Anxiety about anesthesia

WASHINGTON

The anesthesiologist lowers a drug-filled mask over the terrified child's face, holding it in place until the youngster goes limp and the screaming stops.

Often, that's how children are put to sleep for surgery, and it infuriates Dr. Zeev Kain. His research shows that children who cry as they're being put under anesthesia suffer nightmares and even heal more slowly than calm youngsters.

Yet too few hospitals routinely offer simple measures -- like a cherry-flavored sedative before the scary anesthesia mask or a mom hugging her child in the operating room as he falls unconscious -- that can ease tots' fears.

Armed with $3 million from the National Institutes of Health, Kain is out to get the final proof that easing children's anxiety helps their health, research that may change how hospitals prepare their smallest patients for surgery.

"We have a policy in this hospital in which the operating room is a no-crying zone," says Kain, anesthesiologist at Yale-New Haven Hospital and professor of child psychiatry at Yale University School of Medicine.

To minimize children's pain, doctors today induce anesthesia with gas instead of the needle parents may remember getting.

It should be simple: breathe through a mask for a few minutes and drift off.

But up to 65 percent of children experience high anxiety before an operation, especially those under 4 who can't understand what's happening. Much of the anxiety occurs when children are taken from their parents into a noisy operating room to undergo the anesthesia. The gas smells bad and the mask over their nose and mouth is frightening, and young children almost invariably cry and struggle to get away.

There are ways to ease the anxiety. A liquid sedative called Versed leaves youngsters drunkenly relaxed and causes temporary amnesia, so those who still cry don't remember it. It's very safe, but doctors must remember to give it 20 minutes before it's time for the anesthesia.

"It's just so nice not only for the kids ... but it makes the parents feel so much better," says Dr. Carolyn Bannister of Egleston Children's Hospital in Atlanta, which gives Versed to all toddlers and any older child who's anxious -- and rubs the anesthesia mask with bubble-gum-flavored lip balm to disguise the noxious odor.

Help from parentsSome hospitals let parents in the operating room to distract their child, perhaps by singing or playing with a balloon while they're being put under. But parents can't show nervousness or be critical -- Kain recalls one dad making a 3-year-old wail even louder when he said only babies cry. For older children, get-acquainted hospital tours to learn what will happen may help.

No medical guidelines require such steps. Kain says 30 percent of hospitals ban parents from operating rooms. And, he says there is wide geographic disparity in how many routinely offer Versed -- from a mere 5 percent of hospitals in some areas to 45 percent in others.

In fact, some anesthesiologists say crying under the mask is good because kids inhale the gas faster.

"Let them cry under a mask," retorts Kain, who laments that up to 15 percent of children must be physically restrained until the gas takes effect. "The anesthesiologist isn't at home with the parents to see the child with nightmares because of their experience."

Nightmares reportedKain says about 40 percent of children undergoing outpatient surgery developed nightmares, separation anxiety or temper tantrums for weeks afterward. The more traumatic the anesthesia experience, the more behavior changes. About 75 percent of kids who screamed and had to be held down under the mask had nightmares.

Studies in Europe found similar results.

More significantly, Kain discovered that children who were calm before having their tonsils removed needed much less pain medication and returned to school sooner than upset kids.

"Physicians have to be aware of the fact that this preoperative anxiety does have an effect," says Dr. Lynne Haverkos of the NIH -- which just awarded Kain $3 million to study 500 children in hopes of settling just how big a problem that anxiety is and whether Versed or other calming methods work best at easing it.

Many doctors aren't aware there is a problem, says Bannister, who heads an American Society of Anesthesiologists committee monitoring Kain's work. Still, even those who don't routinely offer Versed seldom refuse it, she says -- "but the parent has to know to ask."