Surgery can be a time of intense psychological stress, for both the child and the parents, and the stress comes from several sources. First, there is often a lot of anticipatory anxiety leading up to arrival at the operating room (OR). Second, a significant percentage of children may experience anxiety when separated from their parents. Finally, induction can be one of the most challenging times of the perioperative period for the child. The anesthesia provider’s job is to minimize all of these stresses for both the parent and the child and still accomplish a safe and expeditious induction.

A number of different interventions, which are discussed elsewhere (see Chapter 118), are useful to reduce preoperative anxiety. These interventions include play therapy with distraction techniques and pharmacologic interventions. For relieving separation anxiety for both the patient and the parent as well as for increasing the patient’s compliance in the OR, it has become common practice in many centers to allow one parent to accompany the child to the operating suite. The decision to allow parents into the operating room is still controversial—there are advantages and disadvantages. The obvious benefit of parental presence during induction is that it eliminates the need to separate the child from the parent while the child is still awake. In some cases, parental presence in the OR may eliminate the need for preoperative medication of the child, which can be particularly useful when the risks of using such medication may outweigh the benefits. A parent’s presence in the OR decreases the child’s fears relating to the unfamiliar OR environment. In both pre-school and school-age children, watching the parent dress up in the gown, mask, and cap can be a humorous distraction. It can be comforting for the child to have his parent with him while being introduced to the unfamiliar OR environment and to sit in the parent’s lap until induction is complete.

There are also several potential drawbacks to parental presence at induction of anesthesia. The presence of an anxious parent can actually increase the anxiety of the child, even at very young ages. During the preoperative interview, the anxiety level of the parents must be assessed and taken into account when deciding whether a parent should be invited to accompany
the child. A parent should not be allowed into the operating suite solely to calm his or her own fears. It is better to calm the parent’s fears by engaging them in an open and relaxed discussion about the procedure and the risks and benefits of anesthesia.

The presence of parents in the OR depends, to a certain extent, on the institution’s culture. At some hospitals, a parent almost always comes into the OR, with very few exceptions, whereas, at other hospitals, parents quite rarely enter the OR. Regardless of what the local culture is, the final decision of whether to invite the parent into the OR for induction is the anesthesiologist’s decision. In making this decision, the anesthesiologist must balance the needs of the parents, patient, OR staff, and anesthesia staff. Most experienced anesthesiologists evaluate each family on a case-by-case basis in the preoperative area, taking into account the child’s age, activity level, and overall temperament as well as the baseline anxiety level of the parent. You should consider your options carefully before inviting a parent to enter the OR. Parents that are very upset or hostile are best not brought back to the OR. Non-English speaking parents are generally not good candidates to be present at induction. Generally, only one parent is invited to enter the OR; virtually all experienced anesthesiologists feel that having more than one family member present is a mistake. Finally, in certain emergent or trauma cases, having a parent present might not be appropriate. Once a decision is made, it should be clearly and openly communicated to the parent, with a focus on the child’s safety as the ultimate goal.