Advertisement

Parental Presence at Induction of Anesthesia to Reduce Anxiety: A Systematic Research and Meta-Analysis

      Abstract

      Purpose

      Perioperative anxiety can significantly alter outcomes for pediatric patients. Parental presence at induction of anesthesia (PPIA) is one method of anxiety reduction, but the efficacy remains unclear. This systematic review and meta-analysis aimed to determine if PPIA affects child and caretaker perioperative anxiety levels.

      Design

      Systematic Review and Meta-analysis

      Methods

      This study followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive literature search of PubMed, Scopus, CINAHL, PsycINFO, and Cochrane Library databases was performed on June 29, 2021. Search terms were related to parental presence in the operating room, anesthesia or anesthesia induction, and pediatric patients. The literature search identified English-language studies comparing children receiving PPIA to controls or studies examining attitudes toward PPIA.

      Findings

      A total of 21 articles (n = 9573) met inclusion criteria. Seven studies (n = 776) quantified child anxiety with validated scales, and seven studies quantified parent anxiety (n = 621). There was no significant difference in preoperative anxiety between PPIA and controls for patients (P = .27) or caretakers (P = .99). PPIA patients had 8.40 [0.16, 16.64] (P = .05) lower Modified Yale Preoperative Anxiety Scale scores compared to control at induction, and parents had 3.41 [0.32, 6.50] (P = .03) lower State-Trait Anxiety Inventory State scores. Three studies concluded that PPIA did not increase operating room time or induction time. Twenty-three studies examined parental attitudes toward PPIA and found that 98.03% [96.09%, 99.32%] of parents present at induction would like to be present at subsequent surgeries. Contention in support for PPIA was seen amongst healthcare providers, but attitudes increasingly favored PPIA after implementation.

      Conclusions

      PPIA reduces parental and patient anxiety, may increase parental satisfaction, and may not impede operating room efficiency. PPIA should be considered as a valuable tool to improve surgical outcomes and patient and family satisfaction.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of PeriAnesthesia Nursing
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Davidson AJ
        • Shrivastava PP
        • Jamsen K
        • et al.
        Risk factors for anxiety at induction of anesthesia in children: a prospective cohort study.
        Pediatr Anesth. 2006; 16: 919-927
        • Chieng Y
        • Chan W
        • Klainin-Yobas P
        • He H.
        Perioperative anxiety and postoperative pain in children with adolescents undergoing elective surgical procedures: a quantitative systematic review.
        J Adv Nurs. 2014; 70: 243-255
        • Kotiniemi LH
        • Ryhanen PT
        • Moilanen IK.
        Behavioural changes in children following day-case surgery: a 4-week follow-up of 551 children.
        Anaesthesia. 2004; 52: 970-976
        • Stargatt R
        • Davidson AJ
        • Huang GH
        • et al.
        A cohort study of the incidence and risk factors for negative behavior changes in children after general anesthesia.
        Paediatr Anaesth. 2006; 16: 846-859
        • Bar-Haim Y
        • Lamy D
        • Pergamin L
        • Bakermans-Kranenburg M
        • van Ijzendoorn M.
        Threat-related attentional bias in anxious and nonanxious individuals.
        PsycholBull. 2007; 133: 1-24
        • van der Heijden MJ
        • Araghi SO
        • van Dijk M
        • Jeekel J
        • Hunink MG.
        The effects of perioperative music interventions in pediatric surgery: a systematic review and meta-analysis of randomized controlled trials.
        PLoS One. 2015; 10e0133608
        • Cray SH
        • Dixon JL
        • Heard CM
        • Selsby DS.
        Oral midazolam premedication for pediatric day case patients.
        Paediatr Anaesth. 1996; 6: 265-270
        • Kain ZN
        • Mayes LC
        • Caramico LA
        • et al.
        Parental presence during induction of anesthesia. A randomized controlled trial.
        Anesthesiology. 1996; 84: 1060-1067
        • Kain ZN
        • Caldwell-Andrews AA
        • Maranets I
        • Nelson W
        • Mayes LC.
        Predicting which child-parent pair will benefit from parental presence during induction of anesthesia: a decision-making approach.
        Anesth Analg. 2006; 102: 81-84
        • Wright KD
        • Stewart SH
        • Finley GA
        • Buffett-Jerrott SE.
        Prevention and intervention strategies to alleviate preoperative anxiety in children.
        Behav Modif. 2007; 31: 52-79
        • Johnson YJ
        • Nickerson M
        • Quezado ZMN.
        Case report: an unforeseen peril of parental presence during induction of anesthesia.
        Anesth Analg. 2012; 115: 1371-1372
        • Kain ZN
        • Mayes LC
        • Wang SM
        • Caramico LA
        • Hofstadter MB.
        Parental presence during induction of anesthesia versus sedative premedication: which intervention is more effective?.
        Anesthesiology. 1998; 89: 1147-1156
        • Moher D
        • Liberati A
        • Tetzlaff J
        • Altman DG
        • Group TP.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        PLoS Med. 2009; 6e1000097
        • Moher D
        • Shamseer L
        • Clarke M
        • et al.
        Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement.
        Syst Rev. 2015; 4: 1
        • OCEBM Levels of Evidence Working Group
        The Oxford levels of evidence 2. Oxford Centre for Evidence-Based Medicine.
        2016 (Accessed June 13, 2021) (Published)
        • Borenstein M
        • Hedges LV
        • Higgins JPT
        • Rothstein HR.
        Introduction to meta-analysis.
        John Wiley & Sons, Chichester, United Kingdom2009
        • Egger M
        • Smith GD
        • Schneider M
        • Minder C.
        Bias in meta-analysis detected by a simple, graphical test.
        BMJ. 1997; 315: 629-634
        • Sterne JA
        • Egger M.
        Funnel plots for detecting bias in meta-analysis: guidelines on choice of axis.
        J Clin Epidemiol. 2001; 54: 1046-1055
        • Akinci SB
        • Kose EA
        • Ocal T
        • Aypar U.
        The effects of maternal presence during anesthesia induction on the mother's anxiety and changes in children's behavior.
        Turk J Pediatr. 2008; 50: 566-571
        • SD Amanor-Boadu
        The effect of parental presence at induction of anaesthesia on the behaviour of unsedated Nigerian children presenting for day-case anaesthesia.
        West Afr J Med. 2002; 21: 28-30
        • Arai YC
        • Ito H
        • Kandatsu N
        • Kurokawa S
        • Kinugasa S
        • Komatsu T.
        Parental presence during induction enhances the effect of oral midazolam on emergence behavior of children undergoing general anesthesia.
        Acta Anaesthesiol Scand. 2007; 51: 858-861
        • Blesch P
        • Fisher ML.
        The impact of parental presence on parental anxiety and satisfaction.
        AORN J. 1996; 63: 761-768
        • Bosenberg AT
        • Williams GD
        • Reddy D.
        Attitudes towards parental presence at induction of anaesthesia.
        S Afr Med J. 1996; 86: 644-667
        • Braude N
        • Ridley SA
        • Sumner E.
        Parents and paediatric anaesthesia: a prospective survey of parental attitudes to their presence at induction.
        Ann R Coll Surg Engl. 1990; 72: 41-44
        • Cameron JA
        • Bond MJ
        • Pointer SC.
        Reducing the anxiety of children undergoing surgery: parental presence during anaesthetic induction.
        J Paediatr Child Health. 1996; 32: 51-56
        • Hannallah RS
        • Abramowitz MD
        • Oh TH
        • Ruttimann UE.
        Residents' attitudes toward parents' presence during anesthesia induction in children: Does experience make a difference?.
        Anesthesiology. 1984; 60: 598-601
        • Henderson MA
        • Baines DB
        • Overton JH.
        Parental attitudes to presence at induction of paediatric anaesthesia.
        Anaesth Intens Care. 1993; 21: 324-327
        • Himes MK
        • Munyer K
        • Henly SJ.
        Parental presence during pediatric anesthetic inductions.
        AANA J. 2003; 71: 293-298
        • Hussain A
        • Khan FA.
        Effect of two techniques of parental interaction on children's anxiety at induction of general anaesthesia - a randomized trial.
        Turk J Anaesthesiol Reanim. 2018; 46: 305-310
        • Kain ZN
        • Caldwell-Andrews AA
        • Mayes LC
        • Wang S-M
        • Krivutza DM
        • LoDolce ME.
        Parental presence during induction of anesthesia: physiological effects on parents.
        Anesthesiology. 2003; 98: 58-64
        • Kain ZN
        • Caldwell-Andrews AA
        • Mayes LC
        • et al.
        Family-centered preparation for surgery improves perioperative outcomes in children.
        Anesthesiology. 2007; 106: 65-74
        • Kain ZN
        • Caldwell-Andrews AA
        • Wang SM
        • Krivutza DM
        • Weinberg ME
        • Mayes LC.
        Parental intervention choices for children undergoing repeated surgeries.
        Anesth Analg. 2003; 96: 970-975
        • Kain ZN
        • Fernandes LA
        • Touloukian RJ.
        Parental presence during induction of anesthesia: the surgeon's perspective.
        Eur J Pediatr Surg. 1996; 6: 323-327
        • Kain ZN
        • Mayes LC
        • Wang SM
        • Caramico LA
        • Krivutza DM
        • Hofstadter MB.
        Parental presence and a sedative premedicant for children undergoing surgery.
        Anesthesiology. 2000; 92: 939-946
        • Kam PC
        • Voss TJ
        • Gold PD
        • Pitkin J.
        Behaviour of children associated with parental participation during induction of general anaesthesia.
        J Paediatr Child Health. 1998; 34: 29-31
        • Kazak Z
        • Sezer GB
        • Yilmaz AA
        • Ates Y.
        Premedication with oral midazolam with or without parental presence.
        Eur J Anaesthesiol. 2010; 27: 347-352
        • Leelanukrom R
        • Somboonviboon W
        • Sriprachittichai P.
        Parental presence during induction of anesthesia in children: a study on parental attitudes and children's cooperation.
        J Med Assoc Thai. 2002; 85: S186-S192
        • Luehmann NC
        • Staubach ME
        • Akay B
        • et al.
        Benefits of a family-centered approach to pediatric induction of anesthesia.
        J Pediatr Surg. 2019; 54: 189-193
        • Lui JCZ
        • Wu KK.
        Parental anxiety associated with participation in anaesthetic induction in children: questionnaire survey.
        Hong Kong Med J. 1999; 5: 21-26
        • Marquez JL
        • Wang E
        • Rodriguez ST
        • et al.
        A retrospective cohort study of predictors and interventions that influence cooperation with mask induction in children.
        Pediatr Anesth. 2020; 92: 939-946
        • McEwen AW
        • Caldicott LD
        • Barker I.
        Parents in the anaesthetic room–parents' and anaesthetists' views.
        Anaesthesia. 1994; 49: 987-990
        • Moseley SL
        • Heine C
        • Valente T
        • et al.
        Effects of parental presence during induction of anesthesia on operative and perioperative times in pediatric patients undergoing adenotonsillectomy.
        Int J Pediatr Otorhinolaryngol. 2021; 140110515
        • Ozdogan HK
        • Cetinalp S
        • Kuran G
        • et al.
        The effects of maternal presence during anesthesia induction on salivary cortisol levels in children undergoing tonsillectomy and/or adenoidectomy.
        J Clin Anesth. 2017; 39: 64-66
        • Rasti-Emad-Abadi R
        • Naboureh A
        • Nasiri M
        • Motamed N
        • Jahanpour F.
        The effects of preanesthetic parental presence on preoperative anxiety of children and their parents: A randomized clinical trial study in Iran.
        Iran J Nurs Midwifery Res. 2017; 22: 72-77
        • Roman DE
        • Barker I
        • Reilly CS.
        Anaesthetists' attitudes to parental presence at induction of general anaesthesia in children.
        Anaesthesia. 1993; 48: 338-340
        • Ryder IG
        • Spargo PM.
        Parents in the anaesthetic room. A questionnaire survey of parents' reactions.
        Anaesthesia. 1991; 46: 977-979
        • Sadeghi A
        • Tabari AK
        • Mahdavi A
        • Salarian S
        • Razavi SS.
        Impact of parental presence during induction of anesthesia on anxiety level among pediatric patients and their parents: a randomized clinical trial.
        Neuropsychiatr Dis Treaat. 2017; 12: 3237-3241
        • Sun Y
        • Qi S
        • Qi R
        • Dong X
        • An J
        • Yuan H.
        The effect of parental presence to perioperative anxiety of Chinese children and their parents.
        Biomed Res. 2017; 28: 7519-7522
        • Waseem H
        • Mazzamurro RS
        • Fisher AH
        • et al.
        Parental satisfaction with being present in the operating room during the induction of anesthesia prior to pediatric neurosurgical intervention: a qualitative analysis.
        J Neurosurg Pediatr. 2018; 21: 528-534
        • Yousef Y
        • Drudi S
        • Sant'Anna AM
        • Emil S
        Parental presence at induction of anesthesia: perceptions of a pediatric surgical department before and after program implementation.
        J Pediatr Surg. 2018; 53: 1606-1610
        • Wollin SR
        • Plummer JL
        • Owen H
        • Hawkins RMF
        • Materazzo F.
        Predictors of preoperative anxiety in children.
        Anaesth Intensive Care. 2003; 31: 69-74
        • Kain ZN
        • Wang SM
        • Mayes LC
        • Caramico LA
        • Hofstadter MB.
        Distress during the induction of anesthesia and postoperative behavioral outcomes.
        Anesth Analg. 1999; 88: 1042-1047
        • Caldwell-Andrews AA
        • Kain ZN
        • Mayes LC
        • Kerns RD
        • Ng D.
        Motivation and maternal presence during induction of anesthesia.
        Anesthesiology. 2005; 103: 478-483
        • Fortier MA
        • Gomez SH
        • Kain A.
        Motivation and parental presence during induction of anesthesia: an examination of the role of ethnicity and language.
        Pediatr Anesth. 2012; 22: 1094-1099
        • Jenkins BN
        • Fortier MA
        • Kaplan SH
        • Mayes LC
        • Kain ZN.
        Development of a short version of the modified yale preoperative anxiety scale.
        Anesth Analg. 2014; 119: 643-650
        • Kain ZN
        • Mayes LC
        • Cicchetti DV
        • et al.
        Measurement tool for preoperative anxiety in young children: the yale preoperative anxiety scale.
        Child Neuropsych. 1995; 1: 203-210
        • Kain ZN
        • Mayes LC
        • Cicchetti DV
        • Bagnall AL
        • Finley JD
        • Hofstadter MB.
        The Yale preoperative anxiety scale: how does it compare with a "gold standard"?.
        Anesth Analg. 1997; 85: 783-788
        • Barnes LLB
        • Harp D
        • Jung WS.
        Reliability generalization of scores on the Spielberger state-trait anxiety inventory.
        Educ Psychol Meas. 2002; 62: 603-618
        • Spielberger CD
        • Edwards CD
        • Lushene RE
        • Montouri J
        • Platzek D.
        Preliminary test manual for the state-trait anxiety inventory for children.
        Consulting Psychologists Press, Palo Alto, CA1973
        • Seligman LD
        • Ollendick TH
        • Langley AK
        • Baldacci HB.
        The utility of measures of child and adolescent anxiety: a meta-analytic review of the revised children's manifest anxiety scale, the state-trait anxiety inventory for children, and the child behavior checklist.
        J Clin Child and Adolesc Psychol. 2004; 33: 557-565
        • Cella DF
        • Perry SW.
        Reliability and concurrent validity of three visual-analogue mood scales.
        Psych Rep. 1986; 59: 827-833
        • Folstein MF
        • Luria R.
        Reliability, validity, and clinical application of the visual analogue mood scale.
        Psychol Med. 2009; 3: 479-486
        • Wewers ME
        • Lowe NK.
        A critical review of visual analogue scales in the measurement of clinical phenomena.
        Res Nurs Health. 1990; 13: 227-236