The Effect of Two Distraction Strategies in Reducing Preoperative Anxiety in Children
Condition: Attention-Distributing Strategies; Preoperative Anxiety
MeSH terms: Anxiety Disorders
Study type: Interventional

Summary: 
      As a very threatening stressor, surgery often leads to strong psychological stress reactions
      in surgical patients before surgery, the most typical of which is anxiety. According to
      previous studies, more than 60% of children have severe anxiety during induction of
      anesthesia. Preoperative anxiety in children is not only significantly related to
      postoperative adverse physiological and psychological changes such as delirium during
      recovery from anesthesia, postoperative pain, and sleep disturbance, but also has a serious
      negative impact on their future study and life (such as timidity, nocturia, etc.), even for
      several years. Moreover, if the child is uncooperative, crying violently, and refuses to
      enter the operating room due to preoperative psychological stress, coercive measures are
      often adopted in clinical practice, which can easily cause harm to the physical and mental
      health of the child. Therefore, effective interventions to reduce pre-operative anxiety in
      children is an urgent need.

      At present, most researches adopt different interventions to improve the preoperative anxiety
      of children. Several studies have explored to the efficacy of psychological interventions and
      virtual reality exposure in reducing preoperative anxiety in children undergoing
      surgery,results suggest that these interventions can reduce preoperative anxiety and
      postoperative pain in children. Through toys and video games, researchers verified the
      effects of psychological preparation on perioperative stress, anxiety, and mood in children
      undergoing cardiac surgery. In addition, researchers also conducted specialized games,
      interest induction, childlike and diversified nursing methods to relieve preoperative anxiety
      in children. Although these interventions have achieved certain effects, the intervention
      strategies need professionals accompanied and special arrangements, there also exist problems
      such as time-consuming, labor-intensive, and limited audience, especially during the peak
      operation period.

      Attention distraction is an emotion regulation strategy commonly used in daily life, which
      actively separates the individual's attention from negative emotions and points to neutral or
      positive stimuli. Music and animation are the most common and affordable distraction
      strategies to reduce preoperative anxiety in children, but their effects are inconsistent. It
      is worth noting that Chow believe that the effect of the combination of audio and video is
      better than that of music intervention. Moreover, previous studies confirmed that when a
      mental image is experienced, there is an associated emotion that connects the feeling state
      with the mind and body leading to a physiologic change.

      Therefore, this study intends to use two distraction strategies (music and animation) in
      pediatric surgery patients to compare the effects of the two strategies on preoperative
      anxiety, anesthesia induction cooperation, vital signs, and to explore effective methods to
      improve preoperative anxiety in children.

      This study was a randomized controlled trial according to the CONSORT guidelines.Researchers
      recruited child patients(3-12 years) from a general tertiary hospital in Changsha, Hunan
      province, China. Researchers divided the subjects into three groups, animation group, music
      group and control group. The 181 patients recruited were randomized into three groups.
      Instruments, including preoperative anxiety,the degree of cooperation of children during
      anesthesia induction ,heart rate and blood pressure were assessed at the three moments:
      before entering the operating room (baseline T0), entering the operating room(T1), and before
      induction of anesthesia(T2). The repeated-measures analysis of variance were used to analyze
      the data.
    

Detailed description: 
      The study was a single blind, randomized, controlled trial.Researchers recruited subjects
      from one Central South University-affiliated general tertiary hospital in Changsha, Hunan
      province, China. And the whole trail was on the basis of the CONSORT statements.Study
      procedures were approved by the institutional review boards of all participating centers
      before data collection began. All patients were screened by researchers for eligibility and
      then enrolled in the study if eligible and if the provided consent.

      According to the statistics of the operation center, the main types of operations performed
      on children are adenoidectomy, tonsillectomy and pediatric occult penile surgery. The
      literature shows that the age of children undergoing tonsillectomy and adenoidectomy is
      concentrated in 4-12 years old, and the children with hidden penis surgery are concentrated
      in 3-12 years old. Therefore, the age for the patients were from 3 to 12 years.Researchers
      explained the study purposes,procedures, benefits, and risks involved orally to children's
      parents and participants were recruited with their parents' informed consent.

      According to the sequence of the children entering the study, each group(animation group,
      music group and control group) of 3 persons was randomly divided into 3 subjects in each
      block according to the random number table. The blind copy shall be kept by the personnel of
      the unit who have nothing to do with the experiment. The randomization plan will be saved by
      the statistician, and the researcher only has the number of each subject. After opening the
      envelope according to the number, the researcher knew whether the subject is the control
      group or the intervention group. Investigators involved in the intervention were not involved
      in the analysis of the study data.

      In the music group, on the basis of the routine preoperative care, the preferred music was
      selected from the music library as the intervention content on the day of surgery according
      to the preference of the children in the 1-day preoperative visit. If there was no
      preference, the music was played randomly. During the intervention, the same multimedia audio
      system (Wanderer EDIFIER R1700BT) was used to play music for 30-40 minutes, the volume was
      controlled at 35-80dB, and adjusted in time according to the feedback of the children.The
      children in animation group also chose their favorite cartoons as the intervention content on
      the basis of preoperative care. The same pad (Lenovo TB3-850F) was used to play pre-selected
      cartoons, and volume as the music group. During the intervention period, the children in
      intervention group were also accompanied by a nurse, who was also responsible for the
      implementation and maintenance of the intervention program.

      In the control group, the children were received the routine care. One day before the
      operation, nurses from operating room conducted routine preoperative visits, they
      communicated effectively with the children and their families, and conducted psychological
      counseling. The visit time lasted nearly 30 minutes. On the day of surgery, all children were
      admitted to a special waiting room for children 0.5 h in advance, and venipuncture was
      performed by a circuit nurse. Colorful cartoon patterns were depicted on the walls of the
      waiting room, and various toys for children were placed indoors. After entering the operating
      room, the child was accompanied by a parent in the waiting room for the child to wait for
      surgery. During the period, a nurse in the research group gave routine psychological comfort,
      preoperative guidance, answered questions about anesthesia and surgery raised by the children
      and their parents. Before anesthesia induction, the child was brought into the operating room
      for anesthesia induction and surgery by operating room nurse, anesthesiologist, and surgeon,
      while the child's parents leave the waiting room and wait outside the operating room.

      The researchers assessed the children's anxiety status, the degree of cooperation during the
      induction of anesthesia, and recorded the heart rate and blood pressure of the children at
      three moments: before entering the operating room (baselineT0), entering the operating
      room(T1), and before induction of anesthesia(T2).Before data collection, researchers who
      conducting data collection should be trained in measurement tools and assessment methods. The
      training contents mainly include: (1) explaining the purpose, meaning and the scoring method
      of the measurement tools; (2) Scoring the child's anxiety through pictures at three time
      points, discussing the reasons for consistent or inconsistent results, and repeating until
      the coefficient of agreement κ≥0.8.
    

Intervention name(s): Music Intervention; The animation intervention
Intervention type(s): Other; Other
Intervention description(s): Before the operation, subjects were asked to choose their favorite music to listen so as to reduce the anxiety before the operation and before the induction of anesthesia.; Before surgery, subjects were asked to choose their favorite cartoons to watch to reduce anxiety before surgery and induction of anesthesia.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: In the music group, on the basis of the routine preoperative care, the preferred music was selected from the music library as the intervention content on the day of surgery according to the preference of the children in the 1-day preoperative visit. If there was no preference, the music was played randomly. The children in animation group also chose their favorite cartoons as the intervention content on the basis of preoperative care. During the intervention period, the children in intervention group were also accompanied by a nurse, who was also responsible for the implementation and maintenance of the intervention program.
The control group received routine care, which included routine preoperative visits and psychological comfort to the children.
Masking: Double (Participant, Outcomes Assessor)
Primary purpose: Supportive Care
Keywords: Attention-Distributing Strategies; Preoperative Anxiety; Child; Operation