Acta anaesth. scand. 1977, 21, 541-544
Psychological Changes in Children after Anaesthesia: A Comparison between Halothane and Ketamine K. M. MOUVIG and S. FRIBERG NIELSEN Department of Anaesthesia, Centralsygehuset i Naestved, Nastved, Denmark
The psychological reactions to hospitalization, anaesthesia, and operation in a group of 107 children from 1 to 12 years old, anaesthetized with ketamine or halothane after randomization were investigated through questionnaires, which the parents answered 1 month postoperatively. The percentage of replies was 96.3%. Fifty-three children were anaesthetized with ketamine and 50 with halothane. Thirteen children in the ketamine group and nine in the halothane group reacted with negative personality changes; the reactions were of less than 1 month's duration and were most frequent in the youngest children. The parents' preparation of the children had no influence on the results. The number of personality changes caused by the two anaesthetic agents did not differ significantly. Furthermore, the investigation showed that nine children reacted for the better. Thirty-six per cent of the parents felt insufficiently informed of what the hospitalization implied for their child. Received 15 March, accepted for publication I1 April 1977
It is not easy to separate into separate components the psychological strain inflicted on children by hospitalization, anaesthesia and operation. This paper seeks to investigate whether a difference in the choice of anaesthetic agent changes the total strain, and if personality changes of some duration result. The investigation by ECKENHOFF (1953) showed that in children from 2 to 12 years old, personality changes occurred in 13-1 7% after otolaryngological operations, where the anaesthetic administered was cyclopropane, ether, and vinyl ether. GARFIELD (1974) has also attempted an analysis of the psychological stress in children relating to hospitalization. In this study we compared children anaesthetized with halothane, which is the most widely used inhalation anaesthetic for children in Denmark, with ketamine (Ketalar"), which is recommended as suitable for children (ROBERTS 1967, JENSEN et al. 1970a, PAGEet al. 1972). The ketamine was administered either intramuscularly or intra-
venously. It is well known that ketamine may cause hallucinations during recovery ; these may be of a pleasant or an unpleasant character in adults (CORSSENet al. 1966, JENSEN et al. 1970b COPPELet al. 1973), but this is reported to be the case only rarely in children (ROBERTS1967, MALESANIet al. 1974, THELANCET1976).
MATERIAL AND METHODS All children from 1 to 12 years old undergoing scheduled or emergency operations were included in the investigation if either anaesthetic could be used. The investigation, consisting of 107 children, was randomized: immediately before the induction of anaesthesia a n envelope was drawn which indicated which of the two anaesthetics was to be used. All the children were prernedicated with morphine/scopolamine intramuscularly 30 min before the anaesthetic. Children undergoing emergency operations were given gastric aspiration before anaesthesia. No parents were present during induction of anaesthesia. Postoperatively, the children were under observation in quiet conditions in a recovery unit. One month postoperatively, a questionnaire was
542
K. M. MODVIG A N D S. FRIBERG NIELSEN
sent to parents requesting the answer “yes”, “no”, or “don’t know” to the following questions: I ) Was your child afraid of strangers before hospitalization, and has this changed since the child has come home? 2) Was your child afraid of doctors and nurses before hospitalization, and has this changed since the child has come home? 3) Was your child subject to disturbed sleep before hospitalization, and has this changed since the child has come home? 4) Was your child subject to nightmares before hospitalization, and has this changed since the child has comr home? 5) Was your child subject to temper tantrums and fits of rage before hospitalization, and has this changed since the child has come home? 6 ) Was your child a bed-wetter before hospitalization, and has this changed since the child has come home? 7) Was your child afraid to have his face covered before hospitalization, and has this changed since the child has come home? 8a) Was it possible for you to prepare your child for hospitalization and the problems i t might cause? 8b) Were you sufficiently informed of what was going to happen during hospitalization so that you could tell your child about it? When the completed questionnaire had been studied, the anaesthetic record showing the anaesthetic agent used was looked at, and the questionnaires were grouped.
RESULTS Answers were received to 103 (96.3%) of the 107 questionnaires sent out. Fifty-three patients were anaesthetized with ketamine and 50 patients with halothane. T h e type of procedure is shown in Table 1. T h e recovery phase was uneventful for all the children and there were no signs of hallucinations. Thirteen children in the ketamine group and nine children in the halothane group Table I Type of procedure in relation to anaesthetic. Ketaminr IIalothanc No. of patients No. of patirnts
cystoscopy Herniorrhaphy and minor plastic surgery Skin grafting and skin dressing Orthopardic procedures Incision Ophthalmic procedures
5
6
16
12
2
r
20 I
16 1
9
10
Table 2. Psychological reactions after operation i n relation to anaesthetic and agr. Ketamine Type of psychological reactioii
Afraid of strangers, doctors and nurses Disturbed slerp and /or nightmares Temper tantrum and fits of rage Bed-wetter Afraid to have face covered
Halothane
No. of patients Age (yr) 1-3 4-7 8-12
‘I’otal
No. of patients Age (Yr) 1-3 4-7 8-12
?’oral
5
1
I
7
3
I
0
4
2 0
2 I
4
1
0 1
1 0
2 0 0 0
0
1 0
0 1 1
0
2
2 2 2
0
1
1
8 6 12
5 3 12
2 2
4
I1
4
4
20
18
9 50
0
2 3 0
~
No. of reactions No of patients with reactions Total no. of patients
5 18
3 3 23
16
13 53
Three patients in the ketamine group and two patients in thc halothane group showed more than one type of react ion. There was no statistically significant difference between the ketamine and halothane group (X*-test; P > 0.8).
CIIILDREN, ANAES I'HESIA reacted with personality changes which were ascribed to the hospitalization, anaesthesia, and operation. The distribution of age and reactions appears in Table 2. Among the children who were bed-wetters only one had a cystoscopy. As might be expected, the youngest children reacted most frequently to the strain, whilst the higher the age, the less frequent the reaction. No significant difference in reaction was found between the two anaesthetic groups, just as no significant difference was found in the frequency of reactions relating to whether it was an emergency or a scheduled operation. No statistically significant difference was found between the frequency of reactions in the children who had been prepared for the operation by parents and those who had not, either within the individual groups or between the groups. In all the cases the reactions were of less than 1 month's duration. A comparison between the halothane group and the ketamine group appears to show a higher frequency of personality changes in the children who were anaesthetized with ketamine, but the difference is not statistically significant. In 66 cases, the parents felt that they had been sufficiently informed to be able to prepare their children for the hospitalization, whilst 37 felt they were insufficiently informed. Furthermore, the investigation showed that some children reacted for the better; three children were no longer afraid of doctors and nurses, and three no longer suffered from sleep disturbance and/or nightmares. Four children were no longer subject to temper tantrums and fits of rage, and two children were no longer bed-wetters after hospitalization. The positive changes were distributed equally, with five children in the ketamine group and four children in the halothane group. DISCUSSION Several factors influence children's reactions
AND PSYCHOLOCICAL CHANGES
543
to hospitalization. As stated by GARFIELD (1974) the premorbid mentality comes into play, as well as a normal anxiety for the unknown and the change of surroundings, including a separation from the parents and family. ECKENHOFF(1953) found it was important how the child was prepared for the hospitalization and the discomfort an operation must necessarily cause ;likewise, he found that postoperative emotional disturbances may be attributed to inadequate preoperative sedation. As premedication in our investigation, morphine/scopolamine was chosen, as it has been found to be suitable for children, and is routinely used in this department. Moreover, BOVILLet al. (1971) have shown that morphine/scopolamine premedication for ketamine anaesthetization reduces the frequency of postoperative hallucinations to a greater extent than diazepam. I n order to elucidate the frequency of the emotional disturbances, questions were chosen which corresponded to Eckenhoff's investigation; we did not use supplementary psychological tests as these might influence the children and worry the parents unnecessarily. The questions asked did not affect the children and were only a small inconvenience to the parents. This is probably a contributory factor to the high percentage of replies (96.3%), which may, however, also be taken as an expression of a great interest on the part of the parents. Thirty-six per cent of the parents felt insufficiently informed as to what the hospitalization of their child implied, and better information for the parents is desirable. I t is remarkable that there is no difference in the frequency of reaction between the children whose parents had prepared them for the hospitalization and those whose parents had not; nor was there any difference between those who had emergency or scheduled operations. This may be due to the fact that the staff of the paediatric ward and the anaesthetic department are extremely careful to explain to the children what is happening around them and to them. When some children react with positive personality changes, this may be partly
544
K.
M. MODVIO AND
S. FRIBERG NIELSEN
because they have been cured of their illness, and partly because of the beneficial social influence which the hospital environment may have. It might be expected that an anaesthetic such as ketamine, which induces hallucinations in adults and teenagers, would have the same effect in younger children. It is likely that, although the children cannot describe these experiences, they would show a higher frequency of postoperative personality changes than after a more traditional anaesthetic like halothane. Many anaesthetists have been reluctant to administer ketamine to children because of the fear of inflicting emotional disturbances on them. Our investigation has not shown any statistically significant difference in the frequency of emotional disturbances in children anaesthetized with ketamine and halothane, and therefore we cannot confirm this fear.
ACKNOWLEDGEMENTS We wish to thank Mrs. Hanne Dalgas Christiansen, cand. act., of the Danish Medical Research Councfi for her statistical evaluations.
REFERENCES BOVILL,J. G., CLARKE,R. S. J., DLJNDEE,J. W. PANDIT,S . K. & MOORE,J. (1971) Clinical studies
of induction agents; XXXVIII: Effect of premedicants and supplements on ketamine anaesthesia. Brit. j.Anaesth. 43, 600. COPPEL,D. L., BOVILL, J. G. & DUNDEE, J. W. (1973) The taming of ketamine. Anaesthesia 28, 293. CORSSEN,G. & DOMINO,E. F. (1966) Dissociative anaesthesia: Further pharmacologic studies and first clinical experience with the phencyclidine derivative CI-581. Ancsth. Analg. 45, 29. ECKENHOPF, J. E. (1953) Relationship of anaesthesia to postoperative personality changes in children. Amer. 3. Dis. Child. 86, 587. GARFIELD,J. M. (1974) Psychologic problems i i i anesthesia. Amer. Fam. Physn 10,60. JENSEN, A. M. H. EGEBO,K., HANSEN, A,, JBRCENSEN, C. C. & ST~~RUP, A. G. (1970a) Ketalar" ((21-581): Et nyt kortvirkende anesthetikum. Nord. Med. 84, 1074. A. & STURUP, JENSEN,A. M. H., EGEBO,K., HANSEN, A. G. (1970b) Anaestesi med Ketalar" ti1 200 patienter. Nord. Med. 84, 123. MALESANI, G. C., F A N C H I O ~ G.I ,L., TROPEANO, S. & RIZZOLI,A. (1974) Neuropsychiatric effects of ketamine during and after anesthesia in children. Acta anaesth. ital. 25,417. PAGE,P., MORGAN, M. & LOH, L. (1972) Ketamine anaesthesia in paediatric procedures. Acta anaesth. scand. 16, 155. ROBERTS, F. W. (1967) A new intramuscular anaesthrtic for small children. Anaesthesia 22, 23. T H E LANCET (1976) Medical procedures in children. (Editorial.) Lancet i, 1335.
Address : Karen Margrcthe Modvig, M.D. Department of Anaesthesia Centralsygehuset i Nzstved 4700 Nastved, Denmark
Psychological Changes in Children after Anaesthesia: A Comparison between Halothane and Ketamine K. M. MOUVIG and S. FRIBERG NIELSEN Department of Anaesthesia, Centralsygehuset i Naestved, Nastved, Denmark
The psychological reactions to hospitalization, anaesthesia, and operation in a group of 107 children from 1 to 12 years old, anaesthetized with ketamine or halothane after randomization were investigated through questionnaires, which the parents answered 1 month postoperatively. The percentage of replies was 96.3%. Fifty-three children were anaesthetized with ketamine and 50 with halothane. Thirteen children in the ketamine group and nine in the halothane group reacted with negative personality changes; the reactions were of less than 1 month's duration and were most frequent in the youngest children. The parents' preparation of the children had no influence on the results. The number of personality changes caused by the two anaesthetic agents did not differ significantly. Furthermore, the investigation showed that nine children reacted for the better. Thirty-six per cent of the parents felt insufficiently informed of what the hospitalization implied for their child. Received 15 March, accepted for publication I1 April 1977
It is not easy to separate into separate components the psychological strain inflicted on children by hospitalization, anaesthesia and operation. This paper seeks to investigate whether a difference in the choice of anaesthetic agent changes the total strain, and if personality changes of some duration result. The investigation by ECKENHOFF (1953) showed that in children from 2 to 12 years old, personality changes occurred in 13-1 7% after otolaryngological operations, where the anaesthetic administered was cyclopropane, ether, and vinyl ether. GARFIELD (1974) has also attempted an analysis of the psychological stress in children relating to hospitalization. In this study we compared children anaesthetized with halothane, which is the most widely used inhalation anaesthetic for children in Denmark, with ketamine (Ketalar"), which is recommended as suitable for children (ROBERTS 1967, JENSEN et al. 1970a, PAGEet al. 1972). The ketamine was administered either intramuscularly or intra-
venously. It is well known that ketamine may cause hallucinations during recovery ; these may be of a pleasant or an unpleasant character in adults (CORSSENet al. 1966, JENSEN et al. 1970b COPPELet al. 1973), but this is reported to be the case only rarely in children (ROBERTS1967, MALESANIet al. 1974, THELANCET1976).
MATERIAL AND METHODS All children from 1 to 12 years old undergoing scheduled or emergency operations were included in the investigation if either anaesthetic could be used. The investigation, consisting of 107 children, was randomized: immediately before the induction of anaesthesia a n envelope was drawn which indicated which of the two anaesthetics was to be used. All the children were prernedicated with morphine/scopolamine intramuscularly 30 min before the anaesthetic. Children undergoing emergency operations were given gastric aspiration before anaesthesia. No parents were present during induction of anaesthesia. Postoperatively, the children were under observation in quiet conditions in a recovery unit. One month postoperatively, a questionnaire was
542
K. M. MODVIG A N D S. FRIBERG NIELSEN
sent to parents requesting the answer “yes”, “no”, or “don’t know” to the following questions: I ) Was your child afraid of strangers before hospitalization, and has this changed since the child has come home? 2) Was your child afraid of doctors and nurses before hospitalization, and has this changed since the child has come home? 3) Was your child subject to disturbed sleep before hospitalization, and has this changed since the child has come home? 4) Was your child subject to nightmares before hospitalization, and has this changed since the child has comr home? 5) Was your child subject to temper tantrums and fits of rage before hospitalization, and has this changed since the child has come home? 6 ) Was your child a bed-wetter before hospitalization, and has this changed since the child has come home? 7) Was your child afraid to have his face covered before hospitalization, and has this changed since the child has come home? 8a) Was it possible for you to prepare your child for hospitalization and the problems i t might cause? 8b) Were you sufficiently informed of what was going to happen during hospitalization so that you could tell your child about it? When the completed questionnaire had been studied, the anaesthetic record showing the anaesthetic agent used was looked at, and the questionnaires were grouped.
RESULTS Answers were received to 103 (96.3%) of the 107 questionnaires sent out. Fifty-three patients were anaesthetized with ketamine and 50 patients with halothane. T h e type of procedure is shown in Table 1. T h e recovery phase was uneventful for all the children and there were no signs of hallucinations. Thirteen children in the ketamine group and nine children in the halothane group Table I Type of procedure in relation to anaesthetic. Ketaminr IIalothanc No. of patients No. of patirnts
cystoscopy Herniorrhaphy and minor plastic surgery Skin grafting and skin dressing Orthopardic procedures Incision Ophthalmic procedures
5
6
16
12
2
r
20 I
16 1
9
10
Table 2. Psychological reactions after operation i n relation to anaesthetic and agr. Ketamine Type of psychological reactioii
Afraid of strangers, doctors and nurses Disturbed slerp and /or nightmares Temper tantrum and fits of rage Bed-wetter Afraid to have face covered
Halothane
No. of patients Age (yr) 1-3 4-7 8-12
‘I’otal
No. of patients Age (Yr) 1-3 4-7 8-12
?’oral
5
1
I
7
3
I
0
4
2 0
2 I
4
1
0 1
1 0
2 0 0 0
0
1 0
0 1 1
0
2
2 2 2
0
1
1
8 6 12
5 3 12
2 2
4
I1
4
4
20
18
9 50
0
2 3 0
~
No. of reactions No of patients with reactions Total no. of patients
5 18
3 3 23
16
13 53
Three patients in the ketamine group and two patients in thc halothane group showed more than one type of react ion. There was no statistically significant difference between the ketamine and halothane group (X*-test; P > 0.8).
CIIILDREN, ANAES I'HESIA reacted with personality changes which were ascribed to the hospitalization, anaesthesia, and operation. The distribution of age and reactions appears in Table 2. Among the children who were bed-wetters only one had a cystoscopy. As might be expected, the youngest children reacted most frequently to the strain, whilst the higher the age, the less frequent the reaction. No significant difference in reaction was found between the two anaesthetic groups, just as no significant difference was found in the frequency of reactions relating to whether it was an emergency or a scheduled operation. No statistically significant difference was found between the frequency of reactions in the children who had been prepared for the operation by parents and those who had not, either within the individual groups or between the groups. In all the cases the reactions were of less than 1 month's duration. A comparison between the halothane group and the ketamine group appears to show a higher frequency of personality changes in the children who were anaesthetized with ketamine, but the difference is not statistically significant. In 66 cases, the parents felt that they had been sufficiently informed to be able to prepare their children for the hospitalization, whilst 37 felt they were insufficiently informed. Furthermore, the investigation showed that some children reacted for the better; three children were no longer afraid of doctors and nurses, and three no longer suffered from sleep disturbance and/or nightmares. Four children were no longer subject to temper tantrums and fits of rage, and two children were no longer bed-wetters after hospitalization. The positive changes were distributed equally, with five children in the ketamine group and four children in the halothane group. DISCUSSION Several factors influence children's reactions
AND PSYCHOLOCICAL CHANGES
543
to hospitalization. As stated by GARFIELD (1974) the premorbid mentality comes into play, as well as a normal anxiety for the unknown and the change of surroundings, including a separation from the parents and family. ECKENHOFF(1953) found it was important how the child was prepared for the hospitalization and the discomfort an operation must necessarily cause ;likewise, he found that postoperative emotional disturbances may be attributed to inadequate preoperative sedation. As premedication in our investigation, morphine/scopolamine was chosen, as it has been found to be suitable for children, and is routinely used in this department. Moreover, BOVILLet al. (1971) have shown that morphine/scopolamine premedication for ketamine anaesthetization reduces the frequency of postoperative hallucinations to a greater extent than diazepam. I n order to elucidate the frequency of the emotional disturbances, questions were chosen which corresponded to Eckenhoff's investigation; we did not use supplementary psychological tests as these might influence the children and worry the parents unnecessarily. The questions asked did not affect the children and were only a small inconvenience to the parents. This is probably a contributory factor to the high percentage of replies (96.3%), which may, however, also be taken as an expression of a great interest on the part of the parents. Thirty-six per cent of the parents felt insufficiently informed as to what the hospitalization of their child implied, and better information for the parents is desirable. I t is remarkable that there is no difference in the frequency of reaction between the children whose parents had prepared them for the hospitalization and those whose parents had not; nor was there any difference between those who had emergency or scheduled operations. This may be due to the fact that the staff of the paediatric ward and the anaesthetic department are extremely careful to explain to the children what is happening around them and to them. When some children react with positive personality changes, this may be partly
544
K.
M. MODVIO AND
S. FRIBERG NIELSEN
because they have been cured of their illness, and partly because of the beneficial social influence which the hospital environment may have. It might be expected that an anaesthetic such as ketamine, which induces hallucinations in adults and teenagers, would have the same effect in younger children. It is likely that, although the children cannot describe these experiences, they would show a higher frequency of postoperative personality changes than after a more traditional anaesthetic like halothane. Many anaesthetists have been reluctant to administer ketamine to children because of the fear of inflicting emotional disturbances on them. Our investigation has not shown any statistically significant difference in the frequency of emotional disturbances in children anaesthetized with ketamine and halothane, and therefore we cannot confirm this fear.
ACKNOWLEDGEMENTS We wish to thank Mrs. Hanne Dalgas Christiansen, cand. act., of the Danish Medical Research Councfi for her statistical evaluations.
REFERENCES BOVILL,J. G., CLARKE,R. S. J., DLJNDEE,J. W. PANDIT,S . K. & MOORE,J. (1971) Clinical studies
of induction agents; XXXVIII: Effect of premedicants and supplements on ketamine anaesthesia. Brit. j.Anaesth. 43, 600. COPPEL,D. L., BOVILL, J. G. & DUNDEE, J. W. (1973) The taming of ketamine. Anaesthesia 28, 293. CORSSEN,G. & DOMINO,E. F. (1966) Dissociative anaesthesia: Further pharmacologic studies and first clinical experience with the phencyclidine derivative CI-581. Ancsth. Analg. 45, 29. ECKENHOPF, J. E. (1953) Relationship of anaesthesia to postoperative personality changes in children. Amer. 3. Dis. Child. 86, 587. GARFIELD,J. M. (1974) Psychologic problems i i i anesthesia. Amer. Fam. Physn 10,60. JENSEN, A. M. H. EGEBO,K., HANSEN, A,, JBRCENSEN, C. C. & ST~~RUP, A. G. (1970a) Ketalar" ((21-581): Et nyt kortvirkende anesthetikum. Nord. Med. 84, 1074. A. & STURUP, JENSEN,A. M. H., EGEBO,K., HANSEN, A. G. (1970b) Anaestesi med Ketalar" ti1 200 patienter. Nord. Med. 84, 123. MALESANI, G. C., F A N C H I O ~ G.I ,L., TROPEANO, S. & RIZZOLI,A. (1974) Neuropsychiatric effects of ketamine during and after anesthesia in children. Acta anaesth. ital. 25,417. PAGE,P., MORGAN, M. & LOH, L. (1972) Ketamine anaesthesia in paediatric procedures. Acta anaesth. scand. 16, 155. ROBERTS, F. W. (1967) A new intramuscular anaesthrtic for small children. Anaesthesia 22, 23. T H E LANCET (1976) Medical procedures in children. (Editorial.) Lancet i, 1335.
Address : Karen Margrcthe Modvig, M.D. Department of Anaesthesia Centralsygehuset i Nzstved 4700 Nastved, Denmark
