Strategies to Relax Patients During Anesthetic Induction
Pre-operative anxiety, the psychological distress which patients experience that is provoked by concerns related to their surgical and anesthetic care,1 is estimated to affect up to 75% of children2 and 80% of adult patients.3,4 It has been linked to multiple intra-operative and post-operative complications (e.g., greater volatile anesthetic requirement, increased morbidity and mortality rates, and greater pain somatization and post-operative analgesic requirements).5 Clinicians should be aware of different strategies to relax patients during anesthetic induction to improve the patient’s experience and reduce the risk of adverse events.
In recent years, greater emphasis has been placed on identifying strategies to relax patients who are anxious before their procedure – particularly, during anesthetic induction, given the hemodynamic lability of many induction agents, which can be further compilated by the hemodynamic lability from endogenous surges of catecholamines from the patient’s endogenous stress response.6 Various approaches to relaxing patients during induction have been developed and can be largely grouped based off intended population (i.e., children versus adults) or method (i.e., pharmacologic versus non-pharmacologic).
Pharmacologic methods for facilitating relaxation among pediatric populations predominantly rely upon anxiolytics. The major three anxiolytics are midazolam, ketamine, and dexmedetomidine.7 Anxiolytics are particularly useful for pediatric patients who have developed separation anxiety (i.e., >6-8 months of age).7 Midazolam is most frequently used due to its quick onset as well as anterograde and retrograde amnestic properties. However, it is important to recognize that at higher doses, there is increased risk of paradoxical reactions.8
Non-pharmacologic strategies to relax pediatric patients include parental presence at induction of anesthesia (PPIA). With this method, parents are present at induction, with the intention of providing a sense of familiarity and a reliable, calming presence to the anxious child. In one study, children in the PPIA group were found to have lower preoperative anxiety scores at induction than the control group (P = 0.05).9 Immersive technologies are also emerging as useful methods for attenuating pre-operative anxiety in pediatric populations.10 Bedside Entertainment and Relaxation Theater (also known as “BERT”) has been shown to reduce fear (P = 0.009) and anxiety (P = 0.0015) among pediatric, pre-operative populations.11
Pharmacologic methods to relax adult patients during anesthetic induction also include benzodiazepines, such as midazolam. In a double-blind, randomized, placebo-controlled trial, 5 mg of imtramuscular midazolam demonstrated a greater reduction in postoperative anxiety than in the placebo, control group (P = 0.04).12 However, recent studies are questioning the clinical significance of the use of midazolam, largely due to mixed data surrounding its efficacy in assuaging pre-operative anxiety in adult patients versus only providing enhanced sedation which may be misconstrued as a reduction in anxiety.12,13
Non-pharmacologic methods for adults include easing anxiety through interpersonal interactions. Communicating calmness with eye contact, touch, and quiet talk are frequently employed.14 Additionally, providing ongoing education – for example, informing patients of the steps of induction (e.g., mask placement to help them breathe) and how they may feel as various induction medications are administered (e.g., burning or sleepiness with propofol) – is posited as a simple, but useful method to assuage anxiety.14
While these separations based on intended age group and method of relaxation may serve as helpful heuristics when initially approaching pre-operative anxiety, it is imperative that clinicians use their best clinical judgement in these situations. Some adults may benefit from PPIA, and some children may benefit from education. A multimodal and flexible approach may be the best way to relax patients pre-operatively and during anesthesia induction.
References
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11. Richey AE, Khoury M, Segovia NA, et al. Use of Bedside Entertainment and Relaxation Theater (BERT) to Reduce Fear and Anxiety Associated With Outpatient Procedures in Pediatric Orthopaedics. J Pediatr Orthop. 2022;42(1):30-34. doi:10.1097/BPO.0000000000002005
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