Author: Michael Vlessides
Anesthesiology News
For children undergoing surgery, a virtual parental presence may actually reduce anxiety more than a physical parental presence, preliminary findings show. These findings, the researchers said, may ultimately offer several benefits for both parents and OR personnel.
“The problem of preoperative anxiety is very familiar to those who do a lot of pediatric care,” said Clyde Matava, MD, an assistant professor of anesthesia and the director of eLearning and Technological Innovations at the University of Toronto. “Midazolam and other medications are well known to be very effective, but sometimes they’re not appropriate for patients. So we wanted to see if we have a parent available virtually, would that have any impact on the patient’s anxiety at induction of anesthesia?”
With that in mind, the study aimed to compare the role of virtual parental presence—using parents who had and had not been coached—with physical parental presence, again using parents who had and had not been coached. “There are still no robust data on whether coaching a parent actually improves the experience for both the child and the parent,” Dr. Matava said. “So we also wanted to modulate this in our study.”
The 36 children participating in the trial were randomly assigned into one of four groups: virtual parental presence with coaching, physical parental presence with coaching, virtual parental presence with no coaching, and physical parental presence with no coaching. The study’s primary end point was the change in modified Yale Preoperative Anxiety Scale (mYPAS) score. Secondary measures included parental and physician satisfaction of the virtual parental presence.
All mYPAS raters were trained to an inter-rater reliability of 0.94% against a published gold standard. Parental coaching was standardized using prerecorded videos. Children in the trial were between 4 and 12 years of age.
As Dr. Matava reported at the 2018 annual meeting of the Canadian Anesthesiologists’ Society (abstract 452872), virtual parental presence with coaching demonstrated an improvement in children’s mYPAS scores, from a mean of 28.5 at baseline to 25.5 afterward. By comparison, children with physical parental presence saw their mYPAS scores increase from 24.4 at induction to 32.5 afterward (P=0.03). Both virtual and physical parental presence with no coaching showed no improvement in mYPAS scores.
“So it seems as though virtual presence with coaching has a positive effect compared to the rest,” Dr. Matava explained.
“The mYPAS scores were obviously rated by an observer,” said Mark Ansermino, MBBCh, MMed, a professor of anesthesia at the University of British Columbia, in Vancouver. “How did you make sure that the observer was unbiased about the study?”
“We have a very strict training protocol where all our observers have to score an inter-rater reliability rating greater than 0 on the mYPAS,” Dr. Matava replied. “They each went through about 30 recorded videos that they had to score; it took about two weeks to train everyone.”
“Surely they would know what the intervention was,” Dr. Ansermino said.
“Absolutely,” Dr. Matava replied. “That’s why you train them, so it actually becomes more of an objective evaluation. You can’t randomize that portion of the study; that’s why you have to have a robust training protocol.”
Positive Secondary Outcomes
Of interest, parents reported high levels of satisfaction with both virtual and physical presence. Anesthesiologists and nurses offered positive reviews of the virtual program, as it did not lead to a high task load.
“This is a very interesting study,” said another audience member. “We’ve always found it difficult to show that there’s a benefit from parental presence. Have you looked into whether it’s the video distraction alone versus the parent on the screen? For example, have you done a similar arm with a video game or a movie on the iPad?”
“There is work from the U.K. showing that just the video distraction is great,” Dr. Matava replied. “However, some patients don’t like games, and it might not be as appropriate. And with the whole concept of family-centered care, this offers another avenue for parents to be there virtually but not physically in the room.”
Although these findings need to be borne out in the full trial, Dr. Matava noted that they can have larger clinical implications. “We may have fewer parents coming into the operating room,” he said, “which is certainly good for infection control, because as we know, parents often come without full scrubs, which can have some associated effect on infection.”
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