Distress at induction: prevention and consequences.

PURPOSE OF REVIEW Distress in children during hospitalization is increasingly seen as unacceptable and preventable. Surgery and anaesthesia are distressing events for children with maximum stress at induction of anaesthesia. This review aims to report the recent research relevant to reducing this distress in children with a focus on the preoperative period and the impact of this on behaviour at induction and long-term postoperatively. RECENT FINDINGS The development of new measures of anxiety in children, which are specifically designed to measure anxiety in the perioperative period has allowed better assessment of the efficacy of interventions. Studies continue to demonstrate that a variety of nonpharmacological interventions have a modest effect in reducing anxiety and that sedative premedication is more effective. Clinical indications for preoperative sedative/anxiolytic medication across institutions are very variable. Clonidine and dexmedetomidine (α2-adrenergic agonists) produce satisfactory sedation in children but have long onset times. Recent focus on the importance of minimizing children's distress in clinical areas outside the operating suite is creating pressure on anaesthetists to reassess what is considered 'acceptable' in relation to distress at induction of anaesthesia. The ChildKind Initiative summarizes pain minimization strategies, which should be applied to children. It is logical to extend this concept to minimization of distress unrelated to pain. SUMMARY New measures of anxiety will facilitate better evaluation of children clinically and better future research. The role of α2-adrenergic agonists in premedication remains unclear. There is still little research, which examines outcomes for techniques for minimizing distress, which are based on specific assessment of the child and family.