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Point: A Child Life Specialist's Position on the Use of Midazolam (Versed) in Pre-Operative Settings

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


Mia Bustamante, MS, CCLS
Children's Hospital of Pittsburgh of UPMC
 
When I began my career as a Certified Child Life Specialist three years ago, I couldn’t imagine myself advocating for midazolam (Versed). It was counterintuitive. As an eager specialist, ready to take on any challenge, I believed play, preparation, and individualizing care were the solutions to the hospital stressors that a child may experience. Recently, I found myself with atypically developing 7-year-old, Austin*, who first caught my attention in pre-op when I heard him crying from the hallway. Despite my best attempts at introducing play, humor, and reassuring his safety, Austin withdrew from me, clung to his mom, and covered his head with his blanket. I gave him breaks, telling him I’d return. After I worked with him for 45 minutes, cognizant of his developmental need to master his pre-op experience, he began engaging with me, and I observed a calmer, more comfortable demeanor. But, on one of the breaks when I left the room, I found myself saying to his anesthesia resident, “I’ve done my best, but he definitely will need Versed before induction.” Those words tasted as bitter on my tongue as the pink “silly-juice” would taste on his, but I assessed that this was the best possible option for Austin. We only had 20 more minutes before he would be taken to the OR, and with a 70-patient schedule, this deadline was firm. What changed my assessment and decision making in these past two years?
Versed is an anti-anxiety medication with sedative properties that is commonly administered orally, nasally, or intravenously (Wright,Stewart, Finley, & Buffett-Jerrott,2007). It is fast acting, commonly producing maximum effects within 20 minutes. My initial grievance with Versed two years ago was that it promoted an anti-child life mentality. Research indicates that a Certified Child Life Specialist’s assessment and intervention can reduce the amount of sedative medication required for procedures (Scott et al., 2016). Managing the stressors a child experiences in the hospital was my job, and medical staff wanted me to reduce sedation,so why would unnecessary medication be provided to a patient if I was there to help? Well, yes, managing stressors is my job, but reducing sedation is not. Less use of sedation is certainly a positive outcome of a child life specialist’s hard work, but it is not a child life specialist’s core focus—and this as a critical lesson for me to learn.Versed is not the antagonist to child life interventions. Paraphrasing one anesthesiologist that I often work closely with, “We need child life specialists just as much as we need Versed. Each patient is different. Some patients only need alternative focus while transitioning to the OR and they do just fine, but we never want to traumatize a patient in the OR. Sometimes we need Versed. ”Facilities that have not systemized a culture of parental presence for induction (PPI) may also benefit from the anti-anxiety and amnestic properties of Versed during parent-child separation.


Managing the stressors a child experiences in the hospital was my job, and medical staff wanted me to reduce sedation, so why would unnecessary medication be provided to a patient I was there to help?



Midazolam


According to Kain, Wang, Mayes, Caramico, and Hofstadter (1999), children who experience high levels of anxiety during anesthesia induction may also experience negative behavioral changes postoperatively including nightmares, aggression, and separation anxiety. Therefore, when needed, child life specialists can adapt their interventions to the effects of Versed. We can educate patients on the experience of taking Versed and give realistic choices for how it is administered. Additionally, patients who have difficulty taking oral medication can gain mastery through that experience. Whenever possible, I purposefully seek out patients in the recovery room that received Versed pre-operatively in order to debrief with them. This allows the patient to communicate their experience, assign meaning to it, and create a coping plan for future encounters.

Versed is considered to be a non-invasive and safe pre-procedural medication. Papineni, Lourenco-Matharu, and Ashley(2014) performed a literature review to assess the side effects of oral Versed and categorized the results as significant (life-threatening adverse reactions) and minor (non-life-threatening) side effects. Their evaluations yielded no significant side effects throughout throughout 27 documented trials; the researchers identified nausea and vomiting among 6% of randomized control trials and paradoxical reaction in 3.8% of patients in non-randomized studies (Papineni, Lourenco-Matharu, & Ashley, 2014). Research by Bauer, Dom, Ramirez, and O’Flaherty (2004) observed fewer post-operative instances of patients who received Versed pre-operatively experiencing nausea and vomiting compared to a control group. 
Kainet al. (2000) posit that pre-operativeVersed corresponds withadditional post-operative benefits,including reduced post-operativepain throughout the initialpost-operative week and decreasedlevels of anxiety within the initialpost-operative month. Using these research findings to frame my own child life experiences in pre-op, I feel a deeper understanding for the medical team’s use of Versed.

Instead of perceiving Versed as anti-child life, I have come to view its use as an opportunity to collaborate with our medical staff. Collaboration with patients, families, and medical staff is a standard of clinical practice for child life specialists (Child Life Council, 2001) and is crucial to creating individualized plans of care. In my story of Austin, I would have loved to continue working with him to scaffold his sense of industry, but we were experiencing limitations that are common in the hospital environment. Austin was very slow to warm up, and we did not have the time that would allow him to become comfortable in the environment. Through collaboration with Austin, his mother, and the medical team, we were able to create the best possible outcome for Austin’s outpatient experience.

I have found that engaging in multidisciplinary collaboration creates a positive impression with caregivers. When a child receives child life interventions in conjunction with Versed, a perception is created for the parent that the team is doing everything possible to make their child comfortable. If medical personnel offer a pre-medication to reduce pre-operative stress for a very nervous child, a caregiver is likely to view this as beneficial. This could furthermore reduce caregiver stress pre-operatively and could have post-operative benefits. Kain, Mayes, Caldwell-Andrews, Karas, and McClain (2006) discovered that parents of a low-anxiety pre-operative group later rated their child’s post-operative pain as significantly lower than a high-anxiety group. From this research, we can deduce that reducing state anxiety in a pre-operative setting holds significant post-operative importance.



I have found that engaging in multidisciplinary collaboration creates a positive impression with caregivers. When a child receives child life interventions in conjunction with Versed, a perception is created for the parent that the team is doing everything possible to make their child comfortable.

 Although a multidisciplinary approach is best practice and we dutifully advocate for child life involvement, our presence may not always be possible. In these instances, I have observed that Versed is medical staff’s primary option to attend to the emotional state of an anxious child. Despite its contraindications, the use of Versed does not undermine the benefits of pre-procedural interventions from child life specialists. Each day, I advocate for my services and focus on how I can reduce each patient’s fears. I still strive for my patients to use other tools besides Versed, but I have found an understanding and respect for medical pre-operative intervention. When Versed is given, I acknowledge the unintentional strengths that result from the medical interventions and I adapt my approach and consider even more variables in my assessment to best serve each patient.

REFERENCES

Bauer, K. P., Dom, P. M., Ramirez, A. M., & O’Flaherty, J. E. (2004). Preoperative intravenous midazolam: Benefits beyond anxiolysis. Journal of Clinical Anesthesia, 16(3), 177-183. doi: https://doi. org/10.1016/j.jclinane.2003.07.003

Child Life Council. (2001). Standards of clinical practice. Official Documents of the Child Life Council (pp. 9-11). Rockville, MD: Author.

Kain, Z. N., Mayes, L. C., Caldwell-Andrews, A. A., Karas, D. E., & McClain, B. C. (2006). Preoperative anxiety, postoperative pain, and behavioral recovery in young children undergoing surgery. Pediatrics, 118(2), 651-658. doi: 10.1542/peds.2005-2920

Kain, Z. N., Sevarino, F., Pincus, S., Alexander, G. M., Wang, S. M., Ayoub, C., & Kosarussavadi, B. (2000). Attenuation of the preoperative stress response with midazolam: Effects on postoperative outcomes. Anesthesiology, 93(7), 141- 147.

Kain, Z. N., Wang, S. M., Mayes, L. C., Caramico, L. A., & Hofstadter, M. B. (1999). Distress during the induction of anesthesia and postoperative behavioral outcomes. Anesthesia & Analgesia, 88(5), 1042- 1047.

Papineni, A., Lourenco-Matharu, L., & Ashley, P. F. (2014). Safety of oral midazolam sedation use in paediatric dentistry: A review. International Journal of Paediatric Dentistry, 24(1), 2-13. doi: 10.111/ ipd.12017

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. doi: https://doi. org/10.1016/j.ijrobp.2016.06.001

Wright, K. D., Stewart, S. H., Finley, G. A., Buffett-Jerrott, S. E. (2007). Prevention and intervention strategies to alleviate preoperative anxiety in children: A critical review. Behavior Modification, 31(1), 52- 79. doi: 10.1177/0145445506295055

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