Counterpoint: The Use of Non-Pharmacological Techniques to Support Children with Preoperative Anxiety

ACLP Bulletin | Fall 2018 | VOL. 36 NO. 4

Alanna Kanawalsky, MS, CCLS
Children's Hospital of Pittsburgh of UPMC
"I can’t remember!!” Those were the words echoing down the hall as I approached a bed space in the second phase of our recovery area in same day surgery. Moments earlier, I had received a consult from one of our recovery room nurses for a 10-year-old boy, Drew*,who was so upset that I could hear his crying and screaming through the phone. “I really think he could use your help,” the nurse pleaded over the phone. I approached Drew with a bag of toys in hand and took a quick assessment of the room. The lights were dim, Drew was sitting on the bed, the TV was on, and his mother was at bedside trying her best to comfort her child. My focus immediately turned toward the child who was crying inconsolably. I crouched down on the floor next to his bed to get on his level, introduced myself, and acknowledged and validated his emotions at that moment. Drew was extremely upset because he was unable to recall his experience of breathing into the anesthesia mask in the procedure room due to the amnestic property of midazolam (Versed). He continued to perseverate on having selected a Chapstick scent for his mask but not being able to smell it. I offered the opportunity for post-procedural follow up to provide him with a glimpse of his lost experience. 

At that moment, I took note of the developmental considerations that were influencing the situation. Drew, a typically developing school-age child, was unable to gain mastery or a sense of competence related to his medical experience. He was unable to demonstrate a learned skill or be involved in his care due to his inability to recall the experience due to the amnesic properties that are a side effect of Versed. I wondered: How many other patients like Drew felt the same way when it came to their surgery experience?

Any medical experience can lead to significant emotional distress and anxiety for pediatric patients. Current interventions to reduce patient anxiety include a premedication or age appropriate teaching and preparation provided by a Certified Child Life Specialist in many facilities (Chow, Lieshout, Schmidt, Dobson, & Buckley, 2015). In our same day surgery center, the medical team takes into consideration the patient’s developmental level,temperament, and prior medical experiences to determine if a premedication is necessary. The use of a premedication such as Versed can cause sleepiness, muscle relaxation,short-term memory loss, and reduce anxiety (Wenzel, Bartel, Eggebrecht, Philipp, & Erbel, 2002). 

He was unable to demonstrate a learned skill or be involved in his care due to his inability to recall the experience due to the amnesic properties that are a side effect of Versed.

Doctor and Family
Wenzel et al. (2002) observed some limitations and undesirable side effects that can occur with the use of Versed, including severe aggressive behavior, intense euphoria, severe depression, and severe hiccups. In research conducted by Viitanen, Annila, Viitanen, &Tarkkila (1999), Versed delayed the recovery in small children by up to 30 minutes, consequently delaying discharge. However, the use of Versed did not alter the quality of recovery (Viitanen et al., 1999). Alternatives to pharmacological interventions can also be used to help reduce preoperative anxiety in pediatric patients. These interventions include, but are not limited to,psychological preparation, the use of storybooks and age appropriate reading materials, preoperative tours, and audiovisuals, all of which can be provided by a child life specialist. 
The department of radiation oncology at University of Miami Sylvester Comprehensive Cancer Center and Jackson Memorial Hospital completed a study about reducing anesthesia use for their pediatric radiation patients with the use of interventions provided by a Certified Child Life Specialist and found that when a child life specialist provided therapeutic play and education, the hospital could reduce the rate of anesthesia use by 16% in patients 3 to 12 years of age (Scott et al.,2016). In turn, the hospital saw a cost reduction as one of the benefits of reducing anesthesia use. Chow and colleagues (2015), who conducted a comprehensive systematic review for reducing preoperative anxiety with the use of audiovisual techniques, found non-pharmacological methods to be cost effective, requiring minimal time and healthcare resources. They also concluded that non-pharmacological interventions were as effective as pharmacological treatments. 

There is strong support that identifies significant benefits to the use of non-pharmacological techniques in reducing the anxiety in pediatric patients prior to a stressful medical experience. A child life specialist working in a same day surgery center routinely provides developmentally appropriate education and preparation, often through the use of medical play to introduce the anesthesia mask to patients in a non-threatening way. In some facilities parental presence is also available as a standard of care, and this offers invaluable support to the patient during a stressful time. In the case of Drew, and many other patients who receive Versed, perhaps we are not allowing them to fully engage in their healthcare experience. The role of a child life specialist is to provide education, facilitate coping, and encourage mastery of the medical environment. Versed only masks the environment and anxiety, but does not teach or encourage a child to cope.

*name changed to protect patient confidentiality


Chow, C. H., Lieshout, R. J., Schmidt, L. A., Dobson, K. G., & Buckley, N. (2015). Systematic review: Audiovisual interventions for reducing preoperative anxiety in children undergoing elective surgery. Journal of Pediatric Psychology, 41(2), 182-203.

Scott, M. T., Todd, K. E., Oakley, H., Bradley, J. A., Rotondo, R. L., Morris, C. G., Klein, S., Mendenhall, N. P. & Indelicato, D. J. (2016). Reducing anesthesia and health care cost through utilization of child life specialists in pediatric radiation oncology. International Journal of Radiation Oncology Biology Physics, 96(2), 401-405.

Viitanen, H., Annila, P., Viitanen, M. & Tarkkila, P. (1999). Premedication with midazolam delays recovery after ambulatory sevoflurane anesthesia in children. Anesthesia & Analgesia, 89, 75-79. 

Wenzel, R. Bartel, T., Eggebrecht, H., Philipp, T. & Erbel, R. (2002). Central-nervous side effects of midazolam during transesophageal echocardiography. Journal of the American Society of Echocardiography, 15(10), 1297-1300