PEDIATRIC UROLOGY

Preoperative Anxiety, Postoperative Pain, and Behavioral Recovery in Young Children Undergoing Surgery
Kain ZN, Mayes LC, Caldwell-Andrews AA, Karas DE, McClain BC
Center for the Advancement of Perioperative Health, Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, USA
Pediatrics. 2006; 118: 651-8

• Objective: Findings from published studies suggest that the postoperative recovery process is more painful, slower, and more complicated in adult patients who had high levels of preoperative anxiety. To date, no similar investigation has ever been conducted in young children.
• Methods: We recruited 241 children aged 5 to 12 years scheduled to undergo elective outpatient tonsillectomy and adenoidectomy. Before surgery, we assessed child and parental situational anxiety and temperament. After surgery, all subjects were admitted to a research unit in which postoperative pain and analgesic consumption were assessed every 3 hours. After 24 hours in the hospital, children were discharged and followed up at home for the next 14 days. Pain management at home was standardized.
• Results: Parental assessment of pain in their child showed that anxious children experienced significantly more pain both during the hospital stay and over the first 3 days at home. During home recovery, anxious children also consumed, on average, significantly more codeine and acetaminophen compared with the children who were not anxious. Anxious children also had a higher incidence of emergence delirium compared with the children who were not anxious (9.7% vs 1.5%) and had a higher incidence of postoperative anxiety and sleep problems.
• Conclusions: Preoperative anxiety in young children undergoing surgery is associated with a more painful postoperative recovery and a higher incidence of sleep and other problems.
  
  
• Editorial Comment
  The authors studied the relationship between preoperative anxiety and recovery in a large series of children undergoing tonsillectomy and adenoidectomy. They show clearly that higher levels of preoperative anxiety are associated with increased postoperative morbidity, including more pain, use of more pain medication and less sleep. The differences between the more anxious and less anxious group resolved in about 3 days.
  This study is unique in that it is the only study of its kind in children. Its message is important to those of us doing surgery on children. Based on these results, it suggests the hypothesis that reducing preoperative anxiety will lead to better outcomes in the immediate postoperative period. Hence, better preoperative preparation may yield better outcomes.
  Although this result is something most pediatric urologists would support intuitively, there are some issues with the study. First, all patients had a preoperative visit to the hospital. This is not usually done for minor surgical procedures. Would this have lessened or heightened the anxiety? More important, the study design prohibited the use of preoperative sedation or parents entering the operating room with the child (except in extreme cases). Though good for the study design, this is not typical in the real world. Nearly all our patients get preoperative sedation. Would the high anxiety patients have done better if they had the benefit of preoperative sedation with an amnesic? One would guess so. Further, for purposes of the study, all patients were admitted for 24 hours postoperatively. This is not typical of the procedure that was done and might also have increased the anxiety in those patients with high anxiety to start with.
  Overall, the study is fascinating and tends to agree with common perception. However, more work needs to be done to evaluate whether education and/or pharmacological interventions, which are commonly accepted as standard of care, are truly successful in improving the postoperative course of children undergoing surgery and/or whether selected populations of those most anxious would benefit even more than others.

Dr. Barry A. Kogan
Chief and Professor of Urology and Pediatrics
Albany Medical College
Albany, New York, USA