Healthcare teams should use right timing, technique to prepare children for heart surgery

American Heart Association
Tuesday, 18 November 2003

Healthcare professionals should individualize pre-procedural education to prepare children for heart surgery, says an expert American Heart Association panel.

Their recommendations, published in today's Circulation: Journal of the American Heart Association, suggest that children should be prepared based on age and previous experiences. For example, they say younger children may be less anxious if information is withheld until the day before surgery, while older children may benefit from having information about a week before. Too much information might increase the anxiety of some children who are undergoing invasive cardiac procedures, they said.

"Children who have been through surgery will often react differently than those who have not," said Sarah LeRoy, R.N., M.S.N., pediatric nurse practitioner at the University of Michigan Congenital Heart Center in Ann Arbor.

LeRoy, who led the writing group, said: "Our responsibility as healthcare providers is to help prepare children and adolescents in a way that ensures that these invasive procedures result in as little stress, anxiety and psychological trauma to young patients as possible.

"There is a large body of research that supports simple, low-tech interventions that can be done by a variety of healthcare practitioners, but these techniques have not been used much. Our goal was to pull together available research in a document that would outline these interventions so that healthcare providers can better prepare pediatric patients for cardiac procedures."

Recommendations in the guidelines include coping skills training such as relaxation techniques and guided imagery in which the child learns to focus on a positive, relaxing scene during times of stress.

Another idea is relaxation supported by biofeedback. Most children seem interested in the equipment used for biofeedback and lack the skepticism that some adult patients may have.

Refocusing techniques include using video games to distract children during procedures and having child-friendly waiting and procedure areas. Play therapy is a recommended form of communication for younger patients to present medical concepts. Using "props" such as syringes, masks and dolls with incisions can help prepare children for their hospital experience. For pre-teens and teenagers, child-to-child and parent-to-parent peer counseling has been shown to help patients cope with a cardiac procedure.

Typically, children who need invasive cardiac procedures have congenital heart disease, which affects eight out of every 1,000 live births, two or three of whom will require cardiac catheterization or surgical repair.

"For many patients, these procedures occur over a spectrum of developmental stages," LeRoy said. "They might need a procedure as an infant; another as a toddler; another as a 10-year-old; and still another at age 18. They often have unresolved fears and gaps in information from hospital experiences that occurred at very young ages."

The new guidelines offer these age-appropriate interventions to help ease tensions before cardiac procedures:

• For children from birth to age 2: maximize parental involvement in child's care; avoid separation from parents when possible; use a "blankie" or favorite toy to ease transitions; use adequate pain medication.
• For ages 2 to 7: books about going to the hospital; preoperative classes; medical "play"; refocusing exercises; favorite toy.
• For ages 7 to 11: brief verbal description of procedure using age-appropriate terminology; books about going to the hospital; medical "play" including anticipated sensory experience (pain, numbness, etc.); peer modeling tapes; coping skills training; biofeedback.
• For ages 12 to 15: information-giving, including anticipated sensory experience; peer counseling; peer modeling tapes; coping skills training; biofeedback.

The guidelines also suggest the timing of these interventions.

• For children age 2 and younger, interventions should be the day of, or during, the procedure.
• For those 2 to 7 years old, a 15-minute session the day before the procedure usually suffices. Some 6- to 7-year-olds may benefit from information as early as a week in advance.
• For children ages 7 to 11, information should begin one to two weeks before the procedure. For highly anxious or experienced children in this age group, coping skills training or biofeedback could begin as early as six weeks before the procedure.
• For children ages 12 to 15 years, information may begin when the decision for surgery/catheterization is made; peer counseling can be at any time; coping skills training and biofeedback may begin six weeks before the procedure.

"The bottom line is that not all interventions are for all people. There are factors that need to be assessed and then the intervention tailored accordingly," LeRoy said.

The report explains that everyone on the healthcare team who cares for the child, from physicians to nurses, social workers and pediatric psychiatrists, plays a role in educating children and their families about the interventions.

Co-authors are E. Marsha Elixson, R.Nc., M.S.; Patricia O'Brien, R.N., MSN.; Elizabeth Tong, R.N., M.S., FAAN.; Susan Turpin, R.N., M.S.; and Karen Uzark, R.N., Ph.D., FAAN.

For more information, or to contact American Heart Association, see their website at: www.americanheart.org