Effects of the combination of mask preconditioning with midazolam pretreatment on anxiety and mask acceptance during pediatric inhalational induction and postoperative mask fear in children

Background Anxiety and fear frequently causes an aversion to applying a face mask and increases difficulty during pediatric induction. There is at present little study of this problem. Therefore, the aim of this study was to investigate the effect of the combination of mask preconditioning and midazolam pretreatment on mask acceptance during pediatric induction and on postoperative mask fear. Methods One hundred and sixty children were randomly assigned into four groups： the mask preconditioning group （MaG）, the midazolam pretreatment group （MiG）, the mask/midazolam combination group （Ma/MiG）, and the saline group （SAG）. The Modified Yale Preoperative Anxiety Scale （m-YPAS） was employed to assess the anxiety in the operation room （OR）. A Mask Acceptance Score （MAS） was measured during inhalational induction and the incidence of mask fear （MAS 〈2） was evaluated postoperatively. Results The MaG and Ma/MiG groups had the highest mask acceptance scores but there were no differences between these two groups （P 〈0.05）. The average anxiety level of children entering the OR was much lower in the MaG and Ma/MiG groups than in the SaG group （P 〈0.05）. During induction, the anxiety level increased in the SaG and MaG groups but decreased in the MiG and Ma/MiG groups （P 〈0.05）. At the postoperative third day, the incidence of mask fears was as high as 23% in the SaG group, 15% in the MiG group, but only 2.5% in the MaG and Ma/MiG groups. Conclusions The single use of mask preconditioning has a better influence than midazolam for increasing mask acceptance during inhalational induction and reducing postoperative mask fear, reducing the anxiety level during induction, improving induction compliance and shortening the total mask time. A mask preconditioning and midazolam combination did not increase mask acceptance during inhalational induction, reduce mask fears postoperatively, improve induction compliance, nor shorten the total mask time. But it can better reduce the anxiety level during induction.

Estimation of the minimum effective dose of tramadol for postoperative analgesia in infants using the continual reassessment method

Tramadol is a potent analgesic.However,the analgesia efficacy of tramadol,particularly its minimum effective dose(MED),is not clear.The aim of this study is to find MED of tramadol for postoperative analgesia in infants.The continual reassessment method(CRM)was performed to find MED.Infants undergoing surgeries were included in the 3 phases of this series.In each phase,24 participants were allocated a different tramadol dose.Pain intensity was measured by face,legs,activity,cry,consolability(FLACC)measurement at 3-hour intervals.Tramadol was considered ineffective if the FLACC score was higher than 4 in 10 at anytime.In phase 1,seven dose levels were used within the range 0.1-0.4 mg·kg^(-1)·h^(-1).Phase 1 was insufficient to identify the MED,and we increased the dose to 0.4-0.8 mg·kg^(-1)·h^(-1) in phase 2.Phase 2 was insufficient to identify the MED.In phase 3,local anesthetic wound infiltration was introduced,and the tramadol dose levels tested were the same as in phase 1.The successful analgesia probability of tramadol 0.4 mg·kg^(-1)·h^(-1) was 82.1%(95%CI,0.742-0.925)in phase 1.In phase 2,it was 84.7%(95%CI,0.789-0.991)with the dose 0.8 mg·kg^(-1)·h^(-1).Phase 1 and phase 2 were insufficient to identify the MED.In phase 3,the successful analgesia probability for dose 0.35 mg·kg^(-1)·h^(-1) was 96.7%(95%CI,0.853-0.997).We have demonstrated that tramadol provides insufficient analgesia for surgeries considered to cause moderate-to-severe postoperative pain in infants if used as the sole analgesic,and that local anesthetic wound infiltration enhances the efficacy of tramadol.