Zhang YL, Zhou QY, Zhang P, Huang LF, Jin L, Zhou ZG. Influence of static cartoons combined with dynamic virtual environments on preoperative anxiety of preschool-aged children undergoing surgery. World J Clin Cases 2024; 12(22): 4947-4955 [PMID: 39109038 DOI: 10.12998/wjcc.v12.i22.4947]
Corresponding Author of This Article
Zhi-Guo Zhou, MM, Doctor, Department of Surgical Anesthesia, Hangzhou Children’s Hospital, No. 195 Wenhui Road, Gongshu District, Hangzhou 310014, Zhejiang Province, China. 620zzg@163.com
Research Domain of This Article
Pediatrics
Article-Type of This Article
Retrospective Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Author contributions: Zhang YL designed the research and wrote the first draft of the manuscript; Zhang YL, Zhou QY and Zhang P contributed to conceiving the research and analyzing data; Zhang YL, Huang LF, Jin L and Zhou ZG conducted the analysis; Zhang YL and Zhou ZG provided guidance for the research; All authors reviewed and approved the final manuscript.
Supported byHangzhou Medical and Health Technology Project, No. OO20191141.
Institutional review board statement: This study was approved by the Ethic Committee of Hangzhou Children’s Hospital.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: All authors declare that they have no conflicts of interest.
Data sharing statement: All data and materials are available from the corresponding author.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Zhi-Guo Zhou, MM, Doctor, Department of Surgical Anesthesia, Hangzhou Children’s Hospital, No. 195 Wenhui Road, Gongshu District, Hangzhou 310014, Zhejiang Province, China. 620zzg@163.com
Received: March 25, 2024 Revised: May 22, 2024 Accepted: June 5, 2024 Published online: August 6, 2024 Processing time: 98 Days and 19.8 Hours
Abstract
BACKGROUND
Preschoolers become anxious when they are about to undergo anesthesia and surgery, warranting the development of more appropriate and effective interventions.
AIM
To explore the effect of static cartoons combined with dynamic virtual environments on preoperative anxiety and anesthesia induction compliance in preschool-aged children undergoing surgery.
METHODS
One hundred and sixteen preschool-aged children were selected and assigned to the drug (n = 37), intervention (n = 40), and control (n = 39) groups. All the children received routine preoperative checkups and nursing before being transferred to the preoperative preparation room on the day of the operation. The drug group received 0.5 mg/kg midazolam and the intervention group treatment consisting of static cartoons combined with dynamic virtual environments. The control group received no intervention. The modified Yale Preoperative Anxiety Scale was used to evaluate the children’s anxiety level on the day before surgery (T0), before leaving the preoperative preparation room (T1), when entering the operating room (T2), and at anesthesia induction (T3). Compliance during anesthesia induction (T3) was evaluated using the Induction Compliance Checklist (ICC). Changes in mean arterial pressure (MAP), heart rate (HR), and respiratory rate (RR) were also recorded at each time point.
RESULTS
The anxiety scores of the three groups increased variously at T1 and T2. At T3, both the drug and intervention groups had similar anxiety scores, both of which were lower than those in the control group. At T1 and T2, MAP, HR, and RR of the three groups increased. The drug and control groups had significantly higher MAP and RR than the intervention group at T2. At T3, the MAP, HR, and RR of the drug group decreased and were significantly lower than those in the control group but were comparable to those in the intervention group. Both the drug and intervention groups had similar ICC scores and duration of anesthesia induction (T3), both of which were higher than those of the control group.
CONCLUSION
Combining static cartoons with dynamic virtual environments as effective as medication, specifically midazolam, in reducing preoperative anxiety and fear in preschool-aged children. This approach also improve their compliance during anesthesia induction and helped maintain their stable vital signs.
Core Tip: Preschoolers are particularly prone to anxiety when they are about to undergo anesthesia and surgery. As pharmacological and non-pharmacological interventions have disadvantages, this study explored a more suitable intervention to address preoperative anxiety and anesthesia induction cooperation in preschool-aged children undergoing surgery. This study examined and validated factors such as anxiety level, degree of cooperation during anesthesia induction, and vital signs. Static cartoons combined with dynamic virtual environments were as effective as midazolam in reducing preoperative anxiety and fear in preschool-aged children, improving cooperation with anesthesia induction, and maintaining stable vital signs.
Citation: Zhang YL, Zhou QY, Zhang P, Huang LF, Jin L, Zhou ZG. Influence of static cartoons combined with dynamic virtual environments on preoperative anxiety of preschool-aged children undergoing surgery. World J Clin Cases 2024; 12(22): 4947-4955
Undergoing anesthesia and surgery cause preschoolers to become anxious[1], which may be related to immature physical and psychological development. This is especially true for children who enter the operating room alone to face an unfamiliar environment, which is also among the perioperative challenges encountered with pediatric surgical patients[2,3]. Some children may have low compliance performance, such as violent crying, and even adverse reactions, such as postoperative eating difficulties and sleep disorders[4]. Current methods of alleviating children’s preoperative anxiety are include both pharmacological and nonpharmacological interventions[5,6]. The main pharmacological management is preoperative oral midazolam, which is also proven to reduce preoperative anxiety[7]. However, midazolam is associated with adverse reactions, such as respiratory depression, postoperative restlessness, irritability, behavioral changes, and prolonged recovery time[8]. Nonpharmacological approaches include interest games; pictorial preoperative education; distraction with toys, books, or videos; audiovisual interventions; electric vehicle rides into the operating room; and interactive games on tablet computers or smart phones[9]. These nonpharmacological methods not only smooth the transition to anesthesia induction in the children, but they also ensure stable anesthesia induction[10]. However, the medical cost is relatively high[11].
Static cartoons combined with dynamic virtual environments are a method of attention intervention suitable for preschool-aged children undergoing surgery that can be used in the preoperative preparation room and surgical corridor[12]. Static cartoons and dynamic virtual environments provide an immersive movie-watching experience for preschool-aged children undergoing surgery, shifting their attention to the scene preset by the projection environment and thus reducing preoperative anxiety and improving compliance[13,14]. Such a nonpharmacological intervention method is highly acceptable and has been applied clinically at our hospital. Static cartoons with dynamic virtual environments not only demonstrate intervention efficacy but are accepted by preschool-age children undergoing surgery, their parents, and medical staff[15]. Therefore, we believe that static cartoons combined with dynamic virtual environments represent a novel way of relieving children’s preoperative anxiety while serving as an important measure of promoting high-quality service and humanistic care.
Despite many studies of the use of nonpharmacological methods of reducing preoperative anxiety in preschool-age children, the effects of static cartoons combined with dynamic virtual environments have not been investigated. Therefore, this study: (1) Determined whether static cartoons combined with dynamic virtual environments could reduce preoperative anxiety in preschool-aged children and increase treatment compliance; and (2) Explored whether this approach was comparable to preoperative oral midazolam.
MATERIALS AND METHODS
General information
This retrospective study included 116 preschool-age children undergoing surgery between March and December 2021. It was approved by the Review Committee of Hangzhou Children’s Hospital. The inclusion criteria were being between 3 and 7 years of age, tolerant to general anesthesia, undergoing the first surgical treatment, and having. complete clinical data. The exclusion criteria were contraindication to anesthesia or surgery, history of surgery, mental disorders, severe hearing or visual impairment, and the use of psychoactive drugs. All the children were transferred from the surgical ward to the preoperative preparation room by nurses. The control group (n = 39) did not receive medication or any other intervention. The drug group (n = 37) received oral midazolam (0.5 mg/kg; max = 15 mg)[16] only; and the intervention group (n = 40) watched preselected static cartoons combined with dynamic virtual environments until entering the operating room. They received no other interventions.
Intervention methods
On the day before surgery, the anesthesiologist conducted routine preoperative visits to the three groups of children to understand their condition and establish basic trust with them. In addition, the medical staff told the child’s family, about the perioperative procedures including the anesthesia mode and possible postanesthesia complications and obtained signed consent for anesthesia induction. During the visit, the anesthesiologist collected the favorite cartoons, movie clips, radio stories, children’s programs, etc. from parents or guardians of children in the intervention group and prepared the static cartoons and dynamic virtual environments in the operating room according to the feedback obtained. The ward nurses informed the children’s families in detail about the preoperative precautions, including changing surgical gowns, wearing wristbands, the fasting period, surgical methods, and keeping the children warm to prevent hypothermia.
On the day of surgery, all the children were accompanied by a parent or guardian while being transported to the preoperative preparation room by nursing staff approximately 30 min minutes before the operation. A portable electrocardiogram (ECG) monitor was used to measure mean arterial pressure (MAP), heart rate (HR), and respiratory rate (RR) when the children were brought into the operating room: (1) Upon arrival at the preoperative preparation room, children in the intervention group were allowed to watch the static cartoons combined with dynamic virtual environments until they entered the operating room; (2) Children in the drug group were given midazolam (0.5 mg/kg) orally under the supervision of a traveling nurse when they arrived at the preoperative preparation room; and (3) The control group received no intervention during preoperative preparation. After each child was placed on the operating table, a percutaneous oxygen saturation meter was connected to his/her finger or toe, an ECG monitor replaced the portable ECG monitor, and a blood pressure cuff was placed and inflated every 10 m for blood pressure measurement. Two venous accesses were established, and a visiting nurse assisted the anesthesiologist in performing tracheal intubation and initiating anesthesia.
Outcome measures
Anxiety level: The children’s anxiety levels were assessed during the preoperative visit (T0), before leaving the preoperative preparation room (T1), on leaving the preoperative preparation room (T1), on entering the operating room (T2), and at anesthesia induction (T3) using the modified Yale Preoperative Anxiety Scale (mYPAS)[16]. The total possible score ranged from 21 to 100, with a score of > 30 indicating the presence of evident anxiety.
MAP, HR, and RR: MAP, HR, and RR were measured at the same four times as the anxiety. assessment using the ECG monitor. MAP = (systolic blood pressure + 2 × diastolic blood pressure)/3.
Compliance: The compliance of children with anesthesia induction at T3 was evaluated using the Induction Compliance Checklist (ICC)[17]. The total possible score was from 0 (smooth induction without any uncooperative behavior) to 10 (induction failure; that is, the child was completely passive and had very poor compliance).
Statistical analyses
Measurement data were reported as mean ± SD and count data were reported as number (percentage). One-way analysis of variance (ANOVA) was performed for normally distributed continuous variables. Non-normally distributed continuous variables, such as the time factor in the mYPAS-SF score, were compared using the nonparametric Kruskal–Wallis test. When significant differences were found, the Mann–Whitney U test and Bonferroni adjustment approaches were applied (comparisons among three groups). Differences in mYPAS-SF score, MAP, and HR over time among the three groups were compared using repeated measures ANOVA. Differences of categorical variables were compared using the χ2 test. Statistical analysis was performed using SPSS software with a significance level of P < 0.05.
RESULTS
General characteristics of subjects
No significant differences were found in age, sex, body mass, and other general characteristics among the three groups (Table 1) (P > 0.05).
The mYPAS score did not differ significantly among the three groups at T0 (P > 0.05), but increased in all three groups at T1, T2, and T3 (P < 0.05). The intervention group had a lower mean mYPAS score than the control group at both T1 and T2 (P < 0.05), a lower score than the drug group at T1 (P < 0.05), and a score comparable to those in the drug group at T2 and T3 (P > 0.05) (Figure 1 and Table 2).
Figure 1 Modified Yale Preoperative Anxiety Scale scores of the three patient groups.aP < 0.05 vs T0; bP < 0.01 vs T0; cP < 0.05 vs control group; dP < 0.05 vs drug group. mYAPS: Modified Yale Preoperative Anxiety Scale.
Table 2 Comparison of modified Yale Preoperative Anxiety Scale scores in the three study groups.
MAP, HR, and RR were similar among the three groups at T0 (P > 0.05). At T1 and T2, all three indexes increased in the three groups. The intervention group had lower MAP and RR than the drug and control groups at T2 (P < 0.05) and comparable levels to those of the drug group at T3 (P > 0.05). These indexes were significantly lower in the intervention and drug groups than in the control group (P < 0.05) at T3 (Figure 2 and Table 3).
Figure 2 Mean arterial pressure, heart rate, and respiratory rate in the three patient groups.
A: Mean arterial pressure; B: Heart rate; C: Respiratory rate. aP < 0.05 vs T0; bP < 0.01 vs T0; cP < 0.05 vs control group; dP < 0.05 vs drug group. HR: Heart rate; MAP: Mean arterial pressure; RR: Respiratory rate.
Table 3 Comparison of mean arterial pressure, heart rate, and respiratory rate in the three study groups.
The intervention and drug groups had similar ICC scores at T3 (P > 0.05), both of which were higher than that of the control group (P < 0.001) (Figure 3 and Table 4).
Surgery is a potent stressor that frequently induces various psychological problems in preschool-age children, among which preoperative anxiety is the most prevalent[18]. Anxiety caused by the separation of children from their parents can trigger physiological stress reactions (hyperhidrosis, cardiac acceleration, increased blood pressure, increased blood sugar, sleep disorders, etc.) and psychological stress responses (anxiety and fear) that can affect the nervous, endocrine, and circulatory systems if severe. These responses interfere with the smooth implementation of surgery and anesthesia[19]. Adverse intraoperative moods also influence postoperative recovery and immune resistance[20]. Anesthesia induction is the most threatening and painful stage for children undergoing surgery. Successful anesthesia induction reduces the preoperative use of sedatives and improves the anesthesia success rate[21]. The major manifestation of noncompliance during anesthesia induction is crying, which increases the occurrence of anesthesia-associated risks[22]. At the same time, children undergoing anesthesia induction in an extremely agitated state have a higher risk of intraoperative bleeding[23]. Therefore, nursing intervention before anesthesia induction in preschool-aged children is crucial in many respects.
In this study, the anxiety scores of the three groups of children were all higher at T1 than at T0, indicating the inevitability of separation anxiety in children undergoing surgery, which is in line with the results of Sola et al[24]. The anxiety level continued to increase in the control and drug groups at T2, whereas that of the intervention group was markedly lower. This is consistent with the results reported by Franzoi et al[25]. At T3, the drug and intervention groups had similar anxiety scores and both were significantly lower than that of the control group. These results indicate that children were sensitive to the external environment and became highly anxious in the unfamiliar environment[26]. However, static cartoons combined with dynamic virtual environments can effectively divert children’s attention[27], redirecting their focus from unfamiliar environments, effects that are similar to those of midazolam. Kerimoglu et al[28] reported that video glasses alleviated preoperative anxiety in children, much as midazolam did. However, assessment of the children’s vital signs revealed that MAP, HR, and RR increased in all three groups at T1, indicating renewed anxiety and physiological stress induced by separation from their parent or guardian. In the control group, MAP, HR, and RR remained high from T1 to T3. In the drug group, these indexes were high from T1 to T2 but had decreased at T3, indicating that midazolam helped stabilize the children’s vital signs. The MAP and RR of children in the intervention group were significantly lower than those in the control and drug groups at T2 and were comparable to those in the drug group at T3, indicating that intervention with static cartoons combined with dynamic virtual environments reduced surgery-induced stress. The effect that was comparable to that of midazolam therapy. After entering the operating room, anxiety results from both the unfamiliar environment and separation from their parents. At that time, the child’s greatest need is the assurance of their closest interpersonal relationship, that is, the company and comfort of parents[29,30]. Parental accompaniment can help children endure the anesthesia induction period smoothly and improve their compliance[31]. However, the operating room environment has strict sterile requirements. Furthermore, any changes in the child’s condition during anesthesia induction could affect the rational judgment of parents and hinder the performance of medical activities[32]. Therefore, parent–child companionship in the operating room is discouraged. Progressive brain development in preschool-aged children is indicated by increased eye movement and visual focusing control, improved visual perception and auditory sensitivity, and an increased interest in videos[33]. Therefore, this study simulated a warm and familiar atmosphere for children based on their inherent needs and interests through static cartoons and dynamic virtual environments to effectively divert their attention during preoperative preparation. Our results showed that at T3, the ICC scores of the children in the drug and intervention groups were significantly higher than those in the control group, indicating the effectiveness of watching static cartoons combined with dynamic virtual environments was similar to that of midazolam administration in reducing the anxiety levels of children and improving their compliance with anesthesia induction. These findings are similar to those reported by Simonetti et al[34].
This study has some limitations. First, the patients in this study were recruited from a single center, which may result in some information collection bias. Second, the small sample size (n = 116) may have limited the generalizability of the results. Third, other factors influencing preoperative anxiety and anesthesia induction cooperation in preschool children were not analyzed. Further studies are needed to address these limitations and further optimize the intervention implementing static cartoons combined with dynamic virtual environments.
CONCLUSION
The use of static cartoons combined with dynamic virtual environments was a safe and easily implemented preoperative intervention that reduced the anxiety of preschool-age children undergoing surgery, stabilize vital signs during anesthesia induction, and improve compliance during anesthesia induction. However, considering the small sample size and young age of the children included in this study, further investigation is required to determine the suitability of this program for older children.
Footnotes
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Medicine, research and experimental
Country of origin: China
Peer-review report’s classification
Scientific Quality: Grade C
Novelty: Grade C
Creativity or Innovation: Grade B
Scientific Significance: Grade C
P-Reviewer: Teixeira L, Portugal S-Editor: Liu H L-Editor: Filipodia P-Editor: Guo X
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