BRUTANE Staff restrain a child so they can force the mask over her face, a distressing practice known as brutane (brute force + sevoflurane).

Pediatric induction can be one of the most stressful moments for a child undergoing surgery. Fifty percent of children experience anxiety at induction of anesthesia, according to one study (osmag.net/wrwnj2). Crying, kicking, hitting, and other forms of physical and verbal resistance to the noxious gases often necessitate the need to restrain the child so you can force the mask on his face, euphemistically referred to as brutane (brute force + sevoflurane).

Predictors for "noncompliant children" include younger age and shy temperament, but any child can throw a tantrum once you place the anesthesia mask. No amount of bubblegum flavoring can disguise the scent of sevoflurane and there aren't enough princess stickers, sing-along songs or videos to distract an inconsolable child. That's not to say all children react in this manner, but induction upsets many.

Lingering effects
This distress can last far beyond the minutes it takes for the gases to take effect. When a child suffers anxiety at induction, he often develops a greater degree of emergence delirium. In PACU, he often exhibits crying fits and increased levels of pain. And it doesn't end there. Post-discharge, parents report such behaviors as regression, bedwetting, nightmares, separation anxiety, temper tantrums and distrust of medical personnel. These may last weeks or months, with some on rare occasions extending up to a year.

Parents also feel the stress of induction. Contrary to popular belief, parental presence in the OR doesn't necessarily alleviate the child's or the parents' anxiety. When parents exhibit clinically significant signs of distress, those feelings can transfer from parent to child. Mom or dad sit on the sidelines, ever watchful yet helpless as the child struggles against the anesthesia mask and well-meaning OR staff. The parent is told repeatedly the crying is "normal," the process, "standard." But does standard have to be accepted?

CHILD'S PLAY
CRNA Develops Maskless Induction Device

UNMASKED The PeDIA is a maskless induction device designed to make children ages 3 and up think they're playing with a balloon while they induce themselves. It's currently under FDA review.

Of all the stresses kids have to endure while awaiting surgery, mask placement may be at the top of the list. The unpleasant smell and tight seal often cause children to panic and resist. To turn a child's panic into play, a nurse anesthetist has invented a maskless induction device that's currently under FDA review. The Pediatric Device for Induction of Anesthesia (PeDIA), a balloon-shaped device that looks like an old-time hot-water bottle, lets children ages 3 and up induce themselves, says PeDIA's inventor, Diane Manzella Miller, MHS, CRNA, of Fairfax, Va. "It makes induction fun and engaging," she says.

With PeDIA (PeDIALLC.com), kids are encouraged to sit up, choose their favorite color "balloon" and participate in their own induction. For the provider, PeDIA doesn't manipulate the anesthesia circuit, nor the flow of gases, says Ms. Miller, who notes that the inspiratory and expiratory limbs remain effectively separated to avoid mixing inspired and expired gases. You attach PeDIA to the elbow of the circuit and fill it with nitrous-oxygen. Then, as the patient inhales and exhales the admixture through the device — the mouthpiece at the top is also a siren whistle, so the child hears a fun sound while inhaling and exhaling — you dial in the sevoflurane. "Once the child is too sleepy to continue, you can easily revert to a mask induction, with no anxiety or resistance," says Ms. Miller.

— Jim Burger

Stress reduction
To alleviate the anxiety, we've tried pharmacological modalities with mixed success. At one time, Versed (midazolam) was touted as the magic bullet. But the bullet missed the mark. In some children, oral midazolam causes a paradoxical effect. Instead of sedation, it causes agitation, aggression, restlessness and self-injury, making a bad situation worse. The child's cooperation is imperative; an anxious child may refuse to drink it. Plus, in these days of fast turnovers, pre-op oral sedation may delay emergence from anesthesia and discharge.

On the other end of the spectrum, some nonpharmacological approaches have been shown to reduce perioperative stress. Educational pamphlets, pre-op visits, play therapy, music therapy and even doctors dressed as clowns have been shown to attenuate anxiety. Handheld devices provide a wonderful distraction, but once a child crosses the threshold into the austere and sterile world of the operating room, devices drop and anxiety rises. Once the child realizes the "pilot's mask" doesn't smell like bubblegum, playtime is over. Or is it?

Why not continue the play in the OR? Why not dedicate specific rooms for pediatrics? Have cartoon characters on the wall. Bright colors. Familiar music in the background. Once the child and parent enter the OR, turn your full attention to them: no counting of instruments and OR-talk. The child is the most important person in the room. Treat him with respect and dignity. Maintain eye contact. Speak to him. Give him choices whenever possible. Ask, "Would you like to sit up on the table or on Mom's (or Dad's) lap?" "Which finger do you want the finger-sticker on?" "Do you want to hold the mask?"

Then prepare for induction. Once the anesthesia circuit is primed with nitrous, let the child assist you. Have him hold the mask with you. If he resists the mask, gently hold his hands at his side and sing a song as the anesthetic is dialed in. You could also try an anesthesia induction device. A number of mask-based distraction devices have been created over the years, including a maskless device I've developed (see "CRNA Develops Maskless Induction Device" above).

Are you kid-friendly?
Pediatric induction has remained unchanged for decades. Just lay the child on the OR table, place the anesthesia mask over his nose and mouth, turn on the oxygen-gas admixture, then watch as he gently drifts off to sleep. Sounds simple, but as we know, it can be downright scary for kids and their parents. With the push for greater consumer satisfaction in health care, strive to make your facility kid-friendly. OSM