Should parents be present and assist during inhalational induction of their child? A survey of the APA

Introduction  During the entire peri‐operative period the most stressful procedure a child experiences is the induction of anaesthesia (1). In our experience it may often be the fear of a stranger holding a mask over the child's face that precipitates the child attempting to escape. We have found that some children will more readily accept the facemask if it is held by the familiar parent/carer rather than a trained stranger. This can reduce the stress the child experiences at induction. The aim of this survey was to determine a consensus view from UK paediatric anaesthetic consultants regarding their practice of involving parents in inhalational induction of children. Methods  A postal questionnaire was sent to all UK members of the APA. The results of replies were analysed. Results  The response rate was 64% (141/220). (4 retired members returned blank questionnaires). 51.8% (65/137) said that they would sometimes allow parents to hold the facemask where appropriate. 41.6% (57/137) of respondents have never allowed it and 6.6% (9/137) stated that they routinely allow it. Six respondents said that the concept had never occurred to them. Two of these six expressed an interest in trying this option in future practice. 79.6% (109/137) of responding APA members report that they have always been comfortable with controlled parental presence in the anaesthetic room. 62 of these 109 members have routinely or sometimes allowed these parents to assist in holding the facemask, quoting both a general reduction in child and parental anxiety in a stressful and alien environment allowing a smoother induction. 20.4% (28/137) said that during their consultant paediatric anaesthetic career their views towards parental presence and involvement during induction had changed. The majority of these respondents (22) said that they were more likely to involve the parents and a minority (six) stated that their views had become more negative and found their presence and involvement ‘rarely of help’ and ‘more trouble than it's worth'. 32% (44/137) reported having experienced a variety of critical incidents whilst involving parents in induction. 61 incidents were reported (17 respondents experienced more than one type of critical incident). Parents refusing to let go of their child once asleep was the most common problem (28/61), followed by parents fainting in the anaesthetic room during their childs induction (25/61). Six consultants said that they had experienced a child becoming cyanosed at induction and two reported a laryngospasm. Overview  The results of the survey show that the majority of responding APA members have always had (109/137), or have developed (22/137), positive views towards parental presence and assistance, where appropriate. The remaining 6 respondents expressed a fear of relinquishing control of the airway to an untrained person and in particular to one who is emotionally involved with the patient, although there were few reports of significant desaturation or laryngospasm. Of these six, three members said that involving the parent made induction slower and more demanding. The other three members stated that involving parents was unnecessary and inappropriate as they did not have the FRCA, and that this practice may as well lead to parents injecting propofol and performing regional blocks on their child! Discussion  The majority of responses to this survey indicate that there is already an environment within paediatric anaesthesia which accepts managed parental presence, with or without assistance at induction, yielding benefits for both parent and child if not always for the anaesthetist. It is possible that the failure of recent studies to show a benefit of parental presence, may be explained by the inclusion of data reflecting unmanaged parents who transmit their anxiety to their child, or the effects of the lack of an active, well briefed parental role (2,3,4). The issue which may require more investigation is that of how to manage the roles available to parents in varying states of anxiety balanced with the preoperative state of their child and the demands placed on the anaesthetist to control risk, thus maximising the real and perceived benefits available.