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Preparing pediatric patients for surgery is a complex process. It is necessary that all parties are prepared as well as possible regarding information, preferences, and expectations. Smooth separation of child and family, be it before or after induction, should be clearly facilitated by clearly stated instructions and participation of perioperative personnel. Psychological factors such as sex, age, cognitive level, family learning, and culture; situational factors such as expectation, control, and relevance; emotional factors such as fear, anger, and frustration; and behavioral factors such as coping style, overt distress, and parental response need to be assessed and taken into account.

Necessary preparation includes:

  • an increased focus on family-centered care;

  • a ready anesthesia with age appropriate pediatric equipment (laryngoscope blades, blood pressure cuffs, pediatric circuits), ventilator settings and pressure limits, availability of airways (oral and nasal airways, endotracheal tubes, laryngeal mask airways), intravenous (IV) catheter kits and fluids;

  • anesthetic and emergency medications drawn up in appropriately sized syringes;

  • techniques to reduce anxiety of pediatric patients and parents by both pharmacologic and nonpharmacologic means.

Medical considerations such as exprematurity, upper respiratory tract infections, reactive airway disease, gastroesophageal reflux, obstructive sleep apnea, obesity, behavioral disorders such as autism, congenital heart defects, and CNS disorders such as cerebral palsy need to be considered in choosing an effective safe strategy for premedication or withholding premedication. Families and patients should be included in decisions regarding premedication, parental presence, and the type of induction technique (inhalational vs. IV) to ensure the smoothest and safest induction possible. Emergencies situations such as foreign body aspirations, acute abdomen, penetrating eye injuries, increased intracranial pressure, and trauma require special considerations for induction of anesthesia.

Pharmacologic means include administration of a sedative and/or analgesic premedicant and/or topical anesthesia. Administering a premedicant such as midazolam will reliably decrease anxiety, improve cooperation during induction, and improve parental satisfaction. Younger children (2–5 years of age) and patients who have been in the OR before are at higher risk of being uncooperative during induction and premedication should be considered in this group of patients. Recent studies have concluded that postoperative maladaptive behaviors and sleep difficulties are higher in children who are anxious preoperatively.

Nonpharmacologic means involve either parental presence during induction of anesthesia (PPIA) and/or appropriate psychological preparation of the child. These options may include presurgical tours and/or short movies, distraction techniques (playrooms for pediatric waiting areas supplied with coloring books, story books, video games, internet, and child movies), allowing the child to bring a familiar object with them (pacifiers, toys, music boxes, videos), allowing the child to play with the mask, and allowing them to have control by choosing a flavor to apply to the mask and guided imagery. PPIA has not shown to be effective in relieving anxiety in the children, especially if the parent(s) is anxious. PPAI can be stressful to the parent and should be considered as ...

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