A significant number of young children undergoing general anesthesia experience high levels of preoperative anxiety caused by separation from parents, exposure to an unfamiliar environment, or fear of the surgical procedure. Because preoperative anxiety can complicate the induction of anesthesia and develop negative postoperative behavior [1,2], pediatric anesthesiologists generally use a variety of interventions to reduce preoperative anxiety in children. Surveys conducted in different countries have documented the frequencies of and the reasons for anxiolytic interventions in pediatric patients [3-7]. However, no such study has been previously conducted in Korea. In addition, practices have changed over decades due to the introductions of short-acting anesthetics with fewer side effects, advances in distraction technology, and the increasing trend toward parental presence during induction of anesthesia (PPIA).

The aims of this study were to document current practice and general opinions regarding pharmacological and non-pharmacological interventions for alleviating preoperative anxiety in children about to undergo general anesthesia in Korea.

An approval was obtained from our hospital Institutional Review Board for this study. After obtaining permission from the Korean Society of Pediatric Anesthesiologists (KSPA), we conducted a survey of current clinical practice, preferences, and general opinions regarding perioperative anxiety reduction in Korean children from November 2014 to January 2015. The questionnaire with an explanation of this survey and its significance was emailed to all members (n = 158) of the KSPA in November and a reminder email was sent in December 2014 by the KSPA to ensure personal privacy. Completion of the questionnaire by the participants was conducted on a voluntary, anonymous basis.

The survey (Appendix 1) consisted of 1 open and 23 closed questions in four sections (Table 1), which addressed; 1) respondent demographics, 2) preferences and guidelines for anxiolytic intervention prior to pediatric anesthesia, 3) general opinions and practices of pharmacological intervention for anxiety reduction, and 4) general opinions and practices of non-pharmacological intervention for anxiety reduction.

Statistical analysis was performed using SPSS version 21.0 (IBM Corporation, New York, NY, USA). Descriptive variables are reported as means ± SDs or as medians and ranges. For categorical variables, both single and multiple response questions are reported as numbers (%) of all responses. The respondent demographics were analyzed using the one sample t-test and the chi-square test or Fischer’s exact test. Statistical significance was accepted for P values < 0.05.

This small-scale survey offers insights of current practice and the general opinions of pediatric anesthesiologists regarding preoperative anxiolytic interventions in children undergoing surgery in Korea. We found that the strategies used to reduce child anxiety were determined by an informally standardized hospital protocol or individual experience rather than a written policy. In contrast, 72% of US hospitals have a formal policy for premedication [3]. Without current best evidence, preoperative anxiolytic intervention based on hospital protocol may become dated, to the detriment of patients. In our opinion, decision making should be guided by formal policy integrated with individual clinical expertise and best available scientific evidence to ensure children are provided with the most effective and safe anxiolytic intervention.

Although many non-pharmacological interventions have been reported to be as effective as sedative premedication [8], respondents who wanted effective anxiolysis preferred pharmacological intervention, while those who wanted safe anxiolysis preferred non-pharmacological intervention. Our finding implies that anxiolytic intervention preference of pediatric anesthesiologists was usually determined by customarily established protocol or habitual choice rather than scientific research. And it also explains why actually used interventions did not consistently match with preferred interventions. The two most important purposes of premedication are to reduce anxiety and sympathetic activity during induction of anesthesia. In Korea, the sedative premedication rate for pediatric anesthesia (54.7%), as determined by the present study, is similar to those reported in Turkey, Germany, and the United States [5,9,10], but is much higher than reported in the United Kingdom for day-case surgery (19%) [7]. Although numerous drugs have been used in clinical practice, midazolam is currently the mainstay of sedative premedication for pediatric anesthesia. Its long history of safety, effectiveness, and minimal delay to discharge from post-anesthesia care unit well explain its global use in clinical practice. Because oral or intranasal midazolam, commonly used as a premedication in Europe and the US [5,9], is not currently available in Korea, respondents mostly administered midazolam intravenously in the preoperative holding area.

The routine use of anticholinergic agents prior to anesthesia and surgery now shows a declining tread, because of its adverse effects, such as, an uncomfortable dryness of mouth, and the introduction of less irritating anesthetics [11,12]. In the present study, respondents premedicated anticholinergic agents (glycopyrrolate and less frequently atropine) based on clinical requirements rather than routine use and principally administered via an intravenous route immediately before anesthesia, which is similar to European and Australian practice [5,12,13].

Respiratory depression was the most commonly experienced side effect of premedication, and was the main reason for avoiding sedative premedication in children and for administering premedication in preoperative holding areas equipped with sufficient resources to monitor and manage side effects rather than in ward. We presume that fear for respiratory depression (the most serious side effect of premedication) caused the majority of respondents to forbid the premedication of children less than 1 year old.

Nearly half of the respondents preferred non-pharmacological intervention, which was also the most commonly used type of intervention in clinical practice. PPIA was the most frequently employed non-pharmacological intervention by respondents. Although the large Cochrane review conducted by Yip et al. [8] concluded that PPIA did not reduce preoperative anxiety or improve cooperation during induction of anesthesia, the majority of our respondents believed PPIA is the most effective non-pharmacological anxiolytic intervention. In our survey, 78.0% of respondents agree with PPIA and 19.5% allowed routine PPIA. On the other hand, 50% of American anesthesiologists forbade PPIA [9], and most anesthesiologists in the UK and Canada allowed PPIA [14-16]. Discrepancies between countries may be due to the use of different induction techniques, legal implications, and economic issues, such as, operating room efficiency.

This study has several limitations that bear consideration. First, the response rate was only 26%, and thus, we cannot claim our survey accurately reflects anxiolytic practices used by Korean anesthesiologists in pediatric patients. Accordingly, we suggest a larger-scale study be initiated to confirm and supplement our findings in all anesthesiologists currently worked in Korea. Second, we did not investigate the use of anxiolytic intervention by patient age or hospital stay after surgery, which could significantly affect decision making.

Summarizing, pediatric anesthesiologists in Korea use both pharmacological and non-pharmacological interventions based on informally standardized hospital protocols to reduce child anxiety prior to surgery. Those requiring the effective reduction of anxiety were found to prefer pharmacological intervention and to favor the use intravenous midazolam, whereas those wanting safe reduction of anxiety preferred non-pharmacological intervention and most frequently used parental presence during induction the anesthesia.