child’s perception of their own anxiety; the parent’s perception of their own anxiety; and the parent’s perception of their child’s anxiety. If the child was too young to understand, the scale was left blank. If both parents were present, the mother completed the scales. The modified Yale preoperative anxiety scale (m-YPAS) has been widely used since validation (13). A score above 30 has been shown to have optimal sensitivity and specificity for identifying high anxiety (13). The anesthesiologist completed this scale based upon the behavior of the child during induction of anesthesia. The pediatric anesthesia behavior (PAB) score for measuring behavioral distress during induction of anesthesia (Table 1) was validated in a parallel study (14). The anesthesiologist scored the child’s behavior at the point at which anesthesia was being induced, by either the intravenous or inhalational route. The paediatric anesthesia emergence delirium (PAED) scale (15) is used to measure emergence delirium during recovery from general anesthesia. A PAED scale score of 10 or greater has been shown to have sensitivity 0.64 and specificity 0.86 for emergence delirium (15). The PAED score was completed by the nurse caring for the child in PACU, who also completed a three point scale to describe the child’s behavior during recovery: (1) calm, good recovery; (2) upset or crying but easy to control; (3) agitated and difficult to control requiring physical restraint. Pain during recovery from anesthesia was scored by the PACU nurse using a 100 mm visual analogue scale. The post hospitalization behavior questionnaire is a widely used tool developed and validated in 1966 (16). Parents score whether there is improvement or deterioration in 27 items of behavior. It has been proposed that seven or more negative behavior changes signify a significant deterioration in behavior (17,18). One of four anesthesiologists administered the questionnaire over the telephone one and 7 days postoperatively.
Table 1 Pediatric anesthesia behavior score Score
Description of behavior
1 2
Happy Sad
3
Mad
Calm and controlled. Compliant with induction Tearful and/or withdrawn but compliant with induction Loud vocal resistance (screaming or shouting) AND/OR Physical resistance to induction requiring physical restraint by staff and/or parents
© 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 499–504
R.M. Beringer et al.
Data were collected by a team comprising four anesthesiologists and five nurses. All were trained in the use of each scoring scale. Statistics A sample size of 100 children was targeted on the basis of previous studies reporting an incidence of emergence delirium between 10 and 47% (19–22), and post hospitalization behavioral change between 47 and 67% (4,18). Successful follow up was anticipated in at least 60% of children. Data were analyzed using SPSS (statistics 19; SPSS Inc., Chicago, IL, USA). Analysis for associations was performed using: Pearson’s chi-squared test; Fisher’s exact test for small sample sizes; Mann–Whitney U test for non-parametric data; and Spearman’s rank correlation coefficient (SRCC) for non-parametric correlations. P < 0.05 was considered statistically significant. Where appropriate, results are presented as: median (range [IQR]). Results One hundred and two children were recruited with median age 6 years (range 2–12 [IQR 5–8]). There were 61 girls and 41 boys. Median number of teeth extracted was 4 (1–16 [3–8]). Except for the unequal sex distribution, this sample is comparable to the normal patient population. Preoperative data (anxiety scores, m-YPAS and PAB score) were complete in 99 cases. PAED score was documented for all children. The post hospitalization behavior questionnaire was successfully collected on both days 1 and 7 in 76 children and on only one occasion in 12 children. The parents of 14 children declined to answer the questionnaire. Anesthesia Sedative premedication (oral clonidine) was administered to two children. Ninety-six children had an intravenous induction of anesthesia with propofol and fentanyl. Two children had an inhalational induction with sevoflurane and nitrous oxide. Anesthesia was maintained with isoflurane in 78 children, sevoflurane in 17 children and propofol in four children. Nitrous oxide was used in 69 children. Preoperative anxiety on arrival at the hospital Ninety-one children were able to complete the scale. Scores out of 10 (median (range [IQR])) for: parent’s
© 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 499–504
Observational study of perioperative behavior in children
perception of their own anxiety; parent’s perception of their child’s anxiety; and child’s perception of their own anxiety were: 5 (0–10 [3–7]); 4 (0–10 [2–6]); and 3 (0–10 [1–5]), respectively. There was no correlation between the child’s anxiety and their parent’s anxiety (SRCC 0.079, P = 0.46); and only low to moderate correlation between the child’s anxiety and the parent’s perception of their child’s anxiety (SRCC 0.477, P < 0.001). Behavior during induction of anesthesia The median m-YPAS score was 38 (23–97 [23–50]). Sixty-seven per cent of children had a score above 30, suggesting high anxiety (13). A PAB score of 1, 2 or 3 was recorded for 68, 28 and 3 children, respectively, indicating that 3% of children put up significant vocal or physical resistance during induction. A PAB score of 2 or 3 was strongly associated with a previous history of traumatic events with doctors or dentists (P < 0.001), but not with age (P = 0.73), sex (P = 0.46), previous general anesthetics (P = 0.62) or history of behavioral problems (P = 0.68). Emergence agitation Median PAED score was three (0–20 [0–6]). A PAED score of 10 or above was recorded for 13% of children and was strongly associated with younger age (P = 0.009), previous traumatic experience (P = 0.006), and total number of teeth extracted (P = 0.019), but not with sex (P = 0.841), previous general anesthesia (P = 0.798) or history of behavioral problems (P = 0.251). The nurse in PACU rated the child’s recovery as: calm/good for 88% of children; upset but easy to control for 9%; and agitated/difficult to control requiring physical restraint for 3%. Pain scores in PACU on the 100 mm visual analogue scale were between zero and 10 mm for 92 children; between 10 and 30 mm for eight children and between 60 and 70 mm in two children. There was moderate correlation between pain and PAED scores (SRCC 0.444, P < 0.001). Post-hospital behavior questionnaire On day 1, 52% of children were reported to be demonstrating negative behavior changes (Figure 1), with 9% of children exhibiting negative changes in seven or more items of behavior (believed to signify a significant deterioration in behavior (17,18)).
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Figure 1 Graph representing the frequency of negative behavior changes on days 1 and 7.
Table 2 Reported frequencies of post hospitalization negative behavior changes Number of children for which change reported Negative behavior change
Day 1
Day 7
Making a fuss about eating Sitting or lying and doing nothing Temper tantrums Bad dreams and waking at night Getting upset when left alone Following parent around the house Trying to get and hold parents attention Make a fuss about going to bed at night Having trouble getting to sleep at night
17 16 11 8 10 10 10 9 9
5 1 4 5 3 3 3 3 1
On day 7, 22% of children were demonstrating negative behavior changes, with 3% exhibiting seven or more negative behavior changes. Forty-nine children (54%) demonstrated negative behavior changes on either day 1 or 7. The most frequently reported negative behavior changes are shown in Table 2. Data analysis to determine which factors were associated with PHBC Table 3 presents a statistical comparison between children who demonstrated negative post-hospitalization behavior changes and those who did not. A statistically significant association with PHBC was demonstrated for: male sex; previous traumatic experience with 502
doctors or dentists; higher m-YPAS score; higher PAB score. Discussion The first objective of this study was to determine the incidence of adverse perioperative behavior changes in children undergoing general anesthesia for dental extractions. The results show that significant behavior changes are common: during induction and recovery from anesthesia, as well as following discharge home. Induction of anesthesia The 67% of children demonstrating high anxiety based on their m-YPAS score is higher than the 50.2% observed by Davidson et al. (23) in a large, more heterogeneous study, but reflects the findings of other studies of perioperative anxiety, where anxiety is seen to peak during anesthetic induction (1,19,24). It is of interest that despite the fact that 67% of the children were classified as highly anxious, only 3% were not compliant with the induction, as judged by the PAB score. The PAB score results demonstrated that 68% of children appeared ‘happy’ during induction and a further 28% were tearful or withdrawn, but compliant. This seemingly contradictory difference between the m-YPAS and PAB scores may be because the m-YPAS measures anxiety, whereas the PAB score measures the behavioral response to that anxiety. That the majority of highly anxious children were compliant and did not resist induction of anesthesia suggests a degree of self-control by this group of children for which they are not traditionally renowned. © 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 499–504
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Table 3 Comparison between children who demonstrated negative post-hospitalization behavior changes and those who did not
Variable Median age Male sex Number of teeth extracted mean (SD) Recent significant life event Previous general anesthetic History of behavioral problems Previous traumatic experience with doctors or dentists Parent’s anxiety score (mean) Child’s anxiety score (mean) Parent’s prediction of child’s anxiety (mean) Median modified Yale preoperative anxiety score Pediatric anesthesia behavior score: 1/2/3 Sevoflurane at any time Isoflurane at any time Median paediatric anesthesia emergence delirium score
Presence of negative behavior change at anytime n = 49
No negative behavior change at any time n = 39
P value
5 22 (45%) 5.55 (3.66)
7 12 (31%) 4.90 (2.63)
0.202a 0.020b 0.557a
3 (8%) 7 2 (5%) 3 (8%)
0.817b 0.199b 0.448c 0.003b
5 3 4
5 4 4
0.291a 0.418a 0.703a
40
33
0.025a
28/19/2
32/7/1
0.034d
18 (38%) 37 (95%) 3
13 (33%) 31 (79%) 3
0.728b 0.932b 0.059a
3 (6%) 14 5 (10%) 16 (33%)
a
Mann–Whitney test. Pearson chi-square test. c Fisher’s exact test. d Chi-square with linear-by-linear association. b
A previous traumatic healthcare experience was the only factor significantly associated with increased anxiety or agitation during induction of anesthesia. Identifying these children may aid their preoperative management. Emergence from anesthesia Thirteen per cent of children in this study were classified as having emergence delirium based upon the PAED score. The reported incidence of emergence agitation in the literature varies from 10 to 80% depending upon definition and measurement tools (8). Studies using the PAED score have reported an incidence between 10 and 47% (20–22,25). The reason for the relatively low incidence of emergence delirium in this study is not entirely clear and is probably multifactorial. Propofol and fentanyl have both been shown to reduce the incidence of emergence agitation in certain situations, although not when administered as a single dose (7). © 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 499–504
Post hospitalization behavior changes We identified negative PHBC in 52% of children on day 1 and 22% on day 7. This is less frequent than seen in previous studies with similar methodologies: Kain et al. (19) studied 91 children aged between one and seven and found that 67% exhibited new negative behaviors on day 1 and 23% after 2 weeks; Power et al. (5) studied 131 children aged two to 12 of whom 73% and 59% demonstrated negative behaviors after two and 7 days, respectively. A significant deterioration in behavior (seven or more behavior changes) was identified in 9% and 1% of children on day 1 and 7, respectively. This is lower than identified by Stargatt et al. (18) who reported a significant deterioration in 24% and 16% of children on day 3 and 30, respectively, albeit following a more diverse group of procedures. There are many possible reasons why the observed frequency of PHBC was lower in our study: the dental service is extremely child centered and well organized with thorough preoperative preparation; children seem to respond well to intravenous induction of anesthesia with their parents present; notably, the children in our study did not suffer much postoperative pain, known to be associated with behavioral disturbance (1,4,5). The second objective of this study was to identify risk factors for the development of behavioral changes after discharge home. Three factors were identified: previous traumatic event involving doctors, dentists or hospitals; male sex; and distress during induction of anesthesia (Table 3). Anxiety during induction of anesthesia and previous traumatic hospital experience have previously been shown to be associated with PHBC (1,4,18). It is not clear why more boys demonstrated negative postoperative behavior changes and to our knowledge this has not been previously reported (4,5,18). A previously traumatic healthcare experience was significantly associated with negative behavior changes on induction, during recovery and at home. This emphasizes the importance of minimizing distress during medical procedures, and highlights the long lasting repercussions of a ‘bad experience’. Future research may determine whether these children might benefit from a psychological intervention. Strengths and limitations The strength of this study is that all children were having a similar procedure with consistent perioperative care. Most studies of this type have involved a more heterogeneous group of procedures and anesthetic techniques. However, our findings should be extrapolated to other 503
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groups with caution. Any study of this type is limited by the scoring systems and their interpretation by investigators. Although investigators were trained in the use of each rating scale, we did not formally test intra and inter-rater reliability. Data collection was incomplete in 25% of cases, which although respectable for a study requiring ongoing parental cooperation, may have introduced bias. The associations we have identified through statistical analysis should not be interpreted as causation.
Acknowledgments This study was approved by the National Research Ethics Service Committee South West-Central Bristol. This research was carried out without funding. Conflict of interest No conflicts of interest declared.
References 1 Kain ZN, Mayes LC, Caldwell-Andrews AA et al. Preoperative anxiety, postoperative pain, and behavioral recovery in young children undergoing surgery. Pediatrics 2006; 118: 651–658. 2 Varughese AM, Nick TG, Gunter J et al. Factors predictive of poor behavioral compliance during inhaled induction in children. Anesth Analg 2008; 107: 413–421. 3 Holm-Knudsen RJ, Carlin JB, McKenzie IM. Distress at induction of anaesthesia in children. A survey of incidence, associated factors and recovery characteristics. Pediatr Anesth 1998; 8: 383–392. 4 Kotiniemi L, Ryh€ anen P, Moilanen I. Behavioural changes in children following day-case surgery: a 4-week follow-up of 551 children. Anaesthesia 1997; 52: 970–976. 5 Power NM, Howard RF, Wade AM et al. Pain and behaviour changes in children following surgery. Arch Dis Child 2012; 97: 879–884. 6 Kain ZN, Caldwell-Andrews AA, Maranets I et al. Preoperative anxiety and emergence delirium and postoperative maladaptive behaviors. Anesth Analg 2004; 99: 1648– 1654, table of contents. 7 Dahmani S, Stany I, Brasher C et al. Pharmacological prevention of sevoflurane- and desflurane-related emergence agitation in children: a meta-analysis of published studies. Br J Anaesth 2010; 104: 216–223. 8 Vlajkovic GP, Sindjelic RP. Emergence delirium in children: many questions, few answers. Anesth Analg 2007; 104: 84–91. 9 Faulk DJ, Twite MD, Zuk J et al. Hypnotic depth and the incidence of emergence agita-
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tion and negative postoperative behavioral changes. Pediatr Anesth 2010; 20: 72–81. Kindler CH, Harms C, Amsler F et al. The visual analog scale allows effective measurement of preoperative anxiety and detection of patients’ anesthetic concerns. Anesth Analg 2000; 90: 706–712. Crandall M, Lammers C, Senders C et al. Initial validation of a numeric zero to ten scale to measure children’s state anxiety. Anesth Analg 2007; 105: 1250–1253, table of contents. Bringuier S, Dadure C, Raux O et al. The perioperative validity of the visual analog anxiety scale in children: a discriminant and useful instrument in routine clinical practice to optimize postoperative pain management. Anesth Analg 2009; 109: 737–744. Kain ZN, Mayes LC, Cicchetti DV et al. The Yale Preoperative Anxiety Scale: how does it compare with a “gold standard”? Anesth Analg 1997; 85: 783–788. Beringer RM, Greenwood R, Kilpatrick N. Development and validation of the Pediatric Anesthesia Behavior score – an objective measure of behavior during induction of anesthesia. Pediatr Anesth 2014; 24: 196–200. Sikich N, Lerman J. Development and psychometric evaluation of the pediatric anesthesia emergence delirium scale. Anesthesiology 2004; 100: 1138–1145. Vernon DT, Schulman JL, Foley JM. Changes in children’s behavior after hospitalization. Some dimensions of response and their correlates. Am J Dis Child 1966; 111: 581–593. Kain ZN, Mayes LC, O’Connor TZ et al. Preoperative anxiety in children. Predictors
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and outcomes. Arch Pediatr Adolesc Med 1996; 150: 1238–1245. Stargatt R, Davidson A, Huang G et al. A cohort study of the incidence and risk factors for negative behavior changes in children after general anesthesia. Pediatr Anesth 2006; 16: 846–859. Kain Z, Wang S, Mayes L et al. Distress during the induction of anesthesia and postoperative behavioral outcomes. Anesth Analg 1999; 88: 1042–1047. Abu-Shahwan I. Effect of propofol on emergence behavior in children after sevoflurane general anesthesia. Pediatr Anesth 2008; 18: 55–59. Abu-Shahwan I, Chowdary K. Ketamine is effective in decreasing the incidence of emergence agitation in children undergoing dental repair under sevoflurane general anesthesia. Pediatr Anesth 2007; 17: 846–850. Aouad MT, Yazbeck-Karam VG, Nasr VG et al. A single dose of propofol at the end of surgery for the prevention of emergence agitation in children undergoing strabismus surgery during sevoflurane anesthesia. Anesthesiology 2007; 107: 733–738. Davidson A, Shrivastava P, Jamsen K et al. Risk factors for anxiety at induction of anesthesia in children: a prospective cohort study. Pediatr Anesth 2006; 16: 919–927. Fortier MA, Del Rosario AM, Martin SR et al. Perioperative anxiety in children. Pediatr Anesth 2010; 20: 318–322. Bong CL, Ng AS. Evaluation of emergence delirium in Asian children using the Pediatric Anesthesia Emergence Delirium Scale. Pediatr Anesth 2009; 19: 593–600.
© 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 499–504
ORIGINAL ARTICLE
Observational study of perioperative behavior changes in children having teeth extracted under general anesthesia Richard M. Beringer1, Philip Segar1, Annabel Pearson1, Mala Greamspet1 & Nicky Kilpatrick2 1 Department of Paediatric Anaesthesia, Bristol Royal Hospital for Children, Bristol, UK 2 Murdoch Children’s Research Institute, Melbourne, Australia
Keywords child; child behavior; anesthesia; anesthesia, dental; anesthesia recovery period; anxiety Correspondence Richard M. Beringer, Department of Paediatric Anaesthesia, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol BS2 8BJ, UK Email: [email protected] Section Editor: Brian Anderson Accepted 6 January 2014 doi:10.1111/pan.12362
Summary Background: Perioperative behavioral disturbance is common in children. Negative behavior changes may be seen during induction of anesthesia, during recovery and following discharge home. There has been little research on this subject in the UK. Objectives: The aim of this study was to determine the incidence of behavioral changes within our institution and identify which children are at increased risk. Methods: A prospective observational study of healthy children aged two to 12 undergoing elective dental extractions under general anesthesia. Assessments included: the child’s and parent’s state anxiety; anxiety and behavior during induction of anesthesia (modified Yale preoperative anxiety scale and the pediatric anesthesia behavior score); behavior in PACU (pediatric anesthesia emergence delirium [PAED] scale); behavior at home on postoperative days 1 and 7 (post hospitalization behavior questionnaire). Data were examined for associations and correlations. Results: One hundred and two children with a median age of 6 years were recruited. Sixty-seven per cent exhibited high anxiety during induction of anesthesia, although only 3% demonstrated significant vocal or physical resistance. Thirteen per cent had a PAED score of 10 or more. Post-hospitalization behavior changes were demonstrated by 52% of children on day 1 and 22% on day 7; and were associated with: a previous traumatic healthcare experience, male sex, and distress during induction of anesthesia. Conclusions: Perioperative behavioral disturbance is common in children undergoing anesthesia. Predicting which children are at increased risk may allow us to adapt the management of these children in order to minimize adverse behavior changes.
Background Undergoing general anesthesia is a distressing experience for children and may lead to adverse behavior changes during induction of anesthesia, emergence or following discharge home. A number of studies have reported a clinically significant incidence of perioperative behavioral problems (1–5). Adverse behavior changes have a complex and multifactorial etiology, and may be influenced by © 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 499–504
anesthetic technique (6–9). Most research has focused on behavior during induction and emergence from anesthesia, whereas less is known about post hospitalization behavior changes. Despite the likelihood of significant regional variation, little research of this type has been performed in the United Kingdom. This study was designed to answer two questions: 1. What is the incidence of perioperative behavioral disturbance in children undergoing dental extractions under general anesthesia in a UK hospital? 499
R.M. Beringer et al.
Observational study of perioperative behavior in children
2. Is it possible to identify which children are at risk of developing behavioral problems after discharge home? The study focuses on three time points: anesthetic induction; emergence; and following discharge home.
Methods The National Research Ethics Service committee (South West Bristol) approved this study. Written informed consent was obtained from the parents of all children. This was a prospective observational study. Healthy (ASA 1 or 2) children aged 2–12 years attending the Bristol Dental hospital for day case (same day) extraction of teeth under general anesthesia were eligible to participate. The only exclusion criterion was the inability of the parent(s) to understand the study or consent process. Standard anesthetic management for dental extractions at the Bristol Dental Hospital includes: attendance at the preoperative assessment clinic; preoperative application of Ametop© local anesthetic cream to the dorsum of both hands; preoperative oral paracetamol and a non-steroidal anti-inflammatory drug (either ibuprofen or diclofenac depending upon age and weight); sedative premedication when a child exhibits signs of high anxiety or has a history suggesting that induction of anesthesia may be difficult; parents accompany the child into the operating room for induction; intravenous induction with fentanyl and propofol (inhalational induction is occasionally performed for child preference or failed venous cannulation); a flexible laryngeal mask airway is inserted; anesthesia is maintained with sevoflurane or isoflurane with or without nitrous oxide; local anesthesia is used by the dentist for extraction of permanent teeth, but not primary teeth; the child emerges in the PACU and is discharged home approximately an hour after the procedure, once discharge criteria are met. As well as the validated behavior scores described below, the following data were collected: age; sex; number of teeth extracted; number of previous general anesthetics; whether the child had experienced a significant event within the last month; whether the child had suffered a traumatic experience with doctors or dentists; whether the parent felt the child suffered from behavioral problems; pain or nausea in the PACU; pain or nausea at home. Validated behavior/anxiety scores The linear analogue scale for self-assessment of state anxiety has been validated in adults (10) and children 500
aged 7 years and older (11,12). There is no validated scale for younger children. The scale was used approximately 1 h prior to anesthesia to measure: the child’s perception of their own anxiety; the parent’s perception of their own anxiety; and the parent’s perception of their child’s anxiety. If the child was too young to understand, the scale was left blank. If both parents were present, the mother completed the scales. The modified Yale preoperative anxiety scale (m-YPAS) has been widely used since validation (13). A score above 30 has been shown to have optimal sensitivity and specificity for identifying high anxiety (13). The anesthesiologist completed this scale based upon the behavior of the child during induction of anesthesia. The pediatric anesthesia behavior (PAB) score for measuring behavioral distress during induction of anesthesia (Table 1) was validated in a parallel study (14). The anesthesiologist scored the child’s behavior at the point at which anesthesia was being induced, by either the intravenous or inhalational route. The paediatric anesthesia emergence delirium (PAED) scale (15) is used to measure emergence delirium during recovery from general anesthesia. A PAED scale score of 10 or greater has been shown to have sensitivity 0.64 and specificity 0.86 for emergence delirium (15). The PAED score was completed by the nurse caring for the child in PACU, who also completed a three point scale to describe the child’s behavior during recovery: (1) calm, good recovery; (2) upset or crying but easy to control; (3) agitated and difficult to control requiring physical restraint. Pain during recovery from anesthesia was scored by the PACU nurse using a 100 mm visual analogue scale. The post hospitalization behavior questionnaire is a widely used tool developed and validated in 1966 (16). Parents score whether there is improvement or deterioration in 27 items of behavior. It has been proposed that seven or more negative behavior changes signify a significant deterioration in behavior (17,18). One of four anesthesiologists administered the questionnaire over the telephone one and 7 days postoperatively.
Table 1 Pediatric anesthesia behavior score Score
Description of behavior
1 2
Happy Sad
3
Mad
Calm and controlled. Compliant with induction Tearful and/or withdrawn but compliant with induction Loud vocal resistance (screaming or shouting) AND/OR Physical resistance to induction requiring physical restraint by staff and/or parents
© 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 499–504
R.M. Beringer et al.
Data were collected by a team comprising four anesthesiologists and five nurses. All were trained in the use of each scoring scale. Statistics A sample size of 100 children was targeted on the basis of previous studies reporting an incidence of emergence delirium between 10 and 47% (19–22), and post hospitalization behavioral change between 47 and 67% (4,18). Successful follow up was anticipated in at least 60% of children. Data were analyzed using SPSS (statistics 19; SPSS Inc., Chicago, IL, USA). Analysis for associations was performed using: Pearson’s chi-squared test; Fisher’s exact test for small sample sizes; Mann–Whitney U test for non-parametric data; and Spearman’s rank correlation coefficient (SRCC) for non-parametric correlations. P < 0.05 was considered statistically significant. Where appropriate, results are presented as: median (range [IQR]). Results One hundred and two children were recruited with median age 6 years (range 2–12 [IQR 5–8]). There were 61 girls and 41 boys. Median number of teeth extracted was 4 (1–16 [3–8]). Except for the unequal sex distribution, this sample is comparable to the normal patient population. Preoperative data (anxiety scores, m-YPAS and PAB score) were complete in 99 cases. PAED score was documented for all children. The post hospitalization behavior questionnaire was successfully collected on both days 1 and 7 in 76 children and on only one occasion in 12 children. The parents of 14 children declined to answer the questionnaire. Anesthesia Sedative premedication (oral clonidine) was administered to two children. Ninety-six children had an intravenous induction of anesthesia with propofol and fentanyl. Two children had an inhalational induction with sevoflurane and nitrous oxide. Anesthesia was maintained with isoflurane in 78 children, sevoflurane in 17 children and propofol in four children. Nitrous oxide was used in 69 children. Preoperative anxiety on arrival at the hospital Ninety-one children were able to complete the scale. Scores out of 10 (median (range [IQR])) for: parent’s
© 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 499–504
Observational study of perioperative behavior in children
perception of their own anxiety; parent’s perception of their child’s anxiety; and child’s perception of their own anxiety were: 5 (0–10 [3–7]); 4 (0–10 [2–6]); and 3 (0–10 [1–5]), respectively. There was no correlation between the child’s anxiety and their parent’s anxiety (SRCC 0.079, P = 0.46); and only low to moderate correlation between the child’s anxiety and the parent’s perception of their child’s anxiety (SRCC 0.477, P < 0.001). Behavior during induction of anesthesia The median m-YPAS score was 38 (23–97 [23–50]). Sixty-seven per cent of children had a score above 30, suggesting high anxiety (13). A PAB score of 1, 2 or 3 was recorded for 68, 28 and 3 children, respectively, indicating that 3% of children put up significant vocal or physical resistance during induction. A PAB score of 2 or 3 was strongly associated with a previous history of traumatic events with doctors or dentists (P < 0.001), but not with age (P = 0.73), sex (P = 0.46), previous general anesthetics (P = 0.62) or history of behavioral problems (P = 0.68). Emergence agitation Median PAED score was three (0–20 [0–6]). A PAED score of 10 or above was recorded for 13% of children and was strongly associated with younger age (P = 0.009), previous traumatic experience (P = 0.006), and total number of teeth extracted (P = 0.019), but not with sex (P = 0.841), previous general anesthesia (P = 0.798) or history of behavioral problems (P = 0.251). The nurse in PACU rated the child’s recovery as: calm/good for 88% of children; upset but easy to control for 9%; and agitated/difficult to control requiring physical restraint for 3%. Pain scores in PACU on the 100 mm visual analogue scale were between zero and 10 mm for 92 children; between 10 and 30 mm for eight children and between 60 and 70 mm in two children. There was moderate correlation between pain and PAED scores (SRCC 0.444, P < 0.001). Post-hospital behavior questionnaire On day 1, 52% of children were reported to be demonstrating negative behavior changes (Figure 1), with 9% of children exhibiting negative changes in seven or more items of behavior (believed to signify a significant deterioration in behavior (17,18)).
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Figure 1 Graph representing the frequency of negative behavior changes on days 1 and 7.
Table 2 Reported frequencies of post hospitalization negative behavior changes Number of children for which change reported Negative behavior change
Day 1
Day 7
Making a fuss about eating Sitting or lying and doing nothing Temper tantrums Bad dreams and waking at night Getting upset when left alone Following parent around the house Trying to get and hold parents attention Make a fuss about going to bed at night Having trouble getting to sleep at night
17 16 11 8 10 10 10 9 9
5 1 4 5 3 3 3 3 1
On day 7, 22% of children were demonstrating negative behavior changes, with 3% exhibiting seven or more negative behavior changes. Forty-nine children (54%) demonstrated negative behavior changes on either day 1 or 7. The most frequently reported negative behavior changes are shown in Table 2. Data analysis to determine which factors were associated with PHBC Table 3 presents a statistical comparison between children who demonstrated negative post-hospitalization behavior changes and those who did not. A statistically significant association with PHBC was demonstrated for: male sex; previous traumatic experience with 502
doctors or dentists; higher m-YPAS score; higher PAB score. Discussion The first objective of this study was to determine the incidence of adverse perioperative behavior changes in children undergoing general anesthesia for dental extractions. The results show that significant behavior changes are common: during induction and recovery from anesthesia, as well as following discharge home. Induction of anesthesia The 67% of children demonstrating high anxiety based on their m-YPAS score is higher than the 50.2% observed by Davidson et al. (23) in a large, more heterogeneous study, but reflects the findings of other studies of perioperative anxiety, where anxiety is seen to peak during anesthetic induction (1,19,24). It is of interest that despite the fact that 67% of the children were classified as highly anxious, only 3% were not compliant with the induction, as judged by the PAB score. The PAB score results demonstrated that 68% of children appeared ‘happy’ during induction and a further 28% were tearful or withdrawn, but compliant. This seemingly contradictory difference between the m-YPAS and PAB scores may be because the m-YPAS measures anxiety, whereas the PAB score measures the behavioral response to that anxiety. That the majority of highly anxious children were compliant and did not resist induction of anesthesia suggests a degree of self-control by this group of children for which they are not traditionally renowned. © 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 499–504
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Observational study of perioperative behavior in children
Table 3 Comparison between children who demonstrated negative post-hospitalization behavior changes and those who did not
Variable Median age Male sex Number of teeth extracted mean (SD) Recent significant life event Previous general anesthetic History of behavioral problems Previous traumatic experience with doctors or dentists Parent’s anxiety score (mean) Child’s anxiety score (mean) Parent’s prediction of child’s anxiety (mean) Median modified Yale preoperative anxiety score Pediatric anesthesia behavior score: 1/2/3 Sevoflurane at any time Isoflurane at any time Median paediatric anesthesia emergence delirium score
Presence of negative behavior change at anytime n = 49
No negative behavior change at any time n = 39
P value
5 22 (45%) 5.55 (3.66)
7 12 (31%) 4.90 (2.63)
0.202a 0.020b 0.557a
3 (8%) 7 2 (5%) 3 (8%)
0.817b 0.199b 0.448c 0.003b
5 3 4
5 4 4
0.291a 0.418a 0.703a
40
33
0.025a
28/19/2
32/7/1
0.034d
18 (38%) 37 (95%) 3
13 (33%) 31 (79%) 3
0.728b 0.932b 0.059a
3 (6%) 14 5 (10%) 16 (33%)
a
Mann–Whitney test. Pearson chi-square test. c Fisher’s exact test. d Chi-square with linear-by-linear association. b
A previous traumatic healthcare experience was the only factor significantly associated with increased anxiety or agitation during induction of anesthesia. Identifying these children may aid their preoperative management. Emergence from anesthesia Thirteen per cent of children in this study were classified as having emergence delirium based upon the PAED score. The reported incidence of emergence agitation in the literature varies from 10 to 80% depending upon definition and measurement tools (8). Studies using the PAED score have reported an incidence between 10 and 47% (20–22,25). The reason for the relatively low incidence of emergence delirium in this study is not entirely clear and is probably multifactorial. Propofol and fentanyl have both been shown to reduce the incidence of emergence agitation in certain situations, although not when administered as a single dose (7). © 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 499–504
Post hospitalization behavior changes We identified negative PHBC in 52% of children on day 1 and 22% on day 7. This is less frequent than seen in previous studies with similar methodologies: Kain et al. (19) studied 91 children aged between one and seven and found that 67% exhibited new negative behaviors on day 1 and 23% after 2 weeks; Power et al. (5) studied 131 children aged two to 12 of whom 73% and 59% demonstrated negative behaviors after two and 7 days, respectively. A significant deterioration in behavior (seven or more behavior changes) was identified in 9% and 1% of children on day 1 and 7, respectively. This is lower than identified by Stargatt et al. (18) who reported a significant deterioration in 24% and 16% of children on day 3 and 30, respectively, albeit following a more diverse group of procedures. There are many possible reasons why the observed frequency of PHBC was lower in our study: the dental service is extremely child centered and well organized with thorough preoperative preparation; children seem to respond well to intravenous induction of anesthesia with their parents present; notably, the children in our study did not suffer much postoperative pain, known to be associated with behavioral disturbance (1,4,5). The second objective of this study was to identify risk factors for the development of behavioral changes after discharge home. Three factors were identified: previous traumatic event involving doctors, dentists or hospitals; male sex; and distress during induction of anesthesia (Table 3). Anxiety during induction of anesthesia and previous traumatic hospital experience have previously been shown to be associated with PHBC (1,4,18). It is not clear why more boys demonstrated negative postoperative behavior changes and to our knowledge this has not been previously reported (4,5,18). A previously traumatic healthcare experience was significantly associated with negative behavior changes on induction, during recovery and at home. This emphasizes the importance of minimizing distress during medical procedures, and highlights the long lasting repercussions of a ‘bad experience’. Future research may determine whether these children might benefit from a psychological intervention. Strengths and limitations The strength of this study is that all children were having a similar procedure with consistent perioperative care. Most studies of this type have involved a more heterogeneous group of procedures and anesthetic techniques. However, our findings should be extrapolated to other 503
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groups with caution. Any study of this type is limited by the scoring systems and their interpretation by investigators. Although investigators were trained in the use of each rating scale, we did not formally test intra and inter-rater reliability. Data collection was incomplete in 25% of cases, which although respectable for a study requiring ongoing parental cooperation, may have introduced bias. The associations we have identified through statistical analysis should not be interpreted as causation.
Acknowledgments This study was approved by the National Research Ethics Service Committee South West-Central Bristol. This research was carried out without funding. Conflict of interest No conflicts of interest declared.
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© 2014 John Wiley & Sons Ltd Pediatric Anesthesia 24 (2014) 499–504
