Impact of Video Distraction on Anxiety During Anesthesia Induction in Pediatric Patients Premedicated With Midazolam: A Randomized Controlled Trial

Abstract

Background: Midazolam is commonly used and effective in reducing preoperative anxiety in children. Nonpharmacological interventions, such as video distraction, are also well established for alleviating preoperative anxiety in pediatric patients, particularly those treated in ambulatory settings.

Aims: To explore whether video distraction during anesthesia induction provides additional anxiety reduction in children premedicated with midazolam.

Methods: In this prospective randomized controlled trial, children aged 2-10 years scheduled for elective noncardiac surgery were premedicated with midazolam and randomly assigned to either a video group (n = 54) or a control group (n = 51). In the video group, videoclips were displayed as a distraction prior to anesthesia induction, while the control group received standard care. Anxiety was measured using the short form of the modified Yale Preoperative Anxiety Scale (mYPAS-SF). The primary endpoint was the change in mYPAS-SF scores between transfer to the operating theater and anesthesia induction (ΔmYPAS-SF). Secondary endpoints included emergence delirium, postoperative pain, and compliance during anesthesia induction. Character traits were assessed.

Results: There was no additional anxiety reduction in the video group compared to the control group. The change in mYPAS-SF scores (median [interquartile range]) was 4.2 (-2.1, 16.7) in the control group and 4.16 (-2.1, 7.0) in the video group (p = 0.246). Similarly, there were no significant differences between the groups regarding compliance during anesthesia induction, emergence delirium, or postoperative pain. Compliance during anesthesia induction, emergence delirium, and postoperative pain was similar between the groups. Additional anxiety reduction through video distraction was observed in children with pronounced anxiety traits, including "General Phobia," "Separation," "Panic," and the overall "Total Phobia" score.

Conclusion: In our study, video distraction did not result in additional anxiety reduction in children premedicated with midazolam prior to anesthesia induction in a hospital setting. Certain children with specific personality traits may still benefit from this intervention.

Trial registration: Registry: German Clinical Trial Register; Registration number: DRKS00025411; Principal investigator's name: Armin Sablewski; Date of registration: February 15, 2022; https://drks.de/search/en/trial/DRKS00025411.

Keywords: midazolam; premedication; preoperative anxiety; video distraction.

FIGURE 1

Schematic workflow and measurements recorded through the study. CHIPPS, Children's and Infants' Postoperative Pain Scale; ICC, Induction Compliance Checklist; mYPAS‐SF, Modified Yale Preoperative Anxiety Scale—Short Form; VAS‐anx, Visual analog anxiety scale; VAS‐pain, Visual analog pain scale.

FIGURE 2

Participant workflow diagram for full‐analysis set.

FIGURE 3

Progression of anxiety over time (A) and difference in anxiety between T2 and T3 (B). Boxes show median and IQR; whiskers 5–95 percentile range, outliers as dots; (A) showing the progression of anxiety from T1 = at the ward, T2 = while transfer to theater and T3 = during induction of anesthesia measured by mYPAS‐SF in control group and video group; (B) shows the difference between the anxiety at T3 and T2 measured by mYPAS‐SF; positive scores indicate an increase and negative scores a decrease in the children's anxiety.

FIGURE 4

The impact of personality traits on anxiety during induction of anesthesia. Anxiety measured with mYPAS‐SF at T3 (induction of anesthesia) in control and video group with reference to personality traits. Boxes show median and IQR; whiskers 5–95 percentile range, outliers as spots. Figures show children above or below the median values of their respective raw values for personality traits. (A) Conduct problems expressed with total difficulty score of the SDQ; (B) personality trait “general phobia” of anxiety disorders; (C) personality trait of temperament with item “sensory sensitivity” of IKT.