Anxiety is a normal reaction to anticipated surgery and anesthesia. The vast majority of patients scheduled for surgery will express anxieties about anesthesia. More than half the patients in one study expressed anxiety that they might awake during surgery; others expressed concern about pain after surgery; some were concerned they might not wake up; others feared nausea and vomiting.1
Whatever the reasons for your own anxiety, the adverse physiological and psychological consequences of stress and anxiety are well known. Anxiety can activate the fight-or-flight reaction, mediated by the sympathetic nervous system. Activation of the sympathetic nervous system results in adrenaline secretion by the adrenal glands, increased heart rate, increased blood pressure, increased anxiety, and often a sense of doom.
In the healthy adult or child, this reaction may not be life threatening, but it can be quite unpleasant, and there are consequences stemming from untreated anxiety. More than half the children who receive general anesthesia and surgery displayed "nega tive behaviors" for up to two weeks following the procedure.2 Negative behaviors reported were nightmares, separation anxiety, eating problems, increased fear of doctors, aggressive behavior, bed-wetting, and temper tantrums. In 20 percent of the children studied, these negative behaviors persisted up to six months; in 7 percent they were still evident at a year.3
The approach to the patient with anxiety must be individualized to patient's needs. There is no single method or drug to treat anxiety in all patients. Anxiety about anesthesia and surgery isn't always the patient's main concern. If the most important concern of the patient is pain, he should receive a pain medication. If the primary concern is the need to speak with a family member, then he may need a telephone. If the patient desires to confess his sins before the surgery, then he may need to see a priest. The point is that your specific problems, concerns, and fears must be addressed preoperatively.
The Importance of the Preoperative Visit to Reduce Anxiety
There is no doubt that a well-conducted preoperative visit by the anesthesiologist can significantly reduce your level of anxiety.4 The meeting between you and the anesthesiologist is important for many medical reasons, but it is also an important time to answer any questions about the anesthetic management and to provide psychological support and reassurance. A well-conducted preoperative visit may decrease your postoperative narcotic requirements and shorten your length of stay in the hospital.5
Pharmacological Methods to Reduce Anxiety
Once the preop visit is completed and your concerns and questions have been addressed, you may still have significant anxiety.
Should I (or My Child) Receive Sedative Medication Before Surgery? 31
Administering an anxiety-reducing drug may reduce or eliminate this anxiety. By far and away the most commonly prescribed drug for reducing preoperative anxiety is Versed (midazolam).
Versed is highly effective in reducing preoperative anxiety in both the adult and the child. It is a member of the benzodiazepine family of drugs, the same family of drugs as Valium (diazepam) and Ativan (lorazepam). Versed is about three times as potent as Valium, and it doesn't burn upon injection like Valium. Versed has a considerably faster onset of action than Valium and causes profound amnesia shortly after intravenous administration. The duration of action of Versed is considerably shorter than Valium, which makes it an excellent choice for outpatient surgery.
A spirited discussion often ensues when anesthesiologists discuss premedication for the patient having an outpatient procedure. A few studies report that discharge times in outpatient facilities were prolonged following administration of Versed. Other studies have reported no difference in discharge times with the administration of commonly used doses of Versed. Whether any difference in discharge times exists is debatable, and if there are differences, they are quite small and clinically insignificant. If you are still anxious after the preoperative visit with your anesthesiologist and desire a medication to reduce anxiety, there is no reason you should not receive Versed.
The preoperative visit between the anesthesiologist and the child having anesthesia is just as important as the preoperative visit with an adult. Proper psychological preparation of both the parent(s)
and the child before surgery is critical. A reassuring meeting between the child, the parent(s), and the anesthesiologist is important; the use of play therapy to introduce the child to the anesthesia experience that is about to occur in age-appropriate ways can also be very helpful.
Pharmacological Methods to Reduce Anxiety in the Child
Despite a good preoperative visit between the child, the parent(s), and the anesthesiologist, and despite age-appropriate explanations to the child about the experience of anesthesia and surgery, the child—like the adult—will often have persistent anxiety. Even the very calm and brave child may have some degree of "meltdown" upon leaving for the operating room. In fact, the silent child and the child that appears aloof and calm during the preoperative visit may be more prone to emotional outbursts upon induction of anesthesia. Many of these children will benefit from sedative medication before the trip to the operating room.
Versed is by far the most widely used medication to reduce anxiety in children before surgery because of its rapid onset, reliability, brief duration of action, and minimal side effects. Children who receive Versed premedication demonstrate significantly less anxiety upon separation from parents to go to the operating room, upon arrival to the operating room, and with the introduction of the facemask to go to sleep than children who did not receive premedication with Versed.
The benefits of Versed premedication for children may extend into the period after surgery as well. In one study, children who received Versed premedication demonstrated significantly fewer negative behaviors (e.g., nightmares, separation anxiety, eating disturbances, excessive fear of doctors) in quantity and quality in the
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first week following surgery than those children who did not receive Versed premedication.6 Interestingly, studies have also shown that anxiety levels in the parents of pediatric patients are reduced when the child receives Versed premedication.
The route of administration of Versed is often different in the child than in the adult. Adults invariably have an intravenous in place so we can conveniently administer the Versed by this route. Children under the age of ten are generally terrified of needles, so every effort is made to spare them the further anxiety and pain of the intravenous placement until after they have fallen asleep with a mask. For this reason, we often administer Versed to the child either by mouth (oral) or by nose (intranasal).
Intranasal administration: The nasal route of administration is often chosen for the child less than three years old. The onset of sedative effect is rapid by this route—usually less than ten minutes. Some children will be upset with nose drops because they can cause some minimal stinging, so the oral route may be chosen instead.
Oral route. Versed comes in a cherry-flavored syrup that is well received by most children. The dose has to be increased slightly to achieve the same effect as the intranasal route, and it will takes a few minutes longer to work, but effectiveness on the child (and the parent) is similar to the intranasal route.
Should You Accompany Your Child Into the Operating Room for Induction of Anesthesia?
This is a controversial topic that leads to anxiety in parents, children, and anesthesiologists alike. The answer is a definite "maybe." Sometimes a support person will be a calming influence on the child, but at other times they cause chaos.7
The first priority is always to consider what is best for the child. Allowing parents or other relatives into the operating room during induction may not always be a calming influence on the child. Parents who are anxious and insistent on being present on induction of anesthesia may transfer this anxiety to their child and will thereby increase the child's anxiety. Some parents have a hard time relinquishing control and care of their child to a stranger, which may create stress for all involved during induction of anesthesia. Some parents are critical of the child or give excessive commands—or even excessive reassurances—and this may increase the child's anxiety.
If a parent plans to accompany his child to the operating room, most facilities require that she be evaluated in advance of surgery to be certain that her presence during induction will benefit the child. It is important to note that even if the parent plans to be present at her child's induction of anesthesia, Versed may still be of benefit to both parent and child. Versed premedication has been shown to provide additional anxiety reduction in the child even when the parent is present at induction.8 In fact, a study comparing Versed premedication with a parent present at induction of anesthesia found that Versed premedication was superior to parental presence at induction in reducing the child's anxiety.9 Parental anxiety scores are also significantly lower when the child receives premedicated with Versed.
Anxiety is common in the period before surgery. A good preoperative visit with the anesthesiologist can reduce or even eliminate this anxiety. For those patients with residual anxiety after this meeting, especially children, premedication with Versed can eliminate this anxiety and minimize its negative physical and emotional effects.
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It seems like you hear it all the time from nearly every one you know I'm SO stressed out!? Pressures abound in this world today. Those pressures cause stress and anxiety, and often we are ill-equipped to deal with those stressors that trigger anxiety and other feelings that can make us sick. Literally, sick.