Psychologic
Preparation
Program
for Children
Undergoing
Acute
Appendectomy
Marie
Edwinson,
RN,
Einar
Arnbj#{246}rnsson, MD,
and
Rolt
Ekman,
MD
From the Departments of Pediatric Surgery and Psychiatry and Neurochemistry, University of Lund, Lund, Sweden
ABSTRACT. A psychologic preparation program was
developed for use prior to emergency surgery in chil-dren. The purpose of this study was to determine whether specific information prior to an emergency op-eration would reduce anxiety. The effect of the prepa-ration program was evaluated with clinical and labo-ratory procedures. One group of children who received only general verbal information was compared with an-other group who received specific information. The sub-jects were 24 patients and their parents. The children
were studied at four different clinical units prior to
op-eration, using the Visual Analogue Scale and pulse rate and blood pressure measurements. Stress hormone
1ev-els were measured at three of these clinical units.
Vis-ual Analogue Scales were administered to parents
three times prior to the child’s operation. The results were analyzed for within-group differences from one clinical unit to the next and for between-group differ-ences at the various clinical units. The results indicated
less anxiety in the children who received specific
in-formation. Catecholamine and 3-endorphin
measure-ments were not greatly different between the groups.
Pediatrics i988;82:30-36; preoperative psychologic preparation, appendectomy, surgery, stress, anxiety.
It is important that patients are properly
in-formed prior to medical and surgical
investiga-tions and treatments. Children, especially, are in
need of information to help them cope with their
imagination and to separate reality from fantasy.
This subject has been described in several
an-tides. Betz’ described how children are taught through play therapy and the behavioral signs of stress and they intensify in the absence of proper nursing interventions. Play therapy can be used
to alleviate distress.
Received for publication June 22, 1987; accepted Sept 17, 1987. Reprint requests to (M.E.) Department of Pediatrics, Univer-sity Hospital, 5-221 85, Lund, Sweden.
PEDIATRICS (ISSN 0031 4005). Copyright © 1988 by the
American Academy of Pediatrics.
Brown and Peake2 presented two different
pre-surgical programs, one for outpatients and one for inpatients. The aim ofthese programs was to help
children and their families adjust positively to a
hospital experience.
Stress prevention techniques can be used by nurses to promote behavioral and cognitive con-trols in pediatric patients, thereby reducing the child’s level of stress. This was the conclusion of
Poster and Betz.3
Tamnow and Gutstein4 investigated children’s
behavior prior to elective surgery and
demon-strated the value of studying children’s prepara-tory behavior and parent rating of symptoms and fearfulness following their child’s surgery. The surgical preparation program was a valid way to
improve children’s and parents’ preparatory
be-havior. Visintainer and Wolfer5 concluded that
children who received systematic preparation and
support by the nursing staff showed significantly
less upset and more cooperation and their parents
reported significantly greater satisfaction and
less anxiety than the other groups.
The purpose ofour study was to develop a
prepa-ration program. We gave specific information to
children prior to emergency surgery and we
eval-uated the program by Visual Analogue Scale scores and pulse rate, blood pressure, and stress
hormone measurements.
MATERIALS
AND
METHODS
The study population consisted of 24 children
(11 girls, 13 boys), admitted to the hospital con-secutively for acute abdominal pain and then
op-erated on for appendicitis; their median age was
11 years (range 5 to 14 years). One parent for each child (n = 24) was included in the study. No child
and the child and parent were observed. At the
time of admission the child was assigned to either group 1 (unprepared) or group 2 (prepared). Group 1 was made up of 12 children, five boys and seven girls. Ten had simple appendicitis and two had ruptured appendices. Ten of these children had
never been hospitalized before. This group was
prepared preoperatively by the operating surgeon
as has been the standard procedure. Group 2 con-sisted of 12 children, five boys and seven girls. Six
had simple appendicitis and six had ruptured
ap-pendicies. Nine of these children had never been
hospitalized before. These children were preop-eratively prepared by the operating surgeon and
according to the criteria of the psychologic
prepa-ration program, which included details ofthe
pre-operative and postoperative cane. The information
was given by the same surgeon, who also open-ated, to all children in the study, and the
prepa-ration program was administered by the nurse in
charge at the admission unit.
The psychologic preparation program consisted
of the following: (1) Material to be used for the
procedure was demonstrated, the purpose being
to aquaint the child with what he or she would see while still awake, eg, needle, syringe, sterile clothes, mask and cap, and anesthetic mask. A
doll was used as a model. (2) The procedure was
described by showing a book with photographs of
a child who had previously undergone an opera-tion. The illustrations showed events from pre-medication through induction of anesthesia and
ended with the child waking up after the
opera-tion. What was to be done during the operation was not described. That the child understood the
procedure was determined by the program nurse
and any misconception was corrected. The
meth-ods were a modification of those described by
Pe-tnillo and Sanger.6 The parent was present and
listening while the child received the specific in-formation from the nurse.
Stress
Registration
Stress was registered using the Visual Ana-logue Scale (VAS), a 10-cm graphical rating scale
labeled “very calm” (0 cm) at the left end and
“very afraid” (10 cm) at the right end. This
tech-nique is a modification ofthat described by Clarke
and Spear7 1964. The evaluations were carried
out in four clinical units during the
hospitaliza-tion: (1) in the emergency unit when the IV fluid was started. The groups were then both
unpre-pared; (2) in the admission unit. Group 1 was
in-formed per standard procedure, and group 2 was
also prepared with specific information according to program protocol. The evaluations were made
prior to premedication. The latter was
adminis-tered one hour before operation; (3) on admission
to the operating unit; and (4) preoperatively
be-fore anesthesia.
Pulse rate and blood pressure were measured
at clinical units 1, 2, and 4. In the emergency unit,
the children and parents were rated on the VAS
and the child’s pulse rate and blood pressure were
measured by the nurse on duty; this nurse was
not informed about the existence of the study or
about the purpose of the registration. In the ad-mission unit the nurse who had prepared the child
and performed the VAS registration was
neces-sanily aware of the study. She also administered
the VAS to the parent. The measurements in the
operating unit and before anesthesia were
per-formed by two different nurses who both were
un-aware of the study. The VAS was administered to
the parent by the nurse in the operating unit. As premedication, all children received either
diazepam, approximately 0.5 mg/kg, with
mom-phine, 0.15 mg/kg rectally, or morphine and sco-polamine 0. 1 mg/kg, intramusculany.
Stress
Hormones
Blood samples were drawn and analyzed for
stress hormones, ie, catecholamines (nonadrena-line and adrenaline), ACTH, cortisol, and 3-en-dorphin. One sample for these analyses was
ob-tamed in clinical units 1, 2, and 4, except for the
catecholamine analysis, for which samples were
taken only in clinical units 2 and 4, because, when
the IV fluid was started, insertion of the needle
increases the concentration of catecholamines.
The other stress hormones are probably not
af-fected at insertion of the needle. 3-Endorphin has
been described to increase at the beginning of
sun-gery.8
Analysis
of Stress
Hormones
Immunoactive ACTH was quantified using a
rabbit antiserum directed against ACTH 18-24 (k 11, Ferning AB, MalmO Sweden) in a final dilution
of 1 : 750,000. ‘251-labeled synthetic ACTH 1-24
was used as a tracer after QUSO (Silica G-32,
Philadelphia Quartz Co) purification. The limit of
sensitivity of this method is 8 pmol/L. The
intra-and interassay variations were 5% and 8% (n =
20), respectively. There was no cross-reactivity
against any neuropeptide obtained from the
proo-piomelancoitine precursor molecule except ACTH
1-24. For determination of cortisol we used a
nab-bit antiserum raised against cortisol
21-hemisuc-cinate-bovine serum albumin.9 For
Group Emergency
Unit
Admission Unit Operating Unit Introduction of
Anesthesia
Children
1 2.8 ± 3.3 3.9 ± 2.6k’ 0.8 ± 0.7 0.7 ± 0.8
2 7.7 ± 2.5a 0.7 ± 0.5’ 0.2 ± 0.1 0.2 ± 0.1
Parents
1 1.0 ± 2.r’ 2.9 ± 2.3c 0.8 ± 1.2
2 4.7 ± 2.5c 0.5 ± 0.3 0.2 ± 0.2
* Results are mean centimeters on the scale ± SD. Group 2 children (n = 12) were psychologically prepared preoperatively; group 1 children (n = 12) were not. Statistical significance determined by two-tailed paired t test: a p < .001, emergency unit v ad-mission unit; b p < .01, admission unit v operating unit; CP < #{216}5,admission unit v operating unit.
TABLE 1. Visual Analogue Scale in Four Units*
antiserum, with a lower limit of sensitivity of 12
pg/mL. This antiserum has a negligible
cross-reactivity against 3-lipotropin and the intra- and
interassay coefficients of variation were 7.2% (n
= 21) and 7.1% (n = 52), respectively.’0
Cate-cholamines were measured by high-pressure
liq-uid chromatography with electrochemical
detec-1
Statistical
Methods
The VAS must be regarded as, at best, an
on-dma! scale, and data obtained by this technique
are, therefore, preferably analyzed by
nonpara-metric procedures. Some measurements of
loca-tion and dispersion are, nonetheless, given as
mean values and standard deviations.
Further-more, for analysis of differences within groups
re-garding the various observations, we used the
paired t test (two-tailed)’2 ; although parametric,
the paired t test is reasonably tolerant in the
eva!-uation of mildly nonnonma! variables. We also
used the Mann-Whitney U test and Spearman
rank correlation’3 procedures. Comparisons of
child v parent reaction and pulse rate v child
me-action were also analyzed by simple 2
Wherever possible, two or more statistical
pro-cedures were tried, one as method of choice and
the other as corroborative. In some comparisons,
the paired t test was not usable because of extreme
departures from normality, but, in some such
cases, the differences between clinical units were
consistently unidirectional; here, the signs of
dif-ferences were evaluated by referral to a standard
binomial table,’3 assuming equal probabilities
(.5) for both positive and negative changes.
RESULTS
No statistically significant differences were
found between the groups regarding age or sex
distribution. The results are presented without
reference to the degree of the appendical
(inflam-mation) status.
The mean values and standard deviations of the
VAS ratings are given in Table 1. For group 1 the
level increased between emergency and
admis-sion units and decreased significantly between ad-mission and operating units (P < .01). For group
2, we found a statistically significant decrease
be-tween emergency and admission units (P < .01)
and between admission and operating units (P <
.01). For parents’ VAS scores, we found the same
statistically significant changes as for the chil-dren’s VAS scores. Furthermore, we found a
sta-tistically significant increase between emergency
and admission units for group 1 (P < .05).
The mean values and standard deviations for
pulse rate and blood pressure are shown in Table
2. For group 1, the pulse rates increased between
emergency and admission units and decreased
significantly between admission and operating
units (P < .05). For group 2, we found a
statis-tically significant decrease in pulse rates between emergency and admission units (P < .001), and the systolic blood pressure also decreased signif-icantly between the same units (P < .001).
As shown in Table 3 ACTH values increased moderately between the clinical units for both groups. The normal value is <70 ng/L. Cortiso! concentration increased significantly between emergency and admission units for group 1 (P <
.05) and decreased significantly between admis-sion and operating units (P < .05). In group 2, the levels of cortisol decreased significantly between emergency and admission units (P < .01) and again increased significantly between admission and operating units (P < .05). Normal values for cortisol during late afternoon and midnight are 80 to 360 nmol/L.
ad-TABLE 2. Pulse and Blood Pressure in Three Units*
Vital Sign and Group No. Emergency Admission Unit Operating Unit
Unit
Pulse rate (beats/mm)
1 77 ± 6 85 ± i5’ 70 ± 14
2 749a 60±3 60±3
BP (mm Hg)
Systolic
1 117 ± 8 115 ± 14 110 ± 12
2 125±8a 107±8 104±5
Diastolic
1 72±8 74±14 64±8
2 81±3 69±7 60±5
* Results are means ± SD. Group 2 children (n = 12) were psychologically prepared preoperatively; group 1 children (n = 12) were not. Statistical significance determined by two-tailed paired t test: a p < .ooi, emergency unit v admission unit; bp < .05,
admission unit v operating unit.
TABLE 3. Stress Hormone Determinations in Three Units*
Hormone and Group No. Emergency Unit Admission Unit Operating Unit
ACTH (ng/L)
1 45.9 ± 20.1
(23-87)
53.7 ± 24
(33-113)
62.3 ± 40.5
(25-133)
2 64.8 ± 79.0
(45-262)
70.3 ± 81.1
(45-246)
74.4 ± 90.4
(5-313) Cortisol (nmol/L)
1 342.1 ± 247.2’
(26-783)
567.7 ± 358.5k’ (122-1,072)
456.5 ± 444.39
(73-1,380)
2 628.9 ± 292.4’
(103-1,103)
450.7 ± i79.0’ (252-764)
483.3 ± 229.3
(279-1,052)” Noradrenaline (nmoLIL)
1 Notdone
Notdone
1.9 ± 1.0
(1.0-3.8)
1.6 ± 0.8
(0.8-3.7)
2 (2.2 ± 1.1
(0.8-4.8)
2.5 ± 1.3
(1.1-5.1) Adrenaline (nmol/L)
1 Not done
Notdone
0.5 ± 0.3
(0.2-1.4)
1.2 ± 1.2 (0.2-3.9)
2 1.1 ± 1.0
(0.2-3.6)
1.4 ± 1.3 (0.2-4.5)
3-endorphin (pg/mL)
1 20.4 ± 28.2
(10-106)
13.6 ± 12.1 (10-50)
20.9 ± 29.6
(10-108)
2 15.6 ± 12.6
(10-48)
16.5 ± 14.8 (10-52)
17.5 ± 19.9
(10-77)
* Results are means ± SD. Ranges of values are in parentheses. Group 2 children (n = 12) were psychologically prepared preoperatively. Group 1 children (n = 12) were not. Statistical significance determined by two-tailed binomial test: a p < .05, emer-gency unit v admission unit; bp < .05, admission unit v operating unit; CJ <
emergency unit v admission unit.
mission units from 20.4 to 13.6 pg/mL (normal <10 pg/mL) and increased again in the operating unit to the same levels as were found in the
emer-gency unit, but these changes were not
statisti-cally significant. In group 2, the 3-endorphin con-centration remained unchanged throughout the procedure.
The comparisons between groups 1 and 2 in the different observation clinical units for VAS,
cor-tisol concentration, pulse rate, and diastolic blood pressure are shown in Table 4. No other
param-etems showed significant differences using the Mann-Whitney U test.
In the emergency unit, children in group 2 were more afraid than children in group 1. In the ad-mission unit and operating unit, the results were reversed: group 1 children were more afraid than group 2 children (Fig 1).
For parents’ VAS scones, we found significant
Children’s reaction
10
5
0
0
0
0
0 0
0 Children stress tine
10
5
0
0 5 10 Parents
stress line
Fig 2. Correlation between parent and child on Ver-bal Analogue Scale in admission unit prior to preme-dication. L, Children psychologically prepared; 0, chil-dren not prepared.
TABLE
4. Comparisons Between Groups 1 and 2*Indicator Emergency Admission Unit Operating Unit
Unit
Verbal Analogue Scale
Children’s reaction <.01 <.01 <.05
Parent’s reaction <.01 <.05
Cortisol <.05
Pulse rate <.01
Diastolic BP <.05
* Results are P values. In the emergency unit, group 2 was consistently more frightened
than group 1; in admission and operating units, the opposite was found. Significance levels were estimated using the Mann-Whitney U test.
TABLE 5. Coefficients of Correlation for Selec ted Variables*
Related Variables Emergency Unit Admission Unit Operati ng Unit
Child u parent reaction <.53 <.001 <.94 <.001 <.74 <.001
on Verbal Analogue Scale
Pulse rate v child <.66 <.001 <.44 <.05 reaction on Verbal
Analogue Scale
* Results are P values determined by F test.
Emergency Admission Operating At induction
room unit unit of anoestesia
Fig 1. Children’s reactions on Verbal Analogue Scale at four stages prior to surgery. Results are means ±
SD determined by Mann-Whitney U test. , Children
psychologically prepared; C children not prepared.
For cortisol, the levels for group 2 were
signif-icantly higher than for group 1 in the emergency unit. Also, the diastolic blood pressure was sig-nificantly higher in group 2 in the emergency unit. In the admission unit, pulse rate was sig-nificantly higher in group 1.
The results of the VAS for children in the
dif-ferent observation units are shown in Fig 1. A
significant difference was found between the
un-prepared (group 1) and the prepared (group 2)
groups in the emergency, admission, and open-ating units.
The correlations between children’s and
par-ents’ VAS scores and between pulse rates and
child reaction (VAS) are given in Table 5.
Con-relation between child and parent reactions in
Correlation coefficient for parents’ and chil-dren’s VAS scores in the admission unit was .94 (Fig 2).
DISCUSSION
Children who were assigned to the preparation
program were significantly less anxietious
com-pared with those who were not, with regard to the children’s VAS scone in the admission unit after being given information and in the operating unit. The VAS score in group 1 first increased and then did not decrease significantly until after pre-medication. In group 2 the scores decreased sig-nificantly after the preparation program, which was performed prior to premedication (Table 1, Fig 1).
The recording of the VAS for group 2 done by the nurse in the admission unit might have been biased, because this nurse had given the infor-mation. But the decrease in pulse rate, blood pres-sure (Table 2), and cortisol (Table 3 a) level are in agreement with the VAS results in the admis-sion unit. The VAS administered by the anes-thetic nurse was a control and may also be in agreement with results in the latter clinical unit. Children with high values ofcortisol (Table 3) also had a high registration on the VAS; children with low values of cortisol also had a low registrations on the VAS.
ACTH increased similarly in both groups
be-tween the clinical units (admission unit and op-erating unit). The catecholamines (Table 3) did not change in the different clinical units, but the noradrenaline levels of nearly all children were increased: for group 1: 1.9 and 1.6 nmol/L; for group 2: 2.2 and 2.5; compared with normal: <0.4 nmol/L. This might be a sign of a stress reaction.
In group 1, when cortisol increased, the n-en-dorphin concentration decreased, and after pre-medication, -endorphin was back to the same level as in the emergency unit. We cannot explain this discrepancy. Levels in group 2 remained much the same throughout the procedure.
Cortisol levels and stress scores for children were similar. Statistically significant differences could, however, not be shown in the admission and operating units for cortisol (Table 4). This might be due to the extreme variance of cortisol levels: for one child in group 1 in the emergency unit, the cortisol concentration was 783 nmol/L, in the admission unit it was 1,072 nmol/L, and in the operating unit it was 546 nmol/L. For another child in group 2, the cortisol concentrations were 933, 290, and 286 nmol/L, respectively, in the three units. No statistical correlations between
the status of the appendices and hormonal levels were determined.
Other authors have used clinical parameters to evaluate stress. However, to the best ofour know!-edge, there has not been any comparison between stress rating scales and blood component values indicating stress.
The correlation between the child and parent scores in the different clinical units (Table 5, Fig 2) could be explained in at least two ways: if the child is calm, the parent is comfortable or, if the parent is calm, then the child is relaxed. Is pre-operative preparation important for the child, the parent, or both? Davies” found a positive corre-lation between the mother’s anxiety and behav-ioral upset shown by the hospitalized child. A fol-low-up study of the children in our series may me-veal whether the information given was best recollected by child or parent. In this study, the parents listened while the children were in-formed. In a previous study,’5 significant differ-ences were found between the unprepared and the prepared groups regarding satisfaction with the preoperative information. Parents in the prepared group did not need further information after the child had been prepared. This indicates that in-forming the parents is important; however, it is not yet possible to say whether it is more impor-tant to give detailed information to the child or only to the parents.
ACKNOWLEDGMENTS
Financial support was obtained from the Swedish Medical Research Council and the Medical Faculty of the University of Lund.
The authors thank E. Vinge, MD, PhD, Department of Clinical Pharmacology, University of Lund, for
anal-ysis of cathecolamines, and James Bergseng, for
sta-tistical advice and computer support.
REFERENCES
1. Betz L: Teaching children through play therapy. AORN J 1983;38:709-724
2. Brown B, Peake J: Presurgical education, establishing a
program. AORN J 1984;39:1163-1170
3. Poster E, Betz C: Allaying the anxiety ofhospitalized chil-dren using stress immunization techniques. Compre
Pe-diatr Nurs 1983;6:227-233
4. Tarnow J, Gutstein 5: Children’s preparatory behavior for
elective surgery. JAm Acad Psychoanal 1983;22:365-369
5. Visintainer M, WolferJ: Psychological preparation for
sur-gical pediatric patients: The effect on children’s and
par-ents’ stress responses and adjustment. Pediatrics
1978;56:187-201
6. Petrillo M, Sanger S: Instructions for all patients on the day ofsurgery, in Emotional Care ofthe Hospitalized Chil-dren, ed 2. Philadelphia, JB Lippincott Co, 1980, pp 292-293
7. Clarke P Spear FG: Reliability and sensitivity in the self-assessment of well-being, abstracted. Bull Br Psych Soc
1964;18A
8. Olsson GA, Olsson RD, Kastin AJ: Endogenous opiates: 1985. Peptides 1986;7:907-933
9. Thorell J, Larsson SM: Radioimmunoassay and Related
Techniques. St Louis, CV Mosby Co, 1978, pp 131-136 10. Bramnert M, Ekman R, Larsson I, et al: Characterization
and application ofa radioimmunoassay for beta-endorphin using an antiserum with negligible cross-reactivity against lipotropin. Regul Pept 1982;5:65-75
1 1. Eriksson BM, Persson BA: Determination of cathecolam-ines in rat heart tissue and plasma samples by liquid chro-matography with electrochemical detection. J Chromatog
1982;228:143-154
12. Armitage P: StatisticalMethods in MedicalResearch. Lon-don, Blackwell Scientific Publications, 1980
13. Siegel 5: Nonparametric Statistics for the Behavioral Sci-ences. New York, McGraw-Hill, 1956
14. Davies C: Mother’s anxiety may increase child’s distress. Nurs Mirror 1984;158:30-31
15. Edwinson M, Bj#{246}rkhem G, LundstrOm N-R: The values of increassed information to children prior to heart cathe-terization. Lakartidningen 1985;82:3500-3504
TOWARD
A REDUCTION
IN PUBLICATION
BIAS
Current practice results in the publication of many research studies in
medical and related disciplines which may be criticised on the grounds of
inadequate sample size and statistical power. Small studies continue to be carried out with little more than blind hope of showing the desired effect. Nevertheless, papers based on such work are submitted for publication, es-pecially ifthe results turn out to be statistically significant. There is confusion about what makes a result suitable for publication. Often there is a preference for statistically significant results at the peer review stage. Consequently published reports of small studies tend to contain too many false positive results and to exaggerate the true effects.
The use of a criterion of a posteniori power does not eliminate the bias; a priori power is the criterion of choice. This could be implemented by peer review ofstudy protocols at the planning stage by funding bodies and journals.
Submitted by R. G. Newcombe, PhD
