Children who refuse anesthesia or sedation: a survey of anesthesiologists

Background: Few articles have addressed the issue of the child who refuses anesthesia or sedation for surgery. A survey of members of the Society for Pediatric Anesthesia in the USA was conducted regarding their experience with pediatric refusal and assent for surgery. Methods: Structured response and open-end questions were used in a confidential postal survey to assess the following: details of cancellations, the use of, and attitudes to, physical restraint at induction, premedication, the management of a hypothetical case of child refusal and individual techniques used for uncooperative children. Results:Surveys were received from 453/852 anesthesiologists for a 57% response rate. Nine percent and 45% of respondents had cancelled one or more cases for child refusal in the past year and during their entire career respectively. Forty-four percent of respondents used restraint in the majority of children < 1 year of age, whereas only 2% did so in children > 11 years. Respondents were more uncomfortable with restraint in older children and less likely to proceed with induction. Twelve years was the median age when respondents would respect the child's refusal to proceed. Conclusions: Cancellation of planned surgery because of child refusal is not uncommon. It is important to recognize the potentially uncooperative child, particularly older children with developmental delay or a lack of understanding. Discussion with child and parents, selective use of premedication and different induction agents, distraction, play techniques, gentle restraint and the option of cancellation and review should all be considered.