The uncooperative child
Children can present to hospital out of hours and as acute emergencies, and therefore it is not always possible to prepare an anxious or uncooperative child for theatre. On the other hand, in the elective setting, fantastic work can be carried out by play specialists to prepare children preoperatively. As for any clinical interaction, the anaesthetist needs to judge the level of understanding the patient has and communicate with them at an appropriate level to gain trust and cooperation. Interactions with children may be particularly challenging due to fear, pain, previous experiences, and a lack of comprehension or explanation.
1 Understand the various non-pharmacological approaches to managing the anxious or uncooperative child
2 Consider different oral premedicants in paediatric anaesthesia.
2D02; 2D06
A 4-year-old girl is admitted as a day case for multiple dental extractions. This is her first general anaesthetic, and she is otherwise well. She has no known allergies and is appropriately fasted. She has not long arrived on the ward, and the nurse looking after her tells you she is very withdrawn and clinging to her mother.
Introduce yourself to the child and her parents; try to engage with them and build a rapport. Undertake your standard preoperative anaesthetic assessment, and ask specifically about recent illnesses, including cough or cold symptoms, as this can increase the risk of anaesthetic problems due to a reactive and irritable airway.
Explain the available options for the induction of anaesthesia, specifically discussing IV or inhalational induction. Use age-appropriate and non-threatening descriptions of both techniques, e.g. the use of ‘magic cream’ to allow the placement of a small plastic straw/tube or ‘sleepy wind’ via a face mask. Involve the parents in ascertaining what they believe to be most acceptable to the child, but, if the child has been under anaesthesia before or is of an appropriate age, let them make the decision how they wish to proceed with their anaesthetic. If there is a play specialist available, inform the parents of their role in supporting the child and the parents.
Consider premedication in circumstances where the child appears to be distressed, uncooperative, has had a previous bad experience, or where the child has behavioural or learning difficulties limiting their understanding and compliance. An appropriate premedicant should be prescribed, taking into account the onset time, duration of effect, and side effects, so that the parents or carers can be appropriately informed.
The parents are happy with your explanation of the procedure and would like to try an IV induction. You convey this to her named nurse and the play specialist who starts to prepare the child.
◆ Play to build rapport and trust
◆ An illustrated storybook about a child’s journey in hospital
◆ Props such as face masks, choosing a pleasant smell for inside the face mask, stickers/drawings on ‘magic cream’ dressing, and blowing up balloons
◆ ‘Carrot and stick’: find out what the child’s interests are, and suggest reading a book about it later, i.e. in the anaesthetic room
◆ Distraction techniques in anaesthetic room: books, toys, talking, etc.
It is important to make realistic promises and fulfil them to maintain trust.
The nurse calls you back to the ward to consider premedication for your patient. She cooperated well with the play specialist but will not allow her name bands or topical anaesthetic cream to be put on. It has not been possible to obtain baseline observations. You are in agreement with her nurse, and return to speak to the parents about the premedication.
There are a number of options, but possible choices for oral premedication are:
◆ Midazolam 0.5 mg/kg, up to a maximum of 20 mg: quick onset of around 30 min and offset. It is important to note that benzodiazepines can cause paradoxical agitation in children with autistic spectrum disorder, in which case ketamine may be a better choice
◆ Clonidine 1–4 micrograms/kg: peak onset 60–90 min
◆ Combination of midazolam and clonidine, particularly if either alone has been unsuccessful previously
◆ Ketamine 5 mg/kg: quick onset, with longer duration than midazolam.
Children with attention deficit hyperactivity disorder (ADHD) may require larger doses of benzodiazepines, and the response may be paradoxical agitation. Ketamine may have an unpredictable effect, and the side effects of nausea and vomiting may be accentuated. Clonidine may be a more effective premedicant in this group of patients.
The patient is brought to the anaesthetic room with her parents approximately 30 min following premedication with midazolam. She is settled and looking a little drowsy but reading the book the play specialist had promised. As she had refused Emla® cream, the play specialist had shown her a face mask and practised blowing up balloons. You put a strawberry smell in the mask at her request, and proceed with a successful inhalational induction.
◆ Parents: being truthful and explaining where they are going, why, and what to expect. Patient information leaflets may be helpful
◆ Preoperative visit with the play specialist: ideally about a week beforehand. These visits are usually done in groups, and the child can meet other children undergoing a similar experience. However, visits can be performed on a one–to-one basis, if required, e.g. a very anxious child or one with special needs:
• Show slides
• Use puppets to illustrate ‘magic cream’ and face masks, and mimic the patient journey
• Tour of hospital
• Meet staff who will be looking after them.
On the same dental list is a 9-year-old boy also for dental extractions. He is ASA 2 with mild asthma and takes a salbutamol inhaler infrequently when playing sport. He has no known drug allergies. He had a previous general anaesthetic in another hospital for a grommet insertion 3 years ago. There is no family history of problems with anaesthesia.
He admits to being nervous when you go to see him on the day case unit. Mum tells you that he was very upset when he went off to sleep last time. He had an IV induction last time and does not want the needle again. He did not have any premedication on that occasion.
Explore his fears, and reassure him that he can go to sleep another way, by breathing some ‘sleepy wind’. Discuss the face mask, and offer a nice smell of his choosing to put inside the face mask. Explain that it is similar to using his inhaler with the spacer device, as he did when he was younger, and he can practise with the play specialist beforehand. He and his mum seem reassured, and they have no further questions.
They are seen by the play specialist and prepared for theatre. The nurse, play specialist, and yourself agree he appears more settled and decide against premedication.
However, on arrival in the anaesthetic room, he appears wary. You offer him a choice of smells for the mask and ask him if he would like to hold it himself. He places his hands over his face and refuses to use the mask. He becomes very upset and says, ‘I don’t want to do this’ and ‘you can’t make me’.
Explore his fears, and try to encourage him to proceed. The play specialist and yourself talk to him about the agreed plan, but he is adamant that he will not proceed and buries his face into the bed, crying. He is becoming more upset, with no progress within 10 minutes and mum is asking if you can hold him down.
Explain to mum that physical restraint is not appropriate. Give the patient and his mum the option of sending him back to the ward for premedication to calm him down so that hopefully he can be brought back later in the list to proceed with his cooperation.
Mum is keen to get the procedure done today and agrees to premedication. He is more settled after the premedication, and you perform a successful inhalational induction on the subsequent attempt.
Cancel the procedure, explaining to mum that it is not an emergency procedure and can be done at a later date. Arrange for this child to come on a preoperative visit prior to rescheduling. Document on his anaesthetic form that you recommend premedication on the next attempt at anaesthesia.
◆ More involved in their treatment
◆ Increased awareness and knowledge
◆ Can communicate their fears and discuss them
◆ May have specific requests, e.g. inhalational induction
◆ Require a more detailed explanation of events
◆ Communication is very important
◆ Distraction is less useful, as many want to know what is happening and why.
This is a very difficult situation. It is important to make a balanced decision, based on all risks, in this case, a delay in surgery versus an unprotected airway and a possible risk of aspiration. Ideally, these cases should be discussed with a consultant anaesthetist, as they can be particularly challenging to manage. As previously, honest descriptions of the intended sequence of events should be communicated to the child and their parents during the preoperative assessment. Potential options include:
◆ Proceed with attempts to cannulate the child with the parent’s consent and restraint: this would generally be considered an unsatisfactory option, as this may result in physical or psychological harm to the child
◆ Perform an inhalational induction in head-down and left lateral position: this is a challenging technique to deliver safely in the unfasted child, and it is likely to end in a suboptimal airway management during induction
◆ Send to the ward, and give oral anxiolysis, e.g. midazolam 0.5 mg/kg, and wait for 20 min; then prepare to deliver an IV RSI. The risks of the short delay to surgery are likely to be considerably offset by the benefits of a smoother induction with optimal and safe airway control.
Summary
Considerable skill is required in overcoming the fears of an anxious and uncooperative child in both the emergency and elective surgical situation. Engaging the child and parents in honest conversations about the anticipated course of events, along with support from play therapists, will overcome the vast majority of anxieties. In a small number of patients, oral premedication will be effective and facilitate either an IV or inhalational induction. It is vitally important to maintain trust with the child and parents, and, as such, physical restraint must never be used.
Cote CJ (2008). Round and round we go: sedation—what is it, who does it, and have we made things safer for children? Pediatric Anesthesia, 18, 3–8.
Krauss B and Green SM (2006). Procedural sedation and analgesia in children. Lancet, 367, 766–80.
POEMS for children. Available at: <http://www.poemsforchildren.co.uk>.
Sinha M, Christopher NC, Fenn R, and Reeves L (2006). Evaluation of nonpharmacologic methods of pain and anxiety management for laceration repair in the pediatric emergency department. Pediatrics, 117, 1162–8.
Sury MR and Smith JH (2008). Deep sedation and minimal anesthesia. Pediatric Anesthesia, 18, 18–24.