Perioperative information and parental anxiety: the next generation.
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Adaptation, Psychological↗
Biomedical subjects
Z N Kain
Publications and source records attributed to Z N Kain.
Distress during the induction of anesthesia and postoperative behavioral outcomes.
UNLABELLED: We determined whether children who are extremely anxious during the induction of anesthesia are more at risk of developing postoperative negative behavioral changes compared with children who appear calm during the induction process. Children (n = 91) aged 1-7 yr scheduled for general anesthesia and elective outpatient surgery were recruited. Using validated measures of preoperative anxiety and postoperative behaviors, children were evaluated during the induction of general anesthesia and on Postoperative Days 1, 2, 3, 7, and 14. Using a multivariate logistic regression model, in which the dependent variable was the presence or absence of postoperative negative behavioral changes and the independent variables included several potential predictors, we demonstrated that anxiety of the child, time after surgery, and type of surgical procedure were predictors for postoperative maladaptive behavior. The frequency of negative postoperative behavioral changes decreased with time after surgery, and the frequency of negative postoperative behavioral changes increased when the child exhibited increased anxiety during the induction of anesthesia. Finally, we found a significant correlation (r) of 0.42 (P = 0.004) between the anxiety of the child during induction and the excitement score on arrival to the postanesthesia care unit. We conclude that children who are anxious during the induction of anesthesia have an increased likelihood of developing postoperative negative behavioral changes. We recommend that anesthesiologists advise parents of children who are anxious during the induction of anesthesia of the increased likelihood that their children will develop postoperative negative behavioral changes such as nightmares, separation anxiety, and aggression toward authority. IMPLICATIONS: Anesthesiologists who care for children who are anxious during the induction of anesthesia should inform parents that these children have an increased likelihood of developing postoperative negative behavioral changes.
Anesthesia↗
Preoperative anxiety and intraoperative anesthetic requirements.
UNLABELLED: The purpose of this study was to determine whether larger doses of anesthetics are required in the anxious patient to establish and maintain a clinically sufficient hypnotic component of the anesthetic state. Fifty-seven women undergoing bilateral laparoscopic tubal ligation with a propofol-based anesthetic regimen were enrolled in this cross-sectional study. Trait (baseline) and state (situational) anxiety were assessed in all patients immediately before surgery, and the propofol doses required for the induction and maintenance of anesthesia were recorded. A bispectral index monitor was used to assure that the hypnotic component of the anesthetic state was the same in all patients. We found that patients with high trait anxiety required more propofol for both the induction (2.1+/-0.4 vs 1.8+/-0.3 mg/kg; P = 0.01) and maintenance of anesthesia (170+/-70 vs 110+/-20 microg x kg(-1) x min(-1); P = 0.02), compared with patients with low trait anxiety. State anxiety, however, was not found to affect the propofol doses required for the induction or maintenance of anesthesia. Multiple regression models confirmed that Trait anxiety is an independent predictor for intraoperative propofol requirements (P = 0.02). We conclude that increased baseline (i.e., trait) anxiety is associated with increased intraoperative anesthetic requirements. Thus, we suggest that the initial dose of anesthetic administered by an anesthesiologist should be modified based on the anxiety level exhibited by the patient. IMPLICATIONS: The goal of this study was to assess the relationship between preoperative anxiety and intraoperative anesthetic requirements. We found that high baseline anxiety predicts increased intraoperative anesthetic requirements. We suggest that anesthesiologists should modify the initial induction dose based on the anxiety level exhibited by the patient.
Adult↗
Postoperative behavioral outcomes in children: effects of sedative premedication.
BACKGROUND: Although multiple studies document the effect of sedative premedication on preoperative anxiety in children, there is a paucity of data regarding its effect on postoperative behavioral outcomes. METHODS: After screening for recent stressful life events, children undergoing anesthesia and surgery were assigned randomly to receive either 0.5 mg/kg midazolam in 15 mg/kg acetaminophen orally (n = 43) or 15 mg/kg acetaminophen orally (n = 43). Using validated measures of anxiety, children were evaluated before and after administration of the intervention and during induction of anesthesia. On postoperative days 1, 2, 3, 7, and 14, the behavioral recovery of the children was assessed using the Post Hospitalization Behavior Questionnaire. RESULTS: The intervention group demonstrated significantly lower anxiety levels compared with the placebo group on separation to the operating room and during induction of anesthesia (F[1,77] = 3.95, P = 0.041). Using a multivariate logistic regression model, the authors found that the presence or absence of postoperative behavioral changes was dependent on the group assignment (R = 0.18, P = 0.0001) and days after operation (R = -0.20, P = 0.0001). Post hoc analysis demonstrated that during postoperative days 1-7, a significantly smaller number of children in the midazolam group manifested negative behavioral changes. At week 2 postoperatively, however, there were no significant differences between the midazolam and placebo groups. CONCLUSIONS: Children who are premedicated with midazolam before surgery have fewer negative behavioral changes during the first postoperative week.
Acetaminophen↗
Leptin and the perioperative neuroendocrinological stress response.
The human response to surgical stress is characterized by massive release of neuroendocrine hormones, provoking catabolism, thermogenesis, and hyperglycemia. Considering the possible adverse outcomes of excessive stress hormones, understanding various components of the stress response may improve management of postoperative morbidity. Leptin, initially described as an adipocyte-derived signaling factor, may also play an important role in regulating the hypothalamo-pituitary-adrenocortical axis. In phase I, plasma leptin and cortisol were measured in women before, during, and after total abdominal hysterectomy. The anesthetic technique was strictly controlled, balanced anesthesia. In phase II, plasma leptin and cortisol levels were measured in cardiac surgery patients. These subjects were anesthetized with a high dose opioid technique that blunts the intraoperative surgical stress response. In phase I, mean leptin levels did not change over the week before surgery, had a maximal decrease to 49% of baseline 2 h after surgery, and increased to just above baseline 24 h postoperatively. Cortisol was 176% of the baseline just before surgery, peaked at 2 h after surgery (383%), and remained elevated 24 h (200%) and 48 h (165%) after surgery. During the first 2 h of surgery, the decrease in leptin parallels the increase in cortisol. In phase II, high dose fentanyl limited both the cortisol increase and the leptin decrease; thus, the ratio of cortisol increase to leptin decrease was similar for the cardiac patients and the hysterectomy patients. These data indicate that leptin has a role in the surgically induced acute stress response in humans. Early in surgery the decrease in leptin parallels the increase in cortisol. This suggests a possible relationship between the neurobiology of these two systems, which could have important implications for regulation of the neuroendocrine response to surgical stress.
Adult↗
Practice patterns in managing the difficult airway by anesthesiologists in the United States.
UNLABELLED: Despite the availability of several techniques and devices for the management of the difficult airway, little information has been published regarding the prevalence of their use by anesthesiologists in the United States. To determine current practice patterns, we surveyed clinicians using a questionnaire consisting of 14 difficult airway scenarios. Anesthesiologists were requested to indicate their likely approach to anesthetic induction (e.g., awake but sedated, general anesthesia with spontaneous ventilation, general anesthesia with apnea after assuring a patent airway, or general anesthesia with apnea) and the primary device they would use to intubate (e.g., direct laryngoscopy [DL], flexible fiberoptic bronchoscope [FOB], rigid fiberoptic device, surgical airway, retrograde intubation kit, laryngeal mask airway, gum elastic bougie, or Combitube). The availability of these devices was also determined (in room at all times, available "stat," available if arranged preoperatively, or not available). The survey was mailed to 1000 randomly chosen active members of the American Society of Anesthesiologists. Second and third surveys were mailed to non responders. Four hundred seventy-two completed surveys were returned. Responses by demographic groups were compared by using chi 2 analysis. DL and FOB-aided tracheal intubation techniques were chosen for most cases by most anesthesiologists (P < 0.05). Anesthesiologists with > 10 yr of clinical experience and those older than 55 yr of age preferred DL with apneic conditions (P < 0.05). Anesthesiologists who had attended workshops within the last 5 yr had greater availability of retrograde guidewire equipment and FOBs (P < 0.05). There was little use of newer alternative airway devices. IMPLICATIONS: Although the teaching of alternative methods of securing a difficult airway has become ubiquitous, most anesthesiologists rely on direct laryngoscopy and fiberoptic-aided intubation in most clinical circumstances. Although workshops in the management of the difficult airway may have resulted in increased use of the fiberoptic bronchoscope and the availability of retrograde guidewire intubation equipment, other devices have not enjoyed such an increase.
Adult↗
Preoperative preparation programs in children: a comparative examination.
UNLABELLED: We sought to determine whether an extensive behavioral preparation program for children undergoing surgery is more effective than a limited behavioral program. The primary end point was child and parent anxiety during the preoperative period. Secondary end points included behavior of the child during the induction of anesthesia and the postoperative recovery period. Several days before surgery, children (n = 75) aged 2-12 yr randomly received either an information-based program (OR tour), an information + modeling-based program (OR tour + videotape), or an information + modeling + coping-based program (OR tour + videotape + child-life preparation). Using behavioral and physiological measures of anxiety, we found that children who received the extensive program exhibited less anxiety immediately after the intervention, in the holding area on the day of surgery, and on separation to the operating room. These findings, however, achieved statistical significance only in the holding area on the day of surgery (44[10-72] vs 32[8-50] vs 9[6-33]; P = 0.02). Similarly, parents in the extensive program were significantly less anxious on the day of surgery in the preoperative holding area, as assessed by behavioral (P = 0.015) and physiological measures (P = 0.01). In contrast, no differences were found among the groups during the induction of anesthesia, recovery room period, or 2 wk postoperatively. We conclude that children and parents who received the extensive preoperative preparation program exhibited lower levels of anxiety during the preoperative period, but not during the intraoperative or postoperative periods. IMPLICATIONS: The extensive behavioral preoperative program that we undertook had limited anxiolytic effects. These effects were localized to the preoperative period and did not extended to the induction of anesthesia or the postoperative recovery period.
Anxiety↗
The sedative and analgesic sparing effect of music.
BACKGROUND: To determine whether music influences intraoperative sedative and analgesic requirements, two randomized controlled trials were performed. METHODS: In phase 1, 35 adults undergoing urologic procedures with spinal anesthesia and patient-controlled intravenous propofol sedation were randomly assigned to hear favorable intraoperative music via headset or to have no music. In phase 2, 43 adults undergoing lithotripsy treatment of renal or ureteral calculi and receiving patient-controlled intravenous opioid analgesia were randomly assigned to either a music or no-music group. The effect of music on sedatives and analgesics requirements, recovery room duration, and adverse outcomes was assessed. RESULTS: In phase 1, patients in the music group required significantly less propofol for sedation than patients in the control group (0 [0-150] mg vs. 90 [0-240] mg, median[range]; P < 0.001). These findings persisted after adjusting for duration of surgery (0.3+/-0.1 mg/min vs. 1.6+/-0.4 mg/min; P < 0.001). Similarly, in phase 2, patients who listened to music had a significant reduction in alfentanil requirements (1,600 [0-4,250] microg vs. 3,900 [0-7,200] microg; P = 0.005). This persisted after adjusting for duration of surgery (52+/-9 microg/min vs. 119 +/-16 microg/min, mean +/- SD, P < 0.001). Duration of stay in the postanesthesia care unit and the rate of adverse events was similar in both groups (P = NS). CONCLUSIONS: Use of intraoperative music in awake patients decreases patient-controlled sedative and analgesic requirements. It should be noted, however, that patients in the no-music group did not use a headset during operation. Thus, the decrease in sedative and analgesic requirements could be caused by elimination of ambient operating room noise and not by the effects of music.
Analgesia, Patient-Controlled↗
Parental presence during induction of anesthesia versus sedative premedication: which intervention is more effective?
BACKGROUND: Both midazolam and parental presence during induction of anesthesia are routinely used to treat preoperative anxiety in children. The purpose of this investigation was to determine which of these two interventions is more effective. METHODS: Anxiety of the child during the perioperative period was the primary end point. Secondary end points included anxiety of the parent and compliance of the child during induction. Children (n = 88) were randomly assigned to one of three groups: (1) 0.5 mg/kg oral midazolam; (2) parental presence during induction of anesthesia; or (3) control (no parental presence or premedication). Using multiple behavioral measures of anxiety, the effect of the intervention on the children and their parents was assessed. RESULTS: Observed anxiety in the holding area (T1), entrance to the operating room (T2), and introduction of the anesthesia mask (T3) differed significantly among the three groups (P = 0.032). Post hoc analysis indicated that children in the midazolam group exhibited significantly less anxiety compared with the children in the parental-presence group or control group (P = 0.0171). Similarly, parental anxiety scores after separation were significantly less in the midazolam group compared with the parental-presence or control groups (P = 0.048). The percentage of inductions in which compliance of the child was poor was significantly greater in the control group compared with the parental-presence and midazolam groups (25% vs. 17% vs. 0%, P = 0.013). CONCLUSIONS: Under the conditions of this study, oral midazolam is more effective than either parental presence or no intervention for managing a child's and parent's anxiety during the preoperative period.
Adaptation, Psychological↗
Desire for perioperative information in adult patients: a cross-sectional study.
STUDY OBJECTIVE: To identify which perioperative information outpatients want from their anesthesiologist. DESIGN: Cross-sectional study. SETTING: Outpatient center. PATIENTS: 197 ASA physical status I and II patients undergoing outpatient surgery. INTERVENTIONS: A questionnaire examining for "desire for information". MEASUREMENTS AND MAIN RESULTS: Demographic data including age, ethnicity, gender, socioeconomic status, and history of previous surgery were obtained. Trait, situational anxiety, and coping strategy were assessed using a validated behavioral instrument and a questionnaire adopted from previous studies conducted in Australia, Scotland, and Canada. Each questionnaire contained 14 statements regarding specific perioperative details. An index of the overall patient desire for information (PDI) was calculated for each subject. More than 85% of subjects gave a high priority to being informed for all the 14 items. Scores on the overall index were found to be higher for females than for males (32 +/- 6 vs. 30 +/- 6; p = 0.03), and this finding persisted in a multivariable model that also included coping strategies and anxiety (DF = 1,175, F = 4.6, p = 0.01). Subjects also had higher PDI scores if a first degree relative had a history of previous surgery (33 +/- 5 vs. 31 +/- 6; p = 0.007). On analysis of individual questionnaire items, Latino Americans were significantly less likely than European Americans or African Americans to desire perioperative information (p < 0.05). Similarly, females had a significantly higher desire for information than males. Subjects who were divorced demonstrated a higher desire for information than did single or married subjects. CONCLUSIONS: Ethnicity, gender, coping mechanism, marital status, and a history of previous surgery in a relative have been identified as predictors for the desire for information.
Adaptation, Psychological↗
Parental desire for perioperative information and informed consent: a two-phase study.
The purpose of this investigation was to identify the perioperative anesthetic information parents want from the anesthesiologist, and to determine whether the provision of detailed anesthetic risk information is associated with increased parental anxiety. The investigation consisted of a cross-sectional study followed by a randomized controlled trial. In Phase 1, baseline and situational anxiety, coping strategy, and temperament were obtained from parents of children undergoing surgery (n = 334). A questionnaire examining the desire for perioperative information was administered to all parents. In Phase 2, 47 parents were randomly assigned to receive either routine anesthetic risk information (control) or detailed anesthetic risk information (intervention). The effect of the intervention on parental anxiety was assessed over four time points: prior to the intervention, immediately after the intervention, day of surgery in the holding area, and at separation to the operating room. For Phase 1, the majority of parents (> 95%) preferred to have comprehensive information concerning their child's perioperative period, including information about all possible complications. For selected items, increased parental educational level was associated with increased desire for information (P < 0.05). For Phase 2, when the intervention group was compared with the control group, there were no significant differences in parental anxiety over the four time points [F(1,45) = 0.6, P = 0.4]. Also, the interaction between time and group assignment was not significant [F(3,135) = 1.66, P = 0.18]. We conclude that parents of children undergoing surgery desire comprehensive perioperative information. Moreover, when provided with highly detailed anesthetic risk information, the parental anxiety level did not increase.
Adaptation, Psychological↗
Premedication in the United States: a status report.
We undertook a mailing survey study to assess the current practice of sedative premedication in anesthesia. A total of 5396 questionnaires were mailed to randomly selected physician members of the American Society of Anesthesiologists. Forty-six percent (n = 2421) of those sampled returned the questionnaire after two mailings. The reported rate of sedative premedication in the United States varied widely among age groups and geographical locations. Premedicant sedative drugs were least often used with children younger than age 3 years and most often used with adults less than 65 years of age (25% vs 75%, P = 0.001). Midazolam was the most frequently used premedicant both in adults and children (> 75%). When analyzed based on geographical locations, use of sedative premedicants among adults was least frequent in the Northeast region and most frequent in the Southeast region (50% vs 90%, P = 0.001). When the frequency of premedication was examined against health maintenance organization (HMO) penetration (i.e., HMO enrollment by total population) in the various geographical regions, correlation coefficients (r) ranged from -0.96 to -0.54. Multivariable analysis revealed that HMO penetration is an independent predictor for the use of premedication in adults and children. The marked variation among geographical areas in premedicant usage patterns underscores the lack of consensus among anesthesiologists about the need for premedication. The data suggest that HMO participation may affect delivery of this component of anesthetic care.
Adolescent↗
The Yale Preoperative Anxiety Scale: how does it compare with a "gold standard"?
UNLABELLED: Evaluating the effectiveness of interventions directed toward the treatment of preoperative anxiety in children has been hindered by the absence of a statistically valid measurement tool. In a previous investigation, we developed an instrument (Yale Preoperative Anxiety Scale [YPAS]) that can be used to assess anxiety in children undergoing induction of anesthesia. The purpose of the present investigation was to modify and expand the applicability of the instrument to the preoperative holding area and to validate the modified instrument (m-YPAS) against a recognized "gold standard" (State-Trait Anxiety Inventory for Childrens [STAIC]). Videotapes of children in a preoperative holding area were analyzed by the investigators. The existing five categories of the YPAS were found to reflect most of the behaviors observed. Several items, however, were modified to describe new behaviors observed. Reliability analysis using weighted kappa statistics revealed that inter-observer agreement ranged from 0.68 to 0.86, whereas intraobserver weighted kappa ranged from 0.63 to 0.90. Concurrent validity between the YPAS and the STAIC was acceptable (P = 0.01, r = 0.79). Construct validity was high as assessed by increased m-YPAS scores from the preoperative holding area (28 +/- 8) to entering the operating room (35 +/- 12), to introduction of the anesthesia mask (43 +/- 15;F [1,36] = 0.6, P = 0.001]. Showing good to excellent observer reliability and high concurrent and construct validity, the m-YPAS proved to be an appropriate tool for assessing children's anxiety during the perioperative period. IMPLICATIONS: The absence of a statistically valid measurement tool that can be applied easily in perioperative settings hinders the evaluation of interventions directed toward treatment of preoperative anxiety in children. The authors describe the development of such a tool, the modified Yale Preoperative Anxiety Scale.
Anesthesia↗
Preoperative anxiety in children. Predictors and outcomes.
OBJECTIVE: To determine predictors and behavioral outcomes of preoperative anxiety in children undergoing surgery. DESIGN: A prospective, longitudinal study. SETTING: A university children's hospital. PARTICIPANTS: One hundred sixty-three children, 2 to 10 years of age (and their parents), who underwent general anesthesia and elective surgery. MAIN OUTCOME MEASURES: In the preoperative holding area, anxiety level of the child and parents was determined using self-reported and independent observational measures. At separation to the operating room, the anxiety level of the child and parents was rated again. Postoperative behavioral responses were evaluated 3 times (at 2 weeks, 6 months, and 1 year). RESULTS: A multiple regression model (R2 = 0.58, F = 6.4, P = .007) revealed that older children and children of anxious parents, who received low Emotionality, Activity, Sociability, and Impulsivity (EASI) ratings for activity, and with a history of poor-quality medical encounters demonstrated higher levels of anxiety in the preoperative holding area. A similar model (R2 = 0.42, F = 8.6, P = .001) revealed that children who received low EASI ratings for activity, with a previous hospitalization, who were not enrolled in day care, and who did not undergo premedication were more anxious at separation to the operating room. Overall, 54% of children exhibited some negative behavioral responses at the 2-week follow-up. Twenty percent of the children continued to demonstrate negative behavior changes at 6-month follow-up, and, in 7.3% of the children, these behaviors persisted at 1-year follow-up. Nightmares, separation anxiety, eating problems, and increased fear of physicians were the most common problems at 2-week follow-up. Multivariate analysis demonstrated that child's age, number of siblings, and immediate preoperative anxiety of the child and mother predicted later behavioral problems. CONCLUSIONS: Variables such as situational anxiety of the mother, temperament of the child, age of the child, and quality of previous medical encounters predict a child's preoperative anxiety. Although immediate negative behavioral responses develop in a relatively large number of young children following surgery, the magnitude of these changes is limited, and long-term maladaptive behavioral responses develop in only a small minority.
Age Distribution↗
Preoperative preparation in children: a cross-sectional study.
STUDY OBJECTIVE: To evaluate the effectiveness of a behavioral preparation program on reducing anxiety in children and their parents prior to elective surgery. DESIGN: Cross-sectional study. SETTING: A children's hospital. PATIENTS: 143 children undergoing outpatient surgery, and their parents. INTERVENTIONS: A behavioral preoperative preparation program. MEASUREMENTS AND RESULTS: Overall anxiety in children and their parents did not differ significantly between the group that received the preoperative program and the group that did not (p = NS). Children older than 6 years were least anxious on separation from their parents if they participated in the preparation program more than 5 to 7 days prior to surgery, moderately anxious if they did not receive preparation, and most anxious if they received the preparation 1 day prior to surgery (P = 0.04). Multivariable regression analysis (for overall model, F = 2.14, p = 0.02) revealed that although the preparation program itself was not a predictor of a child's behavior on separation to the operating room, the interaction between child's age and timing of the program (p = 0.003), and child's previous hospitalization were predictors of children's anxiety response. Similarly, in the preoperative holding area, independent predictors of anxiety included timing of the preparation program, age of child, and the child's baseline temperament characteristics. CONCLUSIONS: The results highlight the complexities in assuming that a behavior-based preoperative preparation program is effective for all pediatric outpatients. The effects of such an intervention vary with the child's age, the timing of the intervention, and a history of previous hospitalization.
Ambulatory Surgical Procedures↗
Parental presence during induction of anesthesia: the surgeon's perspective.
Parental presence during induction of anesthesia (PPIA) remains controversial and little is known about surgeons' attitudes toward this clinical practice. A questionnaire was mailed to all the United States (US) members of the Surgical Section of the American Academy of Pediatrics and all members of the British Association of Paediatric Surgeons. Questions were asked about attitudes toward PPIA in the operating room and the prevalence of such practice. A total of 275 subjects, constituting 72.4% of the compared groups, responded after three mailings. Sixty percent of the US respondents and 95% of the Great Britain (GB) respondents said they disagree with the statement "parents should never be present during induction of anesthesia". Ninety-two percent of the GB respondents and 69% of the US respondents thought PPIA decreases anxiety (p = 0.001) and increases the cooperation of the child (86% GB, versus 53% US, p = 0.001). Most US respondents (72%) reported that PPIA occurs in less than 25% of their cases, but most GB respondents (80%) reported PPIA in more than 75% of their cases (p = 0.001). These differences in prevalence persisted after logistic-regression models were used to adjust for potential confounding demographic variables. We conclude that the attitudes and practice toward PPIA held by surgeons from the US and GB differ significantly. While a large percentage of the US sample agree that there are benefits in PPIA, only a minority report the routine use of PPIA in contrast to most respondents from GB who report PPIA as routine in their hospital.
Adult↗
Parental presence during induction of anesthesia. A randomized controlled trial.
BACKGROUND: To determine whether parental presence during induction of anesthesia is an effective preoperative behavioral intervention, a randomized controlled trial with children undergoing outpatient surgery was conducted. METHODS: Eighty-four children were randomly assigned to a parent-present or parent-absent group. Using multiple behavioral and physiologic measures of anxiety, the effect of the intervention on the children and their parents was assessed. Predictors for the response to the intervention were examined using multivariate linear regression analysis. RESULTS: When the intervention group (parent-present) was compared to the control group (parent-absent), overall there were no significant differences in any of the behavioral or physiologic measures of anxiety tested during induction of anesthesia. Using the child's serum cortisol concentration as the outcome, parental presence, the child's age and baseline temperament, and trait anxiety of the parent, were identified as predictors of the child's anxiety during induction. Analysis of variance demonstrated that three groups showed diminished cortisol concentrations with parental presence: children older than 4 yr (P = 0.001), children whose parent had a low trait anxiety (P = 0.02), and children who had a low baseline level of activity as assessed by temperament (P = 0.05). CONCLUSIONS: Children who were older than 4 yr or those with a parent with a low trait anxiety or who had a low baseline level of activity/temperament benefited from parental presence during induction.
Anesthesia↗
Cocaine-abusing parturients undergoing cesarean section. A cohort study.
BACKGROUND: Cocaine use in the United States is prevalent among pregnant women from inner city neighborhoods. To determine the anesthetic implications of cocaine use in parturients undergoing cesarean section delivery, the authors conducted a cohort study. METHODS: One thousand nine hundred seven women presenting for prenatal care were interviewed regarding substance abuse. Urine was analyzed for benzoylecgonine, tetrahydracannabinol, benzodiazepines, and opioids. Next all parturients who underwent cesarean section delivery were identified and their records reviewed for anesthetic and obstetric outcomes. RESULTS: Among the 51 women who were classified as cocaine abusers, the most frequent reasons for cesarean section were fetal distress (48%) and abruptio placenta (21%). In a multivariate model, cocaine abuse before delivery was shown to be an independent predictor of preoperative diastolic hypertension (F = 10.6, P = 0.01). Similarly, univariate analysis showed that immediately after intubation, diastolic blood pressure was significantly higher among parturients who used cocaine (99 +/- 13 mmHg v. 87 +/- 18 mmHg; P = 0.02). In contrast, epidural anesthesia was associated with hypotension significantly more often among cocaine-abusing parturients (44% vs. 10%; P = 0.04). A higher rate of perioperative wheezing was reported among patients who abused cocaine (16% vs. 6%; relative risk = 2.7); this finding, however, did not persist in multivariate analysis. Operative blood loss was similar in all groups (P = NS), and no ventricular dysrhythmias or cerebrovascular or coronary ischemic episodes were reported in any of the parturients. CONCLUSIONS: Although cocaine-abusing parturients are at higher risk for interim peripartum events such as hypertension, hypotension, and wheezing episodes, there is no significant increase in rates of maternal morbidity or death.
Adult↗