Real-time Tool Predicts Perioperative Behavior in Children

By Evan Young

The Perioperative Adult Child Behavioral Interaction Scale, or PACBIS, has been developed by Senthilkumar Sadhasivam, MD, MPH, and colleagues at Cincinnati Children’s Hospital Medical Center, in Ohio.

“Many children will have significant anxiety and fear before surgery, during induction of anesthesia. About 50% have a traumatic experience and develop postoperative maladaptive behaviors,” said Dr. Sadhasivam, associate professor of clinical anesthesia and pediatrics at Cincinnati Children’s and the University of Cincinnati College of Medicine. “We found we can confidently predict new-onset postoperative and post-discharge maladaptive behaviors in children.” Dr. Sadhasivam presented his research at the annual meeting of the American Society of Anesthesiologists, in San Diego

Table. Correlations of PACBIS With Existing Anxiety and Behavioral Scales: Correlation Coefficients During Induction of Anesthesia
Child coping 0.66c 0.53c –0.67c 0.37b
Child distress 0.56c 0.95c 0.77c 0.68c
Parent’s positive –0.01 –0.06 0.31b 0.23a
Parent’s negative 0.2 0.22a 0.1 –0.17
aP<0.05, bP<0.01, cP<0.001CAMPIS-SF, Child-Adult Medical Procedure Interaction Scale–Short Form; ICC, Induction Compliance Checklist; mYPAS, modified Yale Preoperative Anxiety Scale; OSBD, Observational Scale of Behavioral Distress; PACBIS, Perioperative Adult Child Behavioral Interaction Scale

The goal of the study was to use the PACBIS tool to identify favorable or unfavorable behaviors in children and parents before surgery and induction of anesthesia, and correlate these with behaviors in the recovery room, one day and one week after surgery.

The tool presents a numerical scale along with certain behaviors, and requires anesthesiologists and perioperative staff to assign a value to these behaviors. The values range from 0 to 2; after staff are oriented on assessing and coding behaviors, they should not require the scales on paper in front of them. This helps the PACBIS tool to be used more easily in day-to-day practice, as staff can assess and react to behaviors in real time, Dr. Sadhasivam said. For the study, the researchers prospectively enrolled 405 children, aged 3 to 12 years, who were undergoing tonsillectomies and adenoidectomies. They validated the PACBIS using established behavioral assessment tools. The researchers also analyzed correlations between the scale and postoperative and post-discharge pain and behavioral outcomes using pediatric postanesthesia emergence delirium (PAED) scores, post-discharge parental pain measurements, and post-hospitalization behavioral questionnaires on days 1 and 7 following surgery and discharge.

The PACBIS was as effective in assessing perioperative behaviors at all phases of surgery as the other scales, according to the researchers. For example, during induction of anesthesia, a two-unit increase on the PACBIS in measures of child distress matched a six-point increase in the PAED.

Either preoperatively or during anesthesia induction, distraction is often the best immediate real-time intervention, Dr. Sadhasivam said. A distracting story can be a good real-time intervention to minimize child distress and improve coping.

“If parents cope well and distract the child with non-procedural talks, they can help the child. But if parents are anxious and stressed, and exhibit negative behaviors such as crying in front of the child, it worsens the child’s distress. This may lead to a more traumatic experience,” Dr. Sadhasivam said.

Undesirable Behaviors Persist

The researchers were shocked by the incidence and persistence of maladaptive behaviors in children after the tonsillectomies and adenoidectomies were performed. Such behaviors included new-onset bedwetting, nightmares and clinging to parents.

“Those traumatic experiences are unwarranted,” Dr. Sadhasivam said. “Nobody performed any targeted behavioral interventions, because there was no real-time tool to assess and measure behaviors of children and parents perioperatively. Now we have the tool, and hopefully we’ll be able to make a difference in these patients’ lives.”

“One of our central aims in this research was to develop an evidence-based tool that was sufficiently practical to be used in a busy medical setting,” said Lindsey L. Cohen, PhD, associate professor in the Department of Psychology at Georgia State University, in Atlanta, and a PACBIS researcher.

“PACBIS might be useful to staff in identifying families in need of behavioral interventions to optimize the surgical experience. There is a rich body of data supporting psychological approaches to manage families’ anxiety and pain associated with pediatric medical procedures, but further work is needed to tailor the treatments to the specific families and situations,” Dr. Cohen said.

But Alan Jay Schwartz, MD, MSEd, program director of the pediatric anesthesiology fellowship at The Children’s Hospital of Philadelphia, was more skeptical of the study. Dr. Schwartz called the PACBIS a “great idea” in theory. “The ability to assess behaviors in real time has not yet been established, however,” he added, “and I don’t think these authors have established it any better than anybody else who has tried. The goal that they have in mind is a great goal, and you’d love to have kids and parents deal better with anesthetic procedures. Unfortunately, this study doesn’t add anything beyond what can already be found in the current literature.”

The study was supported by a grant from the Foundation for Anesthesia Education and Research.

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