Most of us in medicine like the idea that there is a bit of art to what we do. For the paediatric anaesthetist, the induction space is one of the top examples. Andrew Weatherall has a collection of thoughts around distraction at induction time.
If you’re the sort of nerd who follows anaesthesia news, you can’t have missed it. “iPads are as good as sedative at calming down kids before operations”. Finally, some anaesthetic clickbait hits the media.
Let’s walk right past the fact that this story bounces off a poster (yes, just a poster) at the recent World Congress of Anaesthesia in Hong Kong. Let’s marvel instead at the ability of this team to get so much coverage out of a poster (yes, just a poster) that just says stuff that we already pretty much new. That promotions crew should angle for a job with Kanye.
You see way back in 2014, a crew from Chicago published a randomised trial that demonstrated that a tablet-based interactive distraction system was probably superior (or at least not inferior) to midazolam in terms of anxiety at the time of separating the kid from their parent and in recovery room characteristics. This follows on from other work suggesting that video streaming and iPhones are also super effective. There’s even research out there suggesting that clowns around the time of induction can decrease parental anxiety around the operation. (There’s a serious discussion to be had there about whether parents who find clowns relaxing should be allowed to look after kids, but let’s not go down that creepy balloon-animal lined alleyway.)
So there was an awful lot of noise about the fact that stuff we already knew, and already did, was as good as we already knew.
There’s another interesting point about this sort of research. They always seem to compare this stuff to drugs. That might be reasonable because an awful lot of people choose to premedicate an awful lot of the kids they’re looking after. It’s also pretty predictable and easy to measure. Premedication will always have its place and the particular size of the place you build for it will depend a lot on the individual. Some kids are definitely going to have a more successful trip through the periop period using premedication than any other technique you try with them.
But I didn’t get into kids’ anaesthesia because I was just keen on drugging up little people. I think one of the great and enduring challenges in kids’ anaesthesia is to very quickly create a relationship with a kid and any family that lets you make that trip to the Land of Nod as enjoyable and relaxing as possible. It’s one of the joys and privileges of the job.
So why don’t they compare it to the distraction techniques? Well I guess it’s very hard to standardise that because it really is an art. But art is to be shared. So following is a collection of ephemera I’ve collected over the years from all the anaesthetists cleverer than me to try and make the whole induction phase better.
Now the thoughts below are for the ideal situation. Sometimes things need to be sped up or you don’t get to win the kid over. Any technique you rely on every day for an important job should be pulled apart and examined though.
And most importantly this is a very incomplete list. I’m sort of hoping that by putting some thoughts out there, people might feel like sharing their own tips. I could always do with making my efforts better.
So here they are.
1. The Set-Up
The induction doesn’t start with the mask in hand. It starts before that. As much before that as possible. That might be days before when you call the family to have a chat that includes what to expect. It might be when you catch up in the hospital. It mostly involves establishing that crucial rapport with the kid. The success of induction relies a lot on the patient playing an active role in choosing to go with it. We have to make that choice seem like a natural decision.
You also want to try and get the adults right on board with the plan. In most situations the kid trusts those adults and they’ll pick up if the adult thinks you are bin juice frozen and turned into humanoid form.
So the set-up matters, and there are a bunch of different way to go about it and things to include. I do try to stick to a few crucial guides though:
- Honesty – when you get to the induction bit you’re asking the kid to put a lot of trust in you. If it comes to the induction and you immediately do something you said you definitely wouldn’t do, the whole thing is probably stuffed. So if something is going to hurt, you don’t win in the long run by saying it won’t hurt. Don’t try and pretend the volatile is anything but smelly. Kids dig honesty. Families do too.
- Eye level – we don’t even realise what an immense and daunting figure we can be. Get down to their eye level to have that chat. I’m sure kids have their most relaxed conversations with people they already trust (their important adults) and people roughly their own height. So height is what you have to work with.
- Talk to the kid – this continues on from the last point. The temptation is often to address a lot of the “technical” talk to the adults. It’s the kid who is the centre of the whole thing. If you talk through the technical stuff with your patient, their adult will absolutely pick it up and interpret what you’re saying as you go. If you talk the kid through the process they know what’s coming and familiarity allows less anxiety.
- Give the kid some power – not the sort that has the potential to derail everything. But the job is to try and make them realise that they’re about to do something they’ll actually find pretty easy. When I’m getting to the description of the process, I’ll often start with three questions: “Do you know how to breathe? Do you know how to go to sleep? Do you know how to wake up?” Either the kid has a response along the lines of “Yes I am ace at all of those things, I own this joint” or they get to crack a joke about how they’ve never been to sleep in their life ever or that they are actually asleep right now. Every kid feels great when a joke lands.
- Pick your tactic – if you’re planning to try a story, preface the story beforehand. If it’s bubbles today, mention the bubbles. If you’re going with a magic light, ask them to hold the light for you. The bit that comes later just continues the thing you’ve already started.
2. The Space
How will the environment change how you do it? Will you be inducing in the operating room itself or in an induction bay? How much space is there? What fixtures in the room can be part of your distraction gizmo bag?
I’ve seen anaesthetists do their inhalational inductions with the kid sitting in their adult’s lap. I’ve seen people use beds from the ward. I’ve seen people leave a kid in the pram and I’ve seen the theatre bed used plenty of times.
Each space has advantages and disadvantages and may have particular challenges to make it a smooth process. Think through the dance of patient, staff and parent movements that you might need beforehand.
3. Take Some Time
For the ideal induction it usually pays to take a breath and slow down. That way you’re not rushing the kid with every new thing they’ll encounter for the next month in 18 seconds in an environment that’s already a bit weird and scary. Each new element you introduce needs its own time and space.
4. Right Way Up
It probably lingers from training with adults but consider all the times you’ve approached from the head of the bed while your paediatric patient gets to see what you look like upside down and hovering above them. Now think about how freaky and abnormal that interaction is. Now imagine you’re a kid.
Induce from the front. Crouch down in front of them. Or sit the bed up and have a conversation with you at the same level as them. It’s better. I promise.
You are not Mr Squiggle and you don’t need to do things upside down. (OK, that is a very niche kids’ TV reference for the the Australian anaesthetists out there. You see there was this show with a guy from the moon with a pencil for a nose … never mind.)
5. Getting Inside the Space
Coming up is a tip from one of my favourite educators in the area of working in close personal space. His name is Apollo Robbins and he’s a pickpocket.
The excellent thing about Apollo Robbins is that he has developed an ability to break down his technique for redirecting attention and explain it bit by bit. Then when you know how he does it, you still can’t quite see how he does it.
If you go and check out this clip (the whole thing is good but cut to 4 minutes in for this key point) he explains in one minute how to get close to a stranger without making them throw up a mace cloud. Not too up front and break the eye contact.
As an anaesthetist the aim is to get into the personal space of a kid without them freaking out too. Here’s an example. If you’ve got the kid sitting up in that bed, it’s pretty easy to approach from the front and side of the bed, ask “Is it OK if I sit here because honestly I am pretty old and I need to sit down a lot?” and point and look down to the spot you’re hoping to sit on. You’re still off to the side, you broke that eye contact and when you look up after sitting down, you’re sitting in a great position to have a chat. On the way past you gave the kid a little more power in the interaction too.
6. The Slow Reveal
Anything new needs to be introduced slowly not suddenly thrust in the face or worse still, appear suddenly from behind the head via the peripheral vision. It is not that amazing that a mask seems less threatening if you suggest that maybe it should sit on the knee, or maybe it’s for breathing through your ear as you demonstrate that it doesn’t hurt.
7. Perfect Songs and Perfect Stories
At some point you might want to deploy either the story they’ll hear to keep the mind occupied as they head to sleep, or the song that will fill their ears. Or bubbles. Bubbles are pretty powerful.
But not all songs or stories are equal. Part of this relies on what works in the voice of the individual anaesthetist. I reckon a song with just enough absurdity to keep the kid thinking “What? Wait a minute that seems wrong” instead of thinking about the room or the smell or other things is perfect. I feel like “Twinkle twinkle little star” is just a bit too rational. Others like to reach for the familiar.
I think a good story gives the kid space for their imagination to work with it while also incorporating the things their senses are picking up. So the inhalational induction with the space gas that is called that because it makes you feel like you’re floating off into space might be that bit easier. Particularly when you mention that as they get closer to seeing space people they might notice it smells more and more. (Haven’t you noticed that when you watch TV no one in space ever has a bath? Space people are smelly I’m telling you.)
Another favourite in these parts is to ask the kid to draw a picture of the place they’d like to go. It will have to be a colourful picture and for each colour they add they might notice the smell of the textas gets a little stronger.
The more crucial bit about either songs or stories is probably that they need to be flexible and you need to have a few ready to roll. I should also say that while this post is mostly about the other distraction techniques for induction, we started with tablets and I’m not disputing that technology options like that are clearly very effective and might be perfect for some kids. So use what you’ve got.
8. Plan for the Parents
If the parent is going to be part of the induction they need to get directions for how the scene will play out. In particular it’s worth mentioning the stuff they can expect to see as their kid gets to the deeper phases of the induction where those eyes might roll and the wriggling starts. It is a tremendously difficult thing to hand over your kid for others to take care of them. Unexpected movements do not help.
Likewise the leaving bit needs to be pre-briefed and there has to be someone whose job is to get them out of that room safely. This person might want to carry some tissues.
So there it is. It’s a short list, but I like to think each point actually has a lot that goes with it if you have the time on a long case to break down every little element. Do they always work? No. That’s why I’d call it an art.
And of course you can premedicate everyone. But should you? There’s a whole discussion you could have about whether you should try and work with a kid to normalise the situation because being able to adapt to weird things like this is actually developmentally appropriate. Maybe not for here and now though.
This post is about the songs or stories.
Or maybe just picking up tips to become a really great pickpocket.
The picture of Deano the Clown here came from the flickr Creative Commons area and is unaltered from Brian Dewey’s post.
And I might have had a crack at clowns there but the ones who work in hospital really do an amazing job and have a very deep understanding of how to engage with kids. I would strongly recommend trying to get tips off them if you can get them to shut up with the ukulele. In Australia the Humour Foundation sends out trained performers to help every day in kids’ hospitals. You can find more information here.
Now, to some selected bits of reading. This is not an exhaustive list and any other suggestions for links to put here would be gratefully received.
First up, that poster.
The 2014 paper:
Seidel SC, McMullan S, Sequela-Ramos L, et al. Tablet-based Interactive Distraction (TBID) vs oral midazolam to minimise perioperative anxiety in pediatric patients: a non inferiority randomised controlled trial. Pediatric Anaesthesia. 2014;24:1217-23.
And the streaming one:
Mifflin KA, Hackmann T, Chorney JM. Streamed Video Clips to Reduce Anxiety in Children During Inhaled Induction of Anesthesia. Anesth Analg. 2012;115:1162-7.
And just one of the ones out there on clowns (where interestingly the focus is on parental anxiety):
Agostini F, Monti F, Neri E, et al. Parental anxiety and stress before pediatric anesthesia: a pilot study on the effectiveness of preoperative clown intervention. J Health Psychol. 2014;19:587-601.
Nice breakdown of a highly complex & intense interaction that we have to compress into a few critical minutes. A few points to emphasise & add:
1. The bit about the challenge of establishing a rapport with child & family is my answer to the old joke that anaesthetists don’t have to talk to their patients. This is a unique interaction – it typically occurs only minutes before an experience that is – for parents & sometimes children – highly emotionally charged, rather mysterious & always a little bit scary (kind of like taking off in a plane – you know it’ll probably be fine but there’s still that slight knot in your stomach…). You have to extract & impart relevant information at a time when there’s a fair amount of cognitive scarcity & establish trust with people who really have no choice. So the way paediatric anaesthetists have to talk to their patients is like no other doctor-patient interaction & not everyone is good at it.
2. Space & time. I’ve learned over the years that I do not need to get the induction over with as fast as possible. In fact, I often deliberately don’t have everything quite ready in the room, so that I can potter on for a minute or so after the child enters & let them look around & get a little acclimatised to the environment.
3. We do a lot (like 85-90%) of IV inductions & we are set up logistically & culturally to put IVs into awake children. Everything you’ve said about priming & choreography is equally pertinent. The parent gets a job, which is to put their arm around their child’s shoulder; the child’s arm goes around the parent’s waist, thus blocking their view of the ipsilateral hand (unless they want to watch & they are old/mature enough to do so, in which case I let them). We use bubbles a lot & they work very well most of the time. Movies on the OR screens, & iDevices also work well.
4. Adaptability & flexibility are critical.
5. Always, ALWAYS tell the child & the parent what is going to happen next. Especially with IV induction, which is typically very fast &, if you put remi in the mix, often elicits a cough just before the child becomes apparently lifeless (as more than one parent has described it to me afterwards).
6. An escort for the departing parent is critical, unless you want them to inadvertently wander into your cardiac OR/PICU/sterile core, etc.. No matter how simple the route back to whence they came, most parents cannot find their way out of a paper bag at this moment in their lives.
Thanks so much for reading and this excellent follow-up. We have an institutional tendency to inhalational induction so it’s great to hear the IV stuff nicely summarised but with similar principles. All those same bits about incorporating the experience of the IV induction into stories etc I find particularly useful. Completely agree on point 1 too.
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Really interesting read and comments. Thank you.
I remember in the olden days at Sydney Childrens Hospital doing the paed oncology list three times a week where we gave sedation to children having lumbar puncture and other painful things in a hot, small, unventilated and very claustrophobic room two floors up from theatres.
The anaesthetic nurse had a part time job as a clown for kids parties on weekends and was also quite a large lady. She would turn up for the list in full clown regalia, popped a lot of balloons loudly, really filled a lot of space in that tiny room and the kids were petrified.
The oncology nurse was one of those bulldog types who needed to be in charge of everything and was loud, snappy and very cranky.
The RMOs left unsupervised to do the LPs were as petrified as the children.
The kids and their parents were totally over the whole having cancer and multiple procedures thing.
Suffice to say there was a lot of misery and resistance from the kids.
I worked out a few weeks in that what these kids really needed was a little bit of power back, and started letting them put on their own ECG electrodes, hold their masks and sometimes (watched closely) push the plunger on the propofol syringe. Such a small thing but huge changes. Except for oncology nurse who hit me with more incident reports than i care to recall.
Oh and I also kicked out the clown – her heart was in the right place but it was the wrong moment for that type of kindness.
These days I still do busy paeds lists private hospital setting several times a week and can really agree with everything written. I use midaz maybe three times a year and Lego/Design a Unicorn apps multiple times per day. Poo/bum/fart jokes work very well with primary school aged pts, and I have learned the words to “Let it Go” and “Little Red Frog”.
I have really noticed the drop in post op recovery room screaming since I ditched the midazolam.
Strongly agree with approaching from the front at eye level, just like Crocodile Dundee with the buffalo. And the honesty thing is a no brainer. I anaesthetise most on the operating table as most commonly they have big tonsils and ads about to be removed and start to obstruct very quickly. Parents are talked through the wriggle/eye roll stage but I can see most go ashen no matter what I say.
My biggest problem is having a frank risks discussion w parents as kids are listening to every word. Any suggestions?? We have a website with information sheets about this to read in the days leading up to surgery (with email address to contact with questions) and also a pre op health questionnaire that parents are encouraged to fill with an “any questions” option at the end, but I wonder how many actually do read it as I don’t get a lot of questions. Logistically, phoning lots of people in the days before just doesn’t work as they all want to have a 30min discussion about how nervous they are (parents nervous for themselves that is). Multiplied by approx 30 calls thats a big chunk of time that I just can’t find in my working week and don’t want to take away from my family time.
Thanks again dr Andrew great article
Thanks for taking the time to read and provide such a great comment KM. The risks question is really tough because none of us really understand how to frame risk in our own lives really. I usually have a discussion with the kid about stuff they can expect to notice afterwards or that might happen. So in that phase I’ll discuss things including sore throat, the cannula, PONV, being sore, delirium etc plus adjustments if considering blocks. When it comes to risk I’ll say outright to most kids “lots of people get a little worried about really bad stuff that might happen during the anaesthetic but the chance of those really bad things happening is really tiny…” or “I can’t say that wacky or bad stuff has never happened under anaesthetic but it’s really rare in kids who are well” then give it some anchoring reference like equivalence in terms of hours in a car “which you do all the time, but this feels weird because you don’t do this every day. Plus in the car you don’t have someone whose whole job is just to keep an eye on you.”
I still talk primarily to the kid but I then give the adult in the room the chance to follow-up and ask more queries specifically on serious risks. It’s exceptionally rare to have it asked once I’ve given it “real world equivalence”.