In Reply:—

I thank Dr. Watson for her comments about parental presence at induction of anesthesia (PPIA). Dr. Watson suggests that “a more positive view of parental presence” should be adopted. I disagree. I believe that all interventions should be evidence-based, and, at the present time, no studies indicate that all children benefit from PPIA. 1In contrast, midazolam is uniformly effective without regard to age, temperament, or the child’s or parent’s anxiety level. 2In a busy anesthetic practice, it is easy to understand why midazolam is preferred to PPIA. Dr. Watson also contends that we ought to determine how parental presence “can be made more effective.” I agree. All parents should be required to attend a seminar on induction of anesthesia by responsible physicians, and their role and the limitations of their participation in the induction should be explained. The parents should then be screened: Those who are likely to be positive influences on their children would be permitted to accompany their child, and those who would be negative influences would not be permitted. This is not the standard in most institutions, most likely because of the enormous expense and time that would be needed. It has been my experience that parents request to accompany their child to induction without any preparation for the events that may ensue. Regarding the issue of cardiac dysrhythmias, Kataria et al.  3reported that arrhythmias occurred in 10% of parents during PPIA, with ventricular tachycardia developing in one parent. Finally, cultural, economic, and infrastructure issues are far more complex than alluded to by Dr. Watson. There are few multilingual nurses, few nurses who can leave a child at induction, few induction rooms, and limited resources to address PPIA programs in many institutions. I believe PPIA should be approached in the same manner as any new drug: Properly conducted studies must demonstrate its effectiveness and safety before it is released for widespread use by the public. Until that time, it should be a limited resource.

Kain ZN, Mayes LC, Caramico LA, Silver D, Spleker M, Nygren MM, Anderson G, Rimar S: Parental presence during induction of anesthesia: A randomized controlled trial. Anesthesiology 1996; 84: 1060–7
Kain ZN, Mayes LC, Wang SM, Caramico LA, Hofstadter MB: Parental presence during induction of anesthesia versus  sedative premedication: Which intervention is more effective? Anesthesiology 1998; 89: 1147–56
Kataria B, Christenson D, Montana J: (abstract). World Congress of Anesthesiologists, 1996, D820, p 456. Presented at: 11th World Congress of Anaesthesiologists; April 14–20, 1996; Sydney, Australia