The Use of General Anesthesia for Pediatric Dentistry in Saskatchewan: A Retrospective Study.

INTRODUCTION: The rate of general anesthesia (GA) use for pediatric dental treatment in Saskatchewan is among the highest in Canada. Although the prevalence of and risk factors for early childhood caries (ECC) has been reviewed nationally, few studies have focused on Saskatchewan. The objective of this study was to determine the prevalence of and predictive factors for dental treatment under GA in Saskatchewan. METHODS: This retrospective review focused on pediatric patients who required dental treatment under GA in Saskatchewan between 2015 and 2018. Demographic, dental diagnostic and treatment data and number of previous exposures to GA were collected and analyzed. RESULTS: We reviewed 570 patient records. Dental treatment needs among the sample were complex; children had 10.85 ± 3.56 (mean ± standard deviation) teeth treated, for an average cost of $3231.72 ± $898.95 per child. Children who lived in less accessible or remote locations had a significantly higher caries experience, number of teeth treated and cost of treatment. In addition, children who lived in such locations were more likely to have had previous dental treatment under GA (odds ratio [OR] 1.29, 95% CI 1.029-1.645) compared with those who lived in easily accessible/accessible areas (OR 0.81, 95% CI 0.700-0.953). CONCLUSION: Our findings confirm previous research that children who require dental treatment under GA have extensive caries and treatment needs. Our results suggest that children who live in less accessible and more remote areas of the province have a higher burden of disease and are more likely to require repeated GA exposures for dental treatment.

Pilot Examination of the Efficacy of the Internet-Delivered, Preoperative, Preparation Program (I-PPP).

Limited evidence-based, interactive, Internet-delivered preoperative preparation programs for children and their parents exist. The purpose of this investigation was to compare the Internet-delivered, preoperative program (I-PPP) in alleviating anxiety in children undergoing outpatient surgery delivered alone (I-PPP) and in conjunction with parental presence (I-PPP + parent) to treatment as usual (TAU). 104 children undergoing day surgery procedures at a local hospital and their parents/guardians participated. Primary outcome measures: (a) observer-rated child anxiety and (b) induction compliance. Results demonstrated an interaction between the I-PPP and TAU groups over time, F(1, 64) = 5.11, p = .027, partial η p2 = .07. At anesthetic induction, the I-PPP group demonstrated lower observer-rated anxiety than TAU, F(1, 64) = 4.72, p = .034, η p2 = .07. I-PPP group demonstrated the best anesthesia induction compliance, F(1, 64) = 4.84, p = .031, η p2 = .07. Our findings demonstrate that the I-PPP is an efficacious preoperative preparation intervention for children. The 'real-world' uptake and integration of the I-PPP into pediatric preoperative settings require exploration going forward. Trial retrospectively registered March 2019 (Open Science Registration https://doi.org/10.17605/osf.io/2x8rg ).

A systematic review of technology-based preoperative preparation interventions for child and parent anxiety.

PURPOSE: The purpose of this systematic review was to examine the effect of technology-based preoperative preparation interventions on children's and parents' anxiety. SOURCES: PsycINFO, Cochrane, Science Direct, Taylor and Francis, and Pubmed MEDLINE databases were searched. Studies were restricted to those reporting on technology-based preoperative preparation interventions for pediatric patients (0-18 yr old) receiving elective surgery under general anesthesia. PRINCIPAL FINDINGS: Thirty-eight studies that provided level II or level III evidence were included (33 randomized-controlled trials and five non-randomized-controlled studies). Of the 38 studies, preoperative anxiety (measured by various indices of anxiety) was significantly reduced in children and parents in 25 and 11 studies, respectively. For children, tablet and handheld devices with interactive components were the most encouraging strategies. Video preparation alone may provide sufficient information to manage preoperative anxiety in parents. CONCLUSION: The available literature is extremely heterogeneous and limits the ability to make definitive conclusions about the efficacy of technology-based preoperative preparation interventions. The available literature suggests that, for children, tablet and handheld devices with interactive capacity may represent a viable option to address preoperative anxiety. The findings are more mixed for parents, with video preparation a possible option. Execution of well-designed, methodologically sound studies is required to facilitate a better understanding of the efficacy of technology-based preoperative preparation.

RéSUMé: OBJECTIF: L'objectif de cette revue systématique était d'examiner l'impact des interventions de préparation préopératoire fondées sur la technologie sur l'anxiété des enfants et de leurs parents. SOURCE: Les bases de données PsycINFO, Cochrane, Science Direct, Taylor and Francis et Pubmed MEDLINE ont été passées en revue. Les études retenues se sont limitées à celles rapportant des interventions de préparation préopératoire fondées sur la technologie pour les patients pédiatriques (0-18 ans) recevant une chirurgie non urgente sous anesthésie générale. CONSTATATIONS PRINCIPALES: Trente-huit études présentant des données probantes de niveau II ou III ont été incluses (33 études randomisées contrôlées et cinq études non randomisées contrôlées). Parmi les 38 études, l'anxiété préopératoire (telle que mesurée par divers indices d'anxiété) a été significativement réduite chez l'enfant et les parents dans 25 et 11 études, respectivement. Pour les enfants, les tablettes et les appareils portatifs comprenant des composantes interactives constituaient les stratégies donnant les résultats les plus encourageants. La préparation sur vidéo seule pourrait offrir suffisamment d'informations pour prendre en charge l'anxiété préopératoire des parents. CONCLUSION: La littérature existante est extrêmement hétérogène et limite notre capacité d'émettre des conclusions définitives quant à l'efficacité des interventions de préparation préopératoire fondées sur la technologie. La littérature disponible suggère que, pour l'enfant, les tablettes et appareils portatifs disposant de capacités interactives pourraient constituer une option viable pour prendre en charge l'anxiété préopératoire. Les résultats sont plus mitigés pour les parents, la préparation par vidéo constituant potentiellement une option. L'exécution d'études bien conçues et rigoureuses d'un point de vue méthodologique est nécessaire afin de mieux comprendre l'efficacité des interventions de préparation préopératoire fondées sur la technologie.

Randomized-controlled trial of parent-led exposure to anesthetic mask to prevent child preoperative anxiety.

PURPOSE: To examine the efficacy of parent-directed anesthetic mask exposure and shaping practice to prevent child preoperative anxiety, with a specific focus on timing of exposure. METHODS: This randomized-controlled trial included 110 children ages four to seven years undergoing day surgery dental procedures and their parents. Families were randomly assigned to one of three groups: 1) parent-directed mask exposure/shaping practice at least three times in the week prior to surgery (Group 1); 2) parent-directed mask exposure/shaping practice at least once on the day of surgery (Group 2); 3) no exposure prior to induction (Group 3). Child anxiety was observer-rated using the modified Yale Preoperative Anxiety Scale during the day surgery experience, and induction compliance was observer-rated using the Induction Compliance Checklist. RESULTS: Results demonstrated significant differences in observer-rated child anxiety at anesthetic induction across groups. Group 2 demonstrated significantly lower observer-rated anxiety than Group 3 with a medium effect, F(1, 71) = 4.524, P = 0.04, η p 2 = 0.06. A significant interaction was observed between these two groups over time (i.e., admission to anesthesia induction), F(1, 71) = 4.365, P = 0.04, η p 2 = 0.06 (i.e., small to medium effect). Group 2 demonstrated the best anesthesia induction compliance (i.e., significantly lower scores than Group 3, P = 0.04). CONCLUSION: Timing of the delivery of mask exposure (i.e., on the day of surgery) to address child preoperative anxiety and induction compliance in the day surgery setting may be an important consideration. The current results inform the integration of this simple, effective strategy into practice.

RéSUMé: OBJECTIF: Examiner l'efficacité d'une exposition au masque anesthésique menée par un parent et détermination d'une pratique visant à prévenir l'anxiété préopératoire de l'enfant en se concentrant spécifiquement sur le moment de l'exposition. MéTHODES: Cette étude randomisée contrôlée a inclus 110 enfants âges de quatre à sept ans subissant une procédure dentaire en chirurgie d'un jour et leurs parents. Après randomisation, les familles ont été assignées à l'un des trois groupes suivants : 1) exposition au masque/pratique de modelage comportemental dirigée par le parent au moins trois fois dans la semaine précédant l'intervention (Groupe 1); 2) exposition au masque/pratique de modelage comportemental dirigée par le parent au moins une fois le jour de la chirurgie (Groupe 2); 3) aucune exposition avant l'induction (Groupe 3). L'anxiété de l'enfant a été évaluée par un observateur utilisant l'échelle mYPAS (échelle modifiée d'anxiété préopératoire de Yale) au cours de l'expérience le jour de la chirurgie et la conformité de l'induction a été évaluée par un observateur utilisant l'ICC (liste de vérification de la conformité de l'induction). RéSULTATS: Les résultats ont mis en évidence des différences significatives entre les groupes sur l'anxiété de l'enfant évaluée par un observateur au moment de l'induction anesthésique. Le Groupe 2 a présenté une anxiété évaluée par l'observateur significativement inférieure à celle du Groupe 3 avec un effet médian F (1, 71) = 4,524, P = 0,04, η P 2 = 0,06. Une interaction significative a été observée entre ces deux groupes au fil du temps (c'est-à-dire entre l'admission et l'induction de l'anesthésie), F (1, 71) = 4,365, P = 0,04, η P 2 = 0,06 (soit un effet petit à moyen). Le Groupe 2 a manifesté la meilleure conformité de l'induction de l'anesthésie (c'est-à-dire, des scores significativement inférieurs au Groupe 3, P = 0,04). CONCLUSION: Il peut être important de tenir compte du moment de l'exposition au masque (c'est-à-dire le jour de l'intervention) pour répondre à l'anxiété préopératoire de l'enfant et à la conformité de l'induction dans le cadre de la chirurgie d'un jour. Les résultats actuels renseignent sur l'intégration de cette stratégie simple et efficace dans la pratique.

Internet-delivered, preoperative, preparation program (I-PPP): Development and examination of effectiveness.

STUDY OBJECTIVE: Limited evidence-based, interactive, Internet-delivered preoperative preparation programs for children and their parents exist. The purpose of this investigation was to develop and examine the effectiveness of the Internet-delivered, preoperative program (I-PPP) in alleviating prepoperative anxiety in children undergoing outpatient surgery. In Study 1, the I-PPP was developed and then evaluated by parent/child dyads and health care professionals. In Study 2, the effectiveness of I-PPP was examined. DESIGN: This study was a development and effectiveness study. SETTING: For Study 1, participants were recruited from the community. For Study 2, participants were recruited from the Royal University Hospital. PATIENTS: In Study 1, participants were 9 parent/child dyads and 5 health care professionals. In Study 2, participants were 32 children (3-7years) scheduled for outpatient surgery and one parent for each child. INTERVENTION: In Study 1, I-PPP modules were created and parent/child dyads and health care professionals evaluated I-PPP modules and treatment credibility. In Study 2, child patients and their parents completed the I-PPP prior to day of surgery. MEASUREMENTS: Observer-rated anxiety of child participants was measured during the day surgery experience. Parent state anxiety was measured prior to completing I-PPP, pre- and post-surgery. Post-surgery parents provided comments regarding the I-PPP. Post-surgery child behaviour change was assessed. MAIN RESULTS: For Study 1, ratings for I-PPP components and treatment credibility surpassed our acceptability criterion. Minor changes were made to I-PPP. For Study 2, mYPAS scores were stable across day surgery. mYPAS scores in current study at induction did not differ significantly from benchmark studies. Significant reduction in parent anxiety was observed pre- to post-surgery. Parents positively endorsed the program. Negative post-operative behaviours were observed in a proportion of children. CONCLUSIONS: Our findings suggest that I-PPP represents a viable option for preoperative preparation for children and their parents.

Anesthesiology Resident Wellness Program at the University of Saskatchewan: concept and development.

PURPOSE: We describe the need for an anesthesiology resident wellness program (ARWP) and the challenges associated with its development and implementation. We also present the results of a preliminary program evaluation. METHODS: We conducted a needs assessment of Canadian anesthesiology residency programs for a formal ARWP. This endeavor involved both a cross-sectional survey and a focus group of Canadian anesthesiology residency training program directors (PDs). Following the development and implementation of an ARWP at our own university, we conducted an evaluation. The quantitative data are reported using descriptive statistics. Common themes were generated from qualitative data through an iterative process. RESULTS: Among the 18 PDs across Canada, 10 (56%) responded to the needs assessment. The PDs identified that resident wellness was important to the delivery of their programs but that very few had a formal wellness curriculum. This informed the further development of the ARWP over two years to comprise a Modular Curriculum, a Peer Support Curriculum, Self-Directed Learning Activities, and a Department Wellness Program. Online evaluation of the ARWP was completed by 28 of 31 (90%) of our anesthesiology residents, who reported high levels of satisfaction with the ARWP, the relevance of the topics, and the applicability of skills and information to both work and daily life. Respondents identified Team Building Activities, Mentorship and Orientation, Resident Wellness Nights, and Transitions to Practice Night as the most valuable components of the ARWP. CONCLUSIONS: After identifying the need for a formal ARWP in Canada, we implemented one at the University of Saskatchewan. We found high levels of overall resident satisfaction with the program.

Anesthesiology Resident Wellness Program at the University of Saskatchewan: curriculum content and delivery.

Resident and physician health are increasingly recognized by the Royal College of Physicians and Surgeons of Canada and its CanMEDS framework as integral to residency training in Canada. Resident stress, burnout, and depression also have implications for patient care. Although curricula have been advocated to promote resident wellness and resilience, no such published curricula exist to guide programs in addressing these needs. The purpose of this article is to describe the curriculum content and delivery of the Anesthesiology Residency Wellness Program (ARWP) at the University of Saskatchewan. The ARWP curriculum is comprised of four components: modular curriculum, peer support curriculum, self-directed learning activities, department wellness program. The program matrix illustrates the mission, target population, inputs, outputs, and outcomes of the ARWP. Content and suggestions for delivery of the eight curricular modules are detailed. The described ARWP is a novel innovation in Canadian postgraduate medical education. We believe this ARWP is the first comprehensive, formalized, actualized program in Canada. It also provides a guide and a helpful resource for further development of resident wellness programs by other disciplines in Canada and internationally.

A sequential examination of parent-child interactions at anesthetic induction.

Parental presence is often employed to alleviate distress in children within the context of surgery under general anesthesia. The critical component of this intervention may not be the presence of the parent per se, but more importantly the behaviors in which the parent and child engage when the parent is present. The purpose of the current study was to examine the sequential and reciprocal relationships between parental behaviors and child distress during induction of general anesthesia. Participants were 32 children (3-6 years) receiving dental surgery as a day surgery procedure, and their parents. A modified Child Adult Medical Procedures Interaction Scale-Revised was used to code parent and child behaviors. Initial child distress led to increased parental provision of reassurance and decreased provision of physical comfort. Our findings may inform the development of preoperative preparation programs whereby parents can be appropriately educated about what behaviors will be helpful/unhelpful for their child during induction of general anesthesia.

Awake craniotomy in a developmentally delayed blind man with cognitive deficits.

PURPOSE: To describe the complex perioperative considerations and anesthetic management of a cognitively delayed blind adult male who underwent awake craniotomy to remove a left anterior temporal lobe epileptic focus. CLINICAL FEATURES: A 28-yr-old left-handed blind cognitively delayed man was scheduled for awake craniotomy to resect a left anterior temporal lobe epileptic focus due to intractable epilepsy despite multiple medications. His medical history was also significant for retinopathy of prematurity that rendered him legally blind in both eyes and an intracerebral hemorrhage shortly after birth that resulted in a chronic brain injury and developmental delay. His cognitive capacity was comparable with that of an eight year old. Since patient cooperation was the primary concern during the awake electrocorticography phase of surgery, careful assessment of the patient's ability to tolerate the procedure was undertaken. There was extensive planning between surgeons and anesthesiologists, and a patient-specific pharmacological strategy was devised to facilitate surgery. The operation proceeded without complication, the patient has remained seizure-free since the procedure, and his quality of life has improved dramatically. CONCLUSION: This case shows that careful patient assessment, effective interdisciplinary communication, and a carefully tailored anesthetic strategy can facilitate an awake craniotomy in a potentially uncooperative adult patient with diminished mental capacity and sensory deficits.