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along songs or videos to distract an inconsolable child. That's not to say all children react in this manner, but induction upsets many. Lingering effects This distress can last far beyond the minutes it takes for the gases to take effect. When a child suffers anxiety at induction, he often develops a greater degree of emergence delirium. In PACU, he often exhibits cry- ing fits and increased levels of pain. And it doesn't end there. Post-dis- charge, parents report such behaviors as regression, bedwetting, night- mares, separation anxiety, temper tantrums and distrust of medical per- sonnel. These may last weeks or months, with some on rare occasions extending up to a year. Parents also feel the stress of induction. Contrary to popular belief, parental presence in the OR doesn't necessarily alleviate the child's or the parents' anxiety. When parents exhibit clinically significant signs of distress, those feelings can transfer from parent to child. Mom or dad sit on the sidelines, ever watchful yet helpless as the child strug- gles against the anesthesia mask and well-meaning OR staff. The par- ent is told repeatedly the crying is "normal," the process, "standard." But does standard have to be accepted? Stress reduction To alleviate the anxiety, we've tried pharmacological modalities with mixed success. At one time, Versed (midazolam) was touted as the magic bullet. But the bullet missed the mark. In some children, oral midazolam causes a paradoxical effect. Instead of sedation, it causes agitation, aggression, restlessness and self-injury, making a bad situa- tion worse. The child's cooperation is imperative; an anxious child may refuse to drink it. Plus, in these days of fast turnovers, pre-op oral sedation may delay emergence from anesthesia and discharge. Anesthesia Alert AA 3 6 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • O C T O B E R 2 0 1 6