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SPA Newsletter.
Trends in the practice of parental presence during induction of anesthesia and the use of preoperative sedative premedication in the United States, 1995-2002: results of a follow-up national survey.Kain, Z.N. et al. Anesth Analg 2004; 98:1252-9. A postal survey was conducted in 2002 comparing current pediatric anesthesiology practice to the results from a similar postal survey in 1995, on the issue of sedative premedication (SP) and parental presence on induction (PPIA) use as treatment for pediatric preoperative anxiety. Five thousand questionnaires were mailed in May 2001 to randomly selected members of the American Society of Anesthesiologists (ASA). Excluded were retired physicians, physicians practicing anesthesia outside the United States, and trainees. The anonymous survey questionnaires from 1995 and 2002 differed in the latter omitting several questions regarding reasons for use of SP, and were otherwise identical. Three sections of a total of 37 questions were asked regarding actual practice on use of SP and PPIA, specifically 1) frequency and type of SP used, 2) opinions and practice regarding SP, PPIA, and parental presence in the postanesthesia care unit, and 3) demographics of the respondent. The frequency of SP and PPIA were then classified into six broad geographical areas in the United States. Nonresponders were sent additional surveys in September 2001 and February 2002. A final random selection of 200 of 5,000 anesthesiologists who had not responded by June 2002 were mailed a short anonymous questionnaire containing eight items from the initial survey in an attempt to assess nonresponse bias. The demographics of the two groups of respondents from 1995 and 2002 were similar in age, years in practice, sex, type of hospital, subspecialty training, and percent distribution of practice. Of the 5,000 questionnaires, 16 were discounted as nine had retired and seven had left no forwarding address. Of the remaining anesthesiologists, 1362 (27%) returned the questionnaire after three mailings. Seventy one percent of respondents had a community hospital-based practice in 2002 (76% in 1995), and 11% were university-based in 2002 (17% in 1995); sixty one percent of respondents had subspecialty training in 2002 (52% in 1995.) Concerning SP usage, respondents premedicated a larger proportion of children less than four years old in 2002 (50%) compared with 1995 (30 %), and administered SP mostly by the oral route (93% in 2002, percent unspecified for 1995). Midazolam was the primary SP in both 2002 (96%) and 1995 (percent unspecified), with other options being fentanyl and ketamine. There was significantly less geographical variability in SP usage in 2002 compared with 1995, but interestingly, SP was used least often in the Northeast in both 2002 and 1995 (approximately 20%). The median age below which SP was not given was 12 months. Anesthesiologists who administered SP were younger, practiced in geographical area with less HMO affiliation, were fewer years in practice, and had a higher component of pediatric patients in their practice. Fewer anesthesiologists in children hospitals never administered SP (1.9%) compared to freestanding surgery centers (25.3%). Concerning PPIA usage, there was a higher frequency of use by respondents in 2002 compared with 1995, the most noticeable increase occurring in the Northwest. Overall 10% of respondents used PPIA in 75% of cases, and 27% of respondents used PPIA in 25% of cases. However, while the number of respondents who never used PPIA decreased in every geographical region in the United States, 50% of all respondents still never use PPIA. PPIA was practiced most often in Northeast and least in South Central region. Concerning hospital policy on parental presence, 32% of respondents stated PPIA was allowed in their hospital, 26% indicated PPIA was forbidden, 23% indicated no formal hospital policy. Concerning use of an induction room, 92% of respondents never used an induction room, 5.8% used an induction room in 25% of the pediatric cases. In the nonresponse bias survey, nonresponders were found to not differ from responders in frequency of usage of SP or PPIA or type of SP. Comment: The discussion section contains an important summary of the overall work of the Kain group, since the landmark study comparing efficacy of SP and PPIA.1 Most anesthesiologists are clearly aware of the benefits of SP in regard to alleviating preoperative anxiety in children. Kain has reported that increased preoperative anxiety retards postoperative recovery process in children undergoing surgery.2 Use of SP and PPIA positively impacts outcomes such as reducing maladaptive behavioral changes after surgery and increasing parental satisfaction.3 The study appears to have several limitations. First although the demographics from both surveys are similar, the questionnaires were not sent to the same responders as in 1995. The authors address this first limitation and state this was necessary because of anonymity issues. Thus, the reader cannot directly compare to see if individual respondent's have modified their practice. Second, concerning nonresponse bias assessment, while demographics of nonresponders and responders were similar, no data was supplied on it, and we do not know how many nonresponders became responders. Third, the 5,000 questionnaires were not sent as a general postal survey to various hospitals and anesthesiology practice groups, but were sent to a subset of 5,000/35,000 members of the ASA. The authors make the assumption that the members of the ASA responding to the survey are representative of the anesthesiology community, and this might not be the case. Fourth, the distribution of responses to SP and PPIA were not broken down by type of respondent's practice (community or university), or by presence or absence of subspecialty training in the respondent. We are presented only with overall practice demographics. The authors only state that anesthesiologists who administered SP were younger, practiced in geographical area with less HMO affiliation, were fewer years in practice, and had a higher component of pediatric patients in their practice. Fewer anesthesiologists in children hospitals never administered SP (1.9%) compared to freestanding surgery centers (25.3%). Concerning PPIA, we are only advised that respondents who more frequently use PPIA have a larger percentage of pediatric patients and practice in a geographical area with smaller HMO practice. Overall, the data clearly show SP is in widespread use in pediatric patients among anesthesiologists in the United States, PPIA is on the increase but still not used by the majority of practitioners. The study did not address alternative methods to SP and PPIA such as distraction techniques (ex. magical illusions, interactive video headsets), and the reader is unable to determine if SP and PPIA practice patterns are at all affected by their use. References:
Reviewed by: Helen V. Lauro, MD Table of Contents
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