KORESPONDENCE / CORRESPONDENCE Premedication in children: what if it fails? 54 | ANESTEZIOLOGIE A INTENZIVNÍ MEDICÍNA / Anest intenziv Med. 2025;36(1):52-54 / www.aimjournal.cz For children between the ages of 6 and 12, more complex games need to be prepared. At our department, we have had a good experience with evoking the idea of a child’s stay at the seaside. This game combines elements of imagination with a breathing exercise, asking the child whether they feel cool or warm air when they breathe in. Fun games such as: “make the worst face” or “show me what your dog would look like right now” can also help to calm the patient. A very effective method of reducing preoperative anxiety in children over the age of 12 is the Butterfly Hug Technique. This method was originally developed as a therapeutic intervention for survivors of Hurricane Pauline in Mexico. Currently, the butterfly hug is part of the Eye Movement Desensitisation and Reprocessing Integrative Group Treatment Protocol, which is primarily used in the treatment of post-traumatic stress disorder. This grounding technique is also used to calm down and process unpleasant experiences, including a stay in the operating theatre. The butterfly hug technique begins with the anaesthetist asking the child to cross their arms over their chest so that the tips of their middle fingers are on their collarbones. The child then crosses their thumbs to form the body of a butterfly, while the remaining fingers form the wings of a butterfly. The technique continues with alternating hand movements that mimic the flapping of butterfly wings. To enhance the effect of the technique, deep breathing or positive affirmations can be added [8]. In adolescent patients, listening to favourite music before induction of general anaesthesia can be used to reduce preoperative anxiety. Patients’ musical preferences are recorded during the pre-anaesthesia assessment, and their favourite music is played when they arrive in the operating theatre. However, this is not merely a distraction technique as several studies have shown that adolescents use music as an important means of modulating their mood and coping with negative emotions [9]. The basic rule of communication with a paediatric patient is to provide truthful information to the extent appropriate to the child’s stage of neurobehavioural development. Children between 3 and 6 years of age are particularly fearful of physical harm. Explaining basic surgical and anaesthetic procedures to them can greatly help to reduce preoperative anxiety. Children aged 7–12 years need much more information and their participation in the operating theatre increases their sense of control, thus reducing anxiety. Children can choose or hold a face mask during inhalation anaesthesia. For adolescents, in addition to their involvement in the operating theatre, their sense of shame and need for privacy must be respected [5]. In a restless child who develops severe preoperative anxiety despite preventive measures, immobilisation on the operating table is the usual intervention. Although the primary aim of restricting movement is to ensure the patient’s safety, this method usually results in further aggravation of the child’s anxiety. This is because immobilisation interferes with the natural response to danger, as described above, making it impossible for the child to fight or flee. If immobilisation is necessary, it can be used to play with the child, partially distracting them. Ask the child to shake like their dog at the vet or cross the fingers as hard as possible and count to five. Postoperative anxiety In clinical practice, very little attention is paid to the prevention of postoperative anxiety, which can also negatively influence patient outcomes. After emergence from anaesthesia, the child may feel dizzy and have blurred vision or chills. Children may not have experienced these symptoms before and may interpret them as a feeling of dying or of being already dead. From an early age, children are introduced to death, often unconsciously through fairy tales and stories. Although, according to Piaget’s theory, they are not yet fully aware of its universality and finality, the idea of death can trigger intense postoperative anxiety [10]. An effective method of prevention is to make children aware of these symptoms before the operation, explain them, and reassure them that they will dissipate promptly. Points to remember 1. Preoperative anxiety is common in children and is associated with adverse clinical outcomes. 2. Crisis intervention aims to reconnect the neocortex. 3. The butterfly hug technique can be an effective intervention to reduce preoperative anxiety in children older than 12 years. 4. Prevention of postoperative anxiety in children is often neglected. PROHLÁŠENÍ AUTORŮ: Prohlášení o původnosti: Práce je původní a nebyla publikována ani není zaslána k recenznímu řízení do jiného média. Střet zájmů: Autoři prohlašují, že nemají střet zájmů v souvislosti s tématem práce. Podíl autorů: Všichni autoři rukopis četli, souhlasí s jeho zněním a zasláním do redakce časopisu Anesteziologie a intenzivní medicína. Financování: Žádné. Registrace: N/A. Projednání etickou komisí: N/A. REFERENCES 1. Peng K, Wu SR, Ji FH, Li J. Premedication with dexmedetomidine in pediatric patients: a systematic review and meta-analysis. Clinics (Sao Paulo). 2014 Nov;69(11):777-86. doi: 10.6061/clinics/2014(11)12. PMID: 25518037; PMCID: PMC4255070. 2. Heikal S, Stuart G. Anxiolytic premedication for children. BJA Educ. 2020 Jul;20(7):220-225. doi: 10.1016/j.bjae.2020.02.006. Epub 2020 Apr 21. PMID: 33456954; PMCID: PMC7807914. 3. Deshpande S, Platt MP, Aynsley-Green A. Patterns of the metabolic and endocrine stress response to surgery and medical illness in infancy and childhood. Crit Care Med. 1993 Sep;21(9 Suppl):S359-61. doi: 10.1097/00003246-199309001-00036. PMID: 8365226. 4. Siva N. Preparing children for operations. Lancet Child Adolesc Health. 2022 Jan;6(1):1314. doi: 10.1016/S2352-4642(21)00379-5. PMID: 34921805. 5. Dave NM. Premedication and Induction of Anaesthesia in paediatric patients. Indian J Anaesth. 2019 Sep;63(9):713-720. doi: 10.4103/ija.IJA_491_19. PMID: 31571684; PMCID: PMC6761781. 6. Schmidt NB, Richey JA, Zvolensky MJ, Maner JK. Exploring human freeze responses to a threat stressor. J Behav Ther Exp Psychiatry. 2008 Sep;39(3):292-304. doi: 10.1016/j. jbtep.2007.08.002. Epub 2007 Aug 12. PMID: 17880916; PMCID: PMC2489204. 7. Volchan E, Souza GG, Franklin CM, Norte CE, Rocha-Rego V, Oliveira JM, et al. Is there tonic immobility in humans? Biological evidence from victims of traumatic stress. Biol Psychol. 2011 Sep;88(1):13-9. doi: 10.1016/j.biopsycho.2011.06.002. Epub 2011 Jul 5. PMID: 21693167. 8. Artigas J, Jarero I. The butterfly hug. Implementing EMDR early mental health interventions for man-made and natural disasters. 2014;127-130. 9. North A, Hargreaves D. The Social and Applied Psychology of Music. (Oxford, 2008; online edn, Oxford Academic, 22 Mar. 2012), https://doi.org/10.1093/acprof:oso/9780198567424.001.0001. 10. Speece MW, Brent SB. Children's understanding of death: a review of three components of a death concept. Child Dev. 1984 Oct;55(5):1671-86. PMID: 6510050.
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