Measurement of plasma catecholamine concentrations. An assessment of anxiety

Association between preoperative anxiety and postoperative delirium in older patients: a systematic review and meta-analysis

BACKGROUND

Postoperative delirium (POD) is a common postoperative complication associated with multiple adverse consequences on patient outcomes and higher medical expenses. Preoperative anxiety has been suggested as a possible precipitating factor for the development of POD. As such, we aimed to explore the association between preoperative anxiety and POD in older surgical patients.

METHODS

Electronic databases including MEDLINE (via PubMed), EMBASE (via Embase.com), Web of Science Core Collection, Cumulative Index to Nursing and Allied Health Literature (CINAHL Complete; via EBSCOhost) and clinical trial registries were systematically searched to identify prospective studies examining preoperative anxiety as a risk factor for POD in older surgical patients. We used Joanna Briggs Institute Critical Appraisal Checklist for Cohort Studies to assess the quality of included studies. The association between preoperative anxiety and POD was summarized with odds ratios (ORs) and 95% confidence intervals (CIs) using DerSimonian-Laird random-effects meta-analysis.

RESULTS

Eleven studies were included (1691 participants; mean age ranging between 63.1-82.3 years). Five studies used a theoretical definition for preoperative anxiety, with the Anxiety subscale of Hospital Anxiety and Depression Scale (HADS-A) as the instrument being most often used. When using dichotomized measures and within the HADS-A subgroup analysis, preoperative anxiety was significantly associated with POD (OR = 2.17, 95%CI: 1.01-4.68, I² = 54%, Tau² = 0.4, n = 5; OR = 3.23, 95%CI: 1.70-6.13, I² = 0, Tau² = 0, n = 4; respectively). No association was observed when using continuous measurements (OR = 0.99, 95%CI: 0.93-1.05, I² = 0, Tau² = 0, n = 4), nor in the subgroup analysis of STAI-6 (six-item version of state scale of Spielberger State-Trait Anxiety Inventory, OR = 1.07, 95%CI: 0.93-1.24, I² = 0, Tau² = 0, n = 2). We found the overall quality of included studies to be moderate to good.

CONCLUSIONS

An unclear association between preoperative anxiety and POD in older surgical patients was found in our study. Given the ambiguity in conceptualization and measurement instruments used for preoperative anxiety, more research is warranted in which a greater emphasis should be placed on how preoperative anxiety is operationalized and measured.

Association of perioperative midazolam use and complications: a population-based analysis

INTRODUCTION

The benzodiazepine midazolam is the main sedative used in the perioperative setting, resulting in anxiolysis and a reduction in anesthetic dose requirements. However, benzodiazepine use is also associated with potentially serious side effects including respiratory complications, and postoperative delirium (POD). A paucity of population level data exists on current perioperative midazolam use in adult orthopedic surgery and its effects on complications. Using a large national dataset, we aimed to determine perioperative midazolam utilization patterns and to analyze its effect on postoperative outcomes.

METHODS

Patients who underwent total knee and hip arthroplasty (TKA/THA) were identified from Premier database (2006-2019). Primary exposure of interest was midazolam use on the day of surgery. Multivariable logistic regression models were run to determine if midazolam was associated with postoperative cardiac and pulmonary complications, delirium, and in-hospital falls.

RESULTS

Among 2,848,897 patients, more than 75% received midazolam perioperatively. This was associated with increased adjusted odds for in-hospital falls in TKA/THA (OR 1.1, 95% CI 1.07 to 1.14)/(OR 1.1, 95% CI 1.06 to 1.16), while a decrease in the adjusted odds for cardiac complications in TKA/THA (OR 0.94, 95% CI 0.91 to 0.97)/(OR 0.93, 95% CI 0.89 to 0.97), and pulmonary complications (OR 0.92, 95% CI 0.87 to 0.96) (all p<0.001) was seen. Most notably, the concurrent use of midazolam and gabapentinoids significantly increased the adjusted odds for postoperative complications, including pulmonary complications (OR 1.22, 95% CI 1.18 to 1.27)/(OR 1.29, 95% CI 1.22 to 1.37), naloxone utilization (OR 1.56, 95% CI 1.51 to 1.60)/(OR 1.49, 95% CI 1.42 to 1.56), and POD (OR 1.45, 95% CI 1.38 to 1.52)/(OR 1.32, 95% CI 1.23 to 1.34) in THA/TKA.

CONCLUSION

Perioperative midazolam use was associated with an increase in postoperative patient falls, and a decrease in cardiac complications. Notably, the combined use of midazolam and gabapentinoids was associated with a substantial increase in the odds for respiratory failure and delirium. Given the high prevalence of benzodiazepines perioperatively, the risk benefit profile should be more clearly established to inform perioperative decision making.

Effect of an Information Video before Thyroid Biopsy on Patients Anxiety

AIM

To investigate the effects of video-based information on the anxiety of patients who underwent ultrasound-guided thyroid fine-needle aspiration biopsy.

METHODS

Fifty consecutive patients who underwent thyroid fine needle aspiration biopsy were included in the study prospectively. Patients were divided into two groups before the biopsy. 25 patients in Group 1 received only written information about thyroid biopsy. In Group 2, 25 patients received video-based information along with written information. Baseline anxiety of all the patients was evaluated prior to procedure using STAI-S and STAI-T questionnaires. After the written information was provided to the patients in group 1, the STAI-S questionnaire was repeated. In the same way, group 2 patients were asked to repeat the STAI-S questionnaire after written and video-based information were provided. All patients were asked to evaluate pain during biopsy using visual analog scale (VAS).

RESULTS

There was no significant difference between the groups in terms of age and gender. Although the VAS score was lower in group 2, there was no statistically significant difference between the two groups. When the groups were compared in terms of basal anxiety scores, STAI-T was similar in both groups (p = 0.708). Although STAI-S values were similar in pre and post-information patients in Group 1, the STAI-S values in group 2 were statistically significantly decreased.

CONCLUSION

The video based information provided prior to thyroid biopsy draws the attention as an effective and easy to apply method to decrease the anxiety of the patients.

Rare Association of Takotsubo Cardiomyopathy with Right Bundle Branch Block in the Dual Setting of Asthma Exacerbation and Psychiatric Illness

Patient: Male, 58-year-old

Final Diagnosis: Takotsubo cardiomyopathy

Symptoms: Dyspena

Medication:—

Clinical Procedure: —

Specialty: Cardiology

Patient-reported pain, discomfort, and anxiety during magnetic resonance imaging-targeted prostate biopsy

INTRODUCTION

The addition of targeted prostate biopsy to systemic biopsy impacts patient experience. We examined patient-reported pain, discomfort, anxiety, and tolerability among men undergoing magnetic resonance imaging (MRI)-targeted prostate biopsy in addition to transrectal ultrasound-guided systematic biopsy compared to those undergoing systematic biopsy alone.

METHODS

All patients underwent transrectal systematic 14-core biopsies. Patients with regions of interest on MRI underwent additional targeted biopsies. All patients received equivalent periprostatic nerve block. Four single-item, standard, 11-point numerical rating scales evaluating pain, discomfort, anxiety, and tolerability were completed immediately after biopsy. Differences in means were compared using t-tests. Correlation between rated domains was tested using Spearman's correlation coefficient.

RESULTS

Of 273 consecutive patients, 195 (71%) underwent targeted biopsy and 188 (69%) had undergone prior biopsy. In all men, the median score for pain and tolerability was 3, while the median score for discomfort and anxiety was 4. Pain was rated at 7 or above by 15% of patients. Moderate correlation between pain, discomfort, anxiety, and tolerability of repeat biopsy was observed (Spearman's ρ between 0.48 and 0.76). Compared to patients undergoing systematic biopsy alone, men who received both targeted and systematic biopsies reported higher anxiety scores (difference 1.2; 95% confidence interval [CI] 0.4-2.0; p=0.004) and discomfort (difference 1.0; 95% CI 0.3-1.7; p<0.001).

CONCLUSIONS

Patients undergoing targeted and systematic biopsies report more discomfort and anxiety than patients undergoing systematic biopsies alone. Absolute differences are small, and patients are willing to undergo repeat biopsy if advised. Interventions to reduce biopsy-related anxiety are needed.

An oral presentation causes stress and memory impairments

Laboratory experiments revealed the stress hormone cortisol to decrease memory retrieval of emotional material, but a translation to real-life settings is missing so far. In this study, 51 students encoded a list of neutral, positive, and negative words as well as two neutral, biographical notes one day before attendance at a seminar at the university. In the stress condition, students gave a graded oral presentation, whereas they just attended the same seminar in the control condition immediately before retrieval took place. Measures of state anxiety, salivary cortisol and alpha-amylase confirmed the oral presentation to constitute a potent stressor. Importantly, stress significantly impaired retrieval of negative words, but not retrieval of the biographical notes. These results indicate that a real-life stressor decreases memory retrieval for negative items. In contrast, delayed memory retrieval of neutral information and interrelated details of biographical notes seems to be less prone to stress effects. These results have critical implications for educational settings.

Testing eye temperature assessed with infrared thermography to evaluate stress in meat goats raised in a semi-intensive farming system: a pilot study

The Blanca Serrana goat is selected for meat production and usually raised in an extensive farm system. The meat goat industry is getting bigger in Spain, evolving to more intensive farming systems. The negative influence of stress produced by daily management on animal welfare is even bigger in these animals as they are not used to getting so close to humans. Eye temperature has recently appeared as an appropriate and noninvasive tool for welfare assessment in cattle, but no previous studies have been developed in goats. Thus, the main aim of this pilot study was to test eye temperature as a noninvasive tool to explore stress levels associated with a semi-intensive farming system for meat goats in comparison with the standard measurements of stress. For that, 24 Blanca Serrana goats were used. Heart rate (HR), respiratory rate (RR) and eye temperature (ET), assessed with infrared thermography samples, were collected just before and just after a stressful situation created to check how the routine management of semi-intensive farming systems affected this species. A factorial ANOVA, least square means and Scheffé post hoc comparison analyses found statistically significant differences due to the stress test moment for RR ( p < 0.05 ) and ET ( p < 0.001 ) with higher values shown after the stress test than before it. Differences due to age were found just for HR ( p < 0.05 ) and RR ( p < 0.01 ) stress parameters, with kids showing higher results than adults. Pearson correlations between HR, RR and ET parameters showed a medium-high positive correlation of 0.56 between RR and ET. Thus, ET appears as an appropriate and noninvasive tool to explore stress levels associated with a semi-intensive farming system for meat goats.

Preoperative education reduces preoperative anxiety in cancer patients undergoing surgery: Usefulness of the self-reported Beck anxiety inventory

Background and objectives

Methods

Results

Conclusions

Preoperative Needs-Based Education to Reduce Anxiety, Increase Satisfaction, and Decrease Time Spent in Day Surgery: A Randomized Controlled Trial

BACKGROUND

Too much or too little information during patient education can increase patient anxiety. Needs-based patient education helps to determine the appropriate amount of information required to provide education based on patient needs. This study aimed to compare needs-based patient education with traditional patient education in reducing preoperative anxiety.

METHODS

This was a prospective, multicenter, single-blind, randomized controlled trial with a 1:1 allocation ratio. Patients undergoing day surgery were randomized into a study group (needs-based education) or a control group (traditional education). The primary outcome was patient anxiety. Secondary outcomes were patient satisfaction and time spent in patient education. Patients completed questionnaires to evaluate their anxiety and satisfaction before patient education, after patient education, and after surgery.

RESULTS

In total, 450 patients were randomized and analyzed (study group n = 225, control group n = 225). Comparisons before education, after education, and after surgery showed that there was a significant decrease in patient anxiety and an increase in satisfaction in both groups (p < 0.001). The comparison between needs-based education and traditional education showed a greater decrease in anxiety (7.09 ± 7.02 vs. 5.33 ± 7.70, p = 0.001) and greater increase in satisfaction (21.1 ± 16.0 vs. 16.0 ± 21.6, p < 0.001) in the needs-based group. The needs-based group also had significantly less education time than the traditional group (171.8 ± 87.59 vs. 236.32 ± 101.27 s, p < 0.001).

CONCLUSION

Needs-based patient education is more effective in decreasing anxiety, increasing patient satisfaction, and reducing time spent in education compared with traditional patient education.

TRIAL REGISTRATION

ClinicalTrials.gov, number NCT03003091.

The Measurement of Preoperative Anxiety

Preoperative anxiety was assessed using the hospital anxiety and depression (HAD) scale, multiple affect adjective check list (MAACL) and linear analogue anxiety scale (LAAS) in 100 consecutive day case patients undergoing termination of pregnancy. The HAD scale, a recently introduced self assessment scale comprising 7 multiple choice questions, was readily accepted and easily understood by patients. There was a high degree of correlation between the HAD scale and both the MAACL (correlation coefficient 0.74) and the LAAS (correlation coefficient 0.67). There was only a moderate degree of correlation between the HAD scale and the anaesthetist's assessment of anxiety (correlation coefficient 0.46). The HAD scale is a useful method of subjective measurement of preoperative anxiety.

Psychiatric Illness in Takotsubo (Stress) Cardiomyopathy: A Review

BACKGROUND

Takotsubo cardiomyopathy (TC), also known as stress-induced cardiomyopathy, has been increasingly described in relation to psychiatric illness.

METHODS

We performed a literature review to identify the key findings related to psychiatric illness in TC that may be relevant to the practice of mental health and other health care providers.

RESULTS

The association of psychiatric illness with TC in addition to the spectrum of psychiatric illness found in TC, the role of exacerbation or treatment of psychiatric illness in triggering TC, different modes of presentation, prognostic implications, and long-term management of psychiatric illness in TC are discussed. Additionally, we review the limitations of the pre-existing literature and suggest areas of future research.

CONCLUSIONS

There is a strong association between pre-existing psychiatric illness, particularly anxiety and mood spectrum disorders, and TC. Acute exacerbation of psychiatric illness, rapid uptitration or overdose of certain psychotropic agents, and electroconvulsive therapy may trigger TC. Further studies are needed to better evaluate the prognostic significance and long-term management of psychiatric illness in TC.

Prevention and Intervention Strategies to Alleviate Preoperative Anxiety in Children

Preoperative anxiety (anxiety regarding impending surgical experience) in children is a common phenomenon that has been associated with a number of negative behaviors during the surgery experience (e.g., agitation, crying, spontaneous urination, and the need for physical restraint during anesthetic induction). Preoperative anxiety has also been associated with the display of a number of maladaptive behaviors postsurgery, including postoperative pain, sleeping disturbances, parent-child conflict, and separation anxiety. For these reasons, researchers have sought out interventions to treat or prevent childhood preoperative anxiety and possibly decrease the development of negative behaviors postsurgery. Such interventions include sedative premedication, parental presence during anesthetic induction, behavioral preparation programs, music therapy, and acupuncture. The present article reviews the existing research on the various modes of intervention for preoperative anxiety in children. Clinical implications and future directions are discussed.

Psychosocial implications of pediatric surgical hospitalization

The prevalence of childhood surgical illness and injury requiring hospitalization suggests the need for implementation of an applied intervention to decrease levels of anxiety in these patients. When psychological concerns are not addressed in the present moment, potential for long-term negative psychological effects occur. To respond to the psychosocial needs of pediatric surgical patients it is important to understand foundational stages of development. Age is not always directly correlated with developmental stage and attunement to this subtle differentiation is essential. Some medical facilities offer services to pediatric surgical patients that include education about upcoming procedures as well as medical play which offers the opportunity to express emotions correlated with the hospitalization experience. This approach is directive in nature and controls the process of making sense of the medical environment. An alternative is Child Centered Play Therapy (CCPT) which creates an outlet for any emotions the children choose to express. CCPT offers comprehensive mental health care through a developmentally-appropriate, undirected intervention carried out by a mental health therapist and has been shown to reduce perceived and actual psychological trauma, anxiety, and behavioral issues in children preparing for surgery.

Teaching the psychosocial aspects of pediatric surgery

The optimal care of children with surgical diseases requires acquiring skills in the psychosocial assessment and therapy of children. Developing and implementing a curriculum to teach these concepts to pediatric surgery trainees should result in decreased perioperative stress for the child and improved patient outcomes and family satisfaction.

Availability of preoperative anxiety scale as a predictive factor for hemodynamic changes during induction of anesthesia

Background

The current study evaluated whether the level of preoperative anxiety assessed by the state-trait anxiety inventory (STAI) affects cardiovascular response during anesthetic induction. Furthermore, we evaluated the utility of the preoperative anxiety scale as a predictive factor for hemodynamic changes.

Methods

One hundred twenty patients who were scheduled to undergo elective surgery under general anesthesia were enrolled in this prospective study. The patients were asked to fill out STAI questionnaires the night before the day of surgery. For 5 minutes after tracheal intubation, changes in vital signs were recorded. The correlation between STAI scores and the percent changes in vital signs during the induction of anesthesia for each subgroup was assessed. In addition, the predictability of the 20% change in vital signs by STAI scores was analyzed using receiver operating characteristics curves.

Results

The state anxiety scores of patients 45 years of age or older showed a significant correlation with percent changes in mean blood pressure and heart rate, whereas the state anxiety scores in other subgroups showed no significant correlation with changes in vital signs during the induction of anesthesia. Furthermore, the state anxiety scores in patients 45 years of age or older were shown to be useful in predicting a 20% change in vital signs during anesthetic induction.

Conclusions

The state anxiety scores of patients 45 years of age or above could be a useful tool for predicting changes in vital signs during anesthetic induction. Thus, physician should be mindful of preoperative anxiety.

Plasma catecholamines, blood pressure responses and perceived stress during mental arithmetic stress in young men

We assessed plasma noradrenaline (NA) and adrenaline (A) at rest during a hyperinsulinaemic glucose clamp and responses to a mental arithmetic stress test (MST) in relation to blood pressure (BP) responses (Finapres) and distress in 20 men with high (> or =140/90 mmHg) and 21 men with normal (< or =115/75 mmHg) screening BP, 21-24 years of age. Perceived stress, effort and overall discomfort were scored 1-10. Catecholamines and BP increased in both groups, change in diastolic BP (DeltaDBP; 9.9 vs. 3.8 mmHg, p < 0.05) and DeltaDBP carryover (recovery period minus baseline) (7.2 vs. 2.2 mmHg, p < 0.01) being greater in men with high screening BP. Independently of BP status, change in systolic BP (DeltaSBP) and DeltaSBP carryover were related to A (both p < 0.001), and DeltaDBP and DeltaDBP carryover to DeltaNA (both p < 0.001). The subjective score sum correlated with maximal NA (rs = 0.40) and A (rs = 0.37) (both p < 0.05). Maximal NA was independently related to stress (p < 0.05) and the subjective score sum (p < 0.01). DeltaA% was greater in the high- (score > or =6) than in the low-stress category, independently of BP status (p < 0.05). High screening BP is associated with impaired BP recovery after mental stress. Plasma catecholamine responses are related to BP responses and carryover effects, and reflect perceived stress in young men.

Clonidine premedication effects on inhaled induction with sevoflurane in adults: a prospective, double-blind, randomized study

BACKGROUND

The purpose of this study was to evaluate whether oral clonidine premedication becomes an alternative to N2O in terms of shortening the induction time and attenuation of the adrenergic response to tracheal intubation during inhalation induction with sevoflurane, and to evaluate the quality of anesthetic induction according to the patient's satisfaction.

METHODS

We studied 84 female patients who were randomly allocated into four study groups: Groups I and II received a placebo orally, and Groups III and IV received clonidine at 150 and 300 microg, respectively, 90 min before induction of anaesthesia. Patients were anesthetized using a triple-deep-breath technique with 5% sevoflurane in Groups I, III and IV, and with 60% N2O-5% sevoflurane in group II.

RESULTS

Induction time was significantly longer (P < 0.05) in Group I. Increases in mean blood pressure and heart rate after tracheal intubation were significantly suppressed in Groups III and IV but not in Group II compared with Group I. Comfort and impression of anesthesia was better in Groups III and IV than in Groups I and II.

CONCLUSION

In volatile anesthetic induction, pre-anesthetic clonidine may become an alternative to N2O and may provide more comfort than with N2O.

Assessment of psychological tension after premedication by measurement of salivary chromogranin A

STUDY OBJECTIVE

Although some sedatives or analgesics are commonly used for premedication to reduce psychological tension before surgery or anesthesia, it remains unclear which drug is more suitable. Because salivary chromogranin A is a reliable index for estimating psychological tension, this variable was measured during the perioperative period after premedication.

DESIGN

Prospective, randomized control study.

SETTING

Operating room at a general hospital.

PATIENTS

Thirty adult female patients undergoing abdominal total hysterectomy were randomly assigned to 3 groups of 10 patients each.

INTERVENTIONS

On the day before surgery, saliva was collected, and 0.1 mg/kg of midazolam (midazolam group) or 0.02 mg/kg of butorphanol (butorphanol group) was injected intramuscularly 30 minutes before entering the operating rooms. For the control group, no premedication was performed. Saliva was collected as the patient entered the operating room and then the patient received an epidural catheter insertion followed 5 minutes later by collection of the saliva.

MEASUREMENTS AND MAIN RESULTS

Salivary chromogranin A was assayed using a radioimmunoassay, and revised values calculated from the protein concentration of the saliva were regarded as data. Revised salivary chromogranin A levels increased in the control and butorphanol groups at the time of entrance to the operating room and after epidural treatment compared with the value of the day before surgery, whereas it did not change statistically in the midazolam group.

CONCLUSIONS

From the standpoint of reducing psychological tension before surgery or anesthesia, midazolam as a sedative may be more suitable for premedication.

Benzodiazepine premedication may attenuate the stress response in daycase anesthesia: a pilot study

PURPOSE

Patients undergoing daycase surgery suffer from varying degrees of fear and anxiety. There is conflicting evidence in the literature regarding the benefit of benzodiazepine premedication in daycase surgery. We carried out a prospective, double-blind, randomized pilot study investigating the effect of benzodiazepine premedication on the stress response in patients undergoing daycase anesthesia and surgery.

METHODS

Group I (n = 16) received diazepam 0.1 mg*kg(-1) orally 60 min preoperatively; Group II (n = 15) received diazepam 0.1 mg*kg(-1) orally 90 min preoperatively; Group III (n = 30) received a placebo. The stress response was measured by analyzing urinary catecholamine and cortisol levels and by scoring anxiety levels using state-trait anxiety inventory (STAI) scores and visual analogue scores (VAS).

RESULTS

Anxiety scores (VAS and STAI scores) were not different between groups. We found a statistically significant reduction in urinary cortisol and noradrenaline levels in the groups receiving diazepam vs placebo.

DISCUSSION

The reduction in stress hormones following diazepam premedication, in patients undergoing daycase surgery may support the role for benzodiazepine premedication in this setting. However, further studies are warranted to determine the clinical significance of these findings.

Development and evaluation of a video program for presentation prior to elective cardiac surgery

BACKGROUND

: The objective of the present study was to develop and evaluate the effects of a preparatory videotape on endocrine stress responses of patients prior to cardiac surgery and to analyze patient acceptance of this video for preoperative preparation.

METHODS

: 101 male patients prior to elective cardiac surgery were enrolled into the study. On the day before surgery, patients were assigned to one of the following groups: group 1 (n = 51) saw a video with realistic information about the upcoming perioperative procedure, and group 2 (n = 50) saw a video of the same length without surgery-related information. Venous blood was sampled before and 15 min after the video presentation. On the second postoperative day, patients filled in a questionnaire concerning their experiences of having preoperatively watched the video.

RESULTS

: After viewing the video, blood levels of cortisol, adrenocorticotropic hormone (ACTH), beta-endorphin, prolactin, epinephrine and norepinephrine in patients of group 1 were not significantly different compared to values measured before the video presentation. In patients of group 2, blood levels of cortisol, ACTH, prolactin and norepinephrine were significantly lower after video presentation compared to values obtained before the video. Patients of group 1 (compared to group 2) were significantly more often of the opinion that the video had helped in the preparation for surgery, and that they would like to repeat this adjunct preoperative video preparation in another similar situation.

CONCLUSION

: We conclude from our results that (i); cardiac surgical patients prefer preoperatively an adjunct surgery-related video preparation to a non-specific video presentation, and that (ii); preoperative preparation with realistic information about the upcoming medical procedure in patients undergoing cardiac surgery does not lead to an increase in endocrine stress hormone levels.

Psychological preparation of the parent and pediatric surgical patient

Some 3 million children undergo anesthesia and surgery in the United States every year; 40% to 60% of these children develop significant behavioral stress prior to surgery. Multiple interventions have been suggested to treat the preoperative behavioral stress responses in children. There is a trend toward reducing both behavioral and pharmacological preoperative interventions aimed at children, perhaps because though there is a consensus that preoperative interventions can be useful, almost no outcome studies have evaluated the effects of these interventions on measurable, clinically "important" postoperative outcomes. More research is needed in this area.

Anxiety in patients having caesarean section under regional anaesthesia: a questionnaire and pilot study

The aim of this pilot study was to investigate anxiety levels in patients undergoing elective caesarean section under regional anaesthesia, and to ascertain whether this group of patients considered the administration of anxiolytic premedicant drugs before surgery acceptable. Anxiety was assessed by two means, using a self-reported anxiety score and a physiological evaluation in the form of skin conductance measurements. The patient was given an information sheet explaining the potential advantages and disadvantages associated with the use of temazepam as an anxiolytic premedicant before caesarean section. Having read the information sheet, the patient's opinion regarding the use of anxiolytic premedicant drugs in this context was determined using a questionnaire. Most women reported high preoperative anxiety levels, although the cause of their anxiety was not determined. In our hospital, a significant proportion of such women would accept temazepam as anxiolytic premedication, despite being aware of its potential adverse side effects.

Anesthetic assessment in an outpatient consultation clinic reduces preoperative anxiety

PURPOSE

Preoperative anxiety in relation to anesthesia remains for many patients a major subject of concern. The aim of the present study was to compare the level of preoperative anxiety in patients assessed in an outpatient consultation clinic with the anxiety level of those having been assessed by the anesthesiologist after entering the hospital.

METHOD

We studied two groups of 20 patients who underwent elective transurethral prostate or bladder resection: group A having the anesthetic assessment between one-two weeks before hospitalisation, group B having this assessment the evening before surgery, after entering the hospital. Two different methods to assess anxiety were used: the Multiple-Affect-Adjective-Check-List (MAACL) and the visual analogue scale of anxiety (VAS).

RESULTS

Both anxiety provided scores, assessed by two different methods, were lower in group A, than in group B(P<0.01).

CONCLUSION

The results of this study confirm that an anesthetic assessment in an outpatient consultation clinic reduces preoperative anxiety, when compared with an assessment on the evening before surgery.

Effects of video information on precolonoscopy anxiety and knowledge: a randomised trial

BACKGROUND

The provision of information before medical or surgical procedures should improve knowledge and allay anxiety about the pending procedure. This trial aimed to assess the value of an information video in this process.

METHODS

Patients scheduled to undergo colonoscopy were approached about 1 week before the procedure. All patients were given an information leaflet about colonoscopy, and completed a Spielberger state anxiety inventory (STAI) questionnaire to assess baseline anxiety. The patients were then randomly assigned to watch or not watch the information video. Immediately before colonoscopy, all patients completed a second anxiety questionnaire and a knowledge questionnaire.

FINDINGS

198 patients were screened. 31 declined to participate and 17 were unable to complete the forms. Of the remaining 150 patients, 72 were assigned the video, and 78 no video. The groups were similar with regard to age, sex, educational attainment, and initial anxiety score. Female patients had higher baseline anxiety than male patients (mean STAI 46.3 [95% CI 44.9-47.7] vs 36.9 [35.5-38.3]; difference 9.4 [7.8-12.2], p=0.0008). Patients who had not had a previous colonoscopy had higher baseline anxiety scores than those who had prior experience of the procedure (46.9 [45.4-48.5] vs 36.3 [34.7-37.9]; difference 10.6 [7.5-13.8], p=0.0008). Patients who watched the video were significantly less anxious before colonoscopy than those who did not. The former also scored more highly in the knowledge questionnaire than the latter with regard to the purpose of the procedure, procedural details, and potential complications of colonoscopy.

INTERPRETATION

An information video increases knowledge and decreases anxiety in patients preparing for colonoscopy.

Relation between bispectral index and plasma catecholamines after oral diazepam premedication

The efficacy of anaesthetic premedication has been assessed using sedative scores or a visual analogue scale. However, in both it may be difficult to exclude evaluators' subjectivity or a placebo effect. Plasma concentration of catecholamines may also be useful for the assessment of patient anxiety. Recently bispectral electro-encephalographic analysis has been developed, and the bispectral index monitor has been reported to give measurements which correlate well with the depth of sedation. In the present study, we have examined the relation between bispectral index values and plasma catecholamine concentrations after oral diazepam premedication. Twenty-eight patients scheduled for elective surgery were randomly assigned to one of two groups: diazepam premedication group (group D(+), n = 14) and no premedication group (group D(-), n = 14). The patients were premedicated orally with diazepam 10 mg and roxatidine 75 mg in group D(+), and with roxatidine 75 mg only in group D(-) 90 min before arrival in the operating theatre. After patients arrived in the operating theatre, the bispectral index monitor was applied. Venous blood samples (6 mL) were collected in the case of patients in group D(+) for the measurement of plasma catecholamines levels using high-performance liquid chromatography. The bispectral index level (mean +/- SD) in group D(+): 93.5 +/- 773.5 was significantly lower than that in group D(-): 96.1 +/- 1.8 (P < 0.05). There was a significant correlation between bispectral index and plasma norepinephrine levels (r = 0.567, P < 0.05). The present study suggests that the bispectral index monitor may detect the effect of oral diazepam premedication.

Neurally mediated syncope and syncope due to autonomic failure: differences and similarities

Syncope is a transient loss of consciousness and postural tone caused by a global reduction of blood flow to the brain. Abnormalities in autonomic cardiovascular control can impair blood supply to the brain and produce syncope in two different disorders: autonomic failure and neurally mediated syncope. In autonomic failure, sympathetic efferent activity is chronically impaired so that vasoconstriction is deficient, upon standing blood pressure always falls (i.e., orthostatic hypotension), and syncope or presyncope occurs. Conversely, in neurally mediated syncope, the failure of sympathetic efferent vasoconstrictor traffic (and hypotension) occurs episodically and in response to a trigger. Between syncopal episodes, patients with neurally mediated syncope have normal blood pressure and orthostatic tolerance. This article reviews the characteristics of autonomic failure and describes in more detail the pathophysiology, diagnosis, and treatment of neurally mediated syncope.

Pre-operative anxiety. Effect of early or late position on the operating list

The influence of the relative position on the operating list on pre-operative anxiety was studied in 60 adult female ASA 1 patients undergoing major surgery. Thirty patients were placed first on the operating list (group 1) and 30 were given a time 4-5 h later (group 2). Each patient was visited on the evening prior to surgery and again on the morning of surgery. Anxiety was measured at each visit by objective criteria and part 1 of the State-Trait Anxiety Inventory questionnaire. The pulse rate, systolic blood pressure and the State-Trait Anxiety Inventory questionnaire scores were higher on the second visit than on the first (p < 0.001) in all patients. This increase was greater in group 2 than in group 1 (p < 0.05). The evening anxiety scores were not correlated with those on the morning visit and could not predict them.

Calcium channel blockers do not enhance increases in plasma potassium after succinylcholine in humans

STUDY OBJECTIVE

To determine whether chronic calcium channel blocker therapy exaggerates the rise in plasma potassium concentration ([K+]) after succinylcholine administration.

DESIGN

Prospective clinical study.

SETTING

University and Veterans Affairs hospitals.

PATIENTS

36 ASA physical status III and IV male patients: 21 patients taking chronic calcium channel blockers and 15 patients not receiving calcium channel blockers, all of whom were scheduled for inpatient surgical procedures with general anesthesia.

INTERVENTIONS

In all patients, anesthesia was induced with high-dose opioids plus a sedative-hypnotic, and intubation was facilitated with 1 to 1.5 mg/kg succinylcholine without nondepolarizing neuromuscular blocker pretreatment.

MEASUREMENTS AND MAIN RESULTS

Plasma [K+] was measured prior to induction and 1, 3, 5, 8, 11, and 15 minutes after succinylcholine was administered. A modest average peak rise of 0.5 mEq/L in plasma [K+] was observed, but there were no differences between patients who were or were not receiving calcium channel blockers.

CONCLUSIONS

Patients receiving chronic calcium channel blocker therapy are at no greater risk of hyperkalemia after succinylcholine than those not taking such medications.

Patient Knowledge of Operative Care

To investigate knowledge of perioperative events, a questionnaire was administered to 111 elective surgical patients. Six topics were covered: The operation, the anaesthetic, time spent in the operating theatre, amount of post-operative pain, duration of hospital admission and time required to return to normal fitness. Apart from evaluating information-sources for each topic, the questionnaire assessed degree of knowledge and satisfaction with this information, and the relationship of these to anxiety. More than 30% of the patients responded that they had received no information about anaesthesia, time in theatre, return to fitness or pain. For each topic more than 40% desired further information. Nursing staff provided most information, although for the anaesthetic, time in theatre, return to fitness and pain, more than 60% of patients responded that nobody had provided explanation. There was no correlation between knowledge relating to the topics per se and anxiety, but there was a significant correlation between satisfaction with information and anxiety. This survey shows a considerable need for improved information provision, especially for patients in whom anxiety is associated with a desire for further explanation of operative care.

Health status and the preoperative change in serum potassium concentration

When evaluating preanaesthetic abnormal serum potassium (S-K) levels, the anaesthetist often relies upon blood tests performed on admission to hospital 1 or more days prior to surgery. However, the S-K is often altered between admission to hospital and the induction of anaesthesia. In this study, we examined the effects of health status and medication on the preoperative change in S-K concentration in 150 unselected elderly men awaiting urological operations. Oral daily medication was not given preoperatively on the day of surgery. One third of the patients showed a change of 0.4 mmol/l or more (range -1.1 to +1.2), with an increase as common as a decrease. Those on treatment with calcium-channel blockers or diuretics showed an increase in the S-K concentration in the preoperative period, while patients using oral antidiabetics showed a decrease. The use of beta-adrenoceptor antagonists was not a significant predictor of the change in S-K concentration. In conclusion, we found that alterations in serum potassium were common prior to surgery, but only a small fraction of this variance could be accounted for by health status and medication.

Measuring patient anxiety in coronary care. Part 1

Patient anxiety is a common problem identified by nurses. However, the difficulty of assessing the level and significance of the anxiety is problematic. This paper discusses the issue of measuring patient anxiety, specifically in Coronary Care. As well as discussing physiological measures, three appropriate psychometric instruments are identified (the State-Trait Anxiety Inventory--STAI; the Hospital Anxiety and Depression Scale--HAD; a Linear Analogue Anxiety Scale--LAAS), along with a review of the relevant literature. Systematic anxiety measurement, and management of maladaptive anxiety would appear to be appropriate and meaningful nursing functions within the provision of holistic patient care in Coronary Care.

Early anesthesia evaluation of the ambulatory surgical patient: does it really help?

STUDY OBJECTIVE

To evaluate whether early evaluation by the anesthesiologist is more beneficial for the ambulatory surgical patient than a day-of-surgery visit.

DESIGN

A randomized study evaluating patients with different surgical procedures.

SETTING

Ambulatory surgical outpatients at a university-affiliated integrated ambulatory surgical unit.

PATIENTS

Sixty-three ASA physical status I and II women scheduled to undergo elective dilatation and curettage or gynecologic laser surgery.

INTERVENTIONS

Approximately half of the patients received an early (1 to 7 days preoperative) anesthesia evaluation, and half received a day-of-surgery evaluation. All patients underwent the surgical procedures with a standardized general anesthetic.

MEASUREMENTS AND MAIN RESULTS

The effect of an early versus a day-of-surgery anesthesia visit was evaluated with regard to patient anxiety levels; patient satisfaction with the surgical and anesthetic experience; operating room, recovery room, and ambulatory surgery unit time; anesthetic and analgesic requirements; and frequency of postoperative problems within 72 hours at home. There were no differences between the groups in demographic characteristics, anesthesia or analgesic requirements, degree of satisfaction with the ambulatory surgical experience, time spent in recovery room, or frequency of problems on postoperative follow-up. We were unable to demonstrate any differences between those patients seen early versus those seen on the day of surgery in anxiety levels preoperatively and postoperatively.

CONCLUSIONS

Healthy ASA physical status I and II ambulatory surgical patients do not benefit from reducing preoperative anxiety by visiting the anesthesiologist prior to the day of surgery.

Does alfentanil preserve left ventricular pump function during rapid sequence induction of anaesthesia?

A double-blind, randomised trial was conducted in 24 patients without cardiopulmonary disorders (20-43 years), to assess the effect of an intravenous bolus of alfentanil on the circulatory and catecholamine responses to rapid sequence induction of general anaesthesia. Induction included injection of thiopentone 5 mg/kg and suxamethonium 1.5 mg/kg in rapid succession, followed by laryngoscopy and intubation. Half of the patients received alfentanil 100 micrograms/kg immediately before thiopentone. The other half received saline. Blood pressure, heart rate, and plasma catecholamine concentrations were measured repeatedly, together with left ventricular ejection fraction assessed by radionuclide angiocardiography. The responses following laryngoscopy and intubation were completely different in the saline vs. the alfentanil group: rate pressure product +76% vs. -32%, mean arterial blood pressure +46% vs. -25%, heart +46% vs. no change, noradrenaline +117% vs. -25%, adrenaline +50% vs. -53%, and left ventricular ejection fraction -32% vs. no change. In conclusion, during rapid sequence induction of anaesthesia with thiopentone and suxamethonium, an intravenous bolus of alfentanil 100 micrograms/kg 1 min before laryngoscopy and intubation completely prevents hypertension, tachycardia, decrease in left ventricular ejection fraction, and activation of plasma catecholamines, though at the expense of moderate hypotension.

Characteristics of muscle nerve sympathetic activity during general anaesthesia in humans

General anaesthesia influences the cardiovascular system at different levels. To increase our knowledge of how sympathetic outflow is affected by anaesthetic interventions, we used direct microelectrode recordings of muscle sympathetic activity (MSA) in the peroneal nerve in 18 patients scheduled for ENT-surgery. During induction of anaesthesia (propofol 2.1 mg/kg or methohexitone 1.4 mg/kg), all patients showed reductions in MSA (from 41 +/- 4 to 20 +/- 4 bursts/min). With endotracheal intubation there was a sudden increase of activity and in several patients the normal pulse-synchrony of MSA was lost temporarily. Maintenance of anaesthesia with nitrous oxide (n = 12) increased MSA and methohexitone (n = 2), propofol (n = 3) and isoflurane (n = 8) decreased MSA, while the effect of halothane (n = 3) varied. Baroreflex mechanisms were still operative but seemed to be depressed in relation to anaesthetic agent and depth. Laryngeal and surgical stimuli caused increases in MSA and blood pressure, lasting several minutes after the stimulation. It is concluded that the strength of MSA is profoundly influenced by the choice of anaesthetic agent. A suppression of activity is more common than an increase. Qualitatively, several sympathetic reflexes operate in a similar way during light anaesthesia as in awake subjects, but are depressed or absent during deep anaesthesia.

Diazepam and atropine as premedicants: no discrimination by monoamine metabolite and catecholamine measurements in cerebrospinal fluid and plasma

The relationships between self-reported assessments of the quality of the preoperative night's sleep, preoperative anxiety, and several biochemical and physiological indicators of stress reaction were investigated in pregnant women at term receiving no premedication (n = 15), a placebo tablet (n = 15), diazepam 5 mg p.o. (n = 15), or atropine 0.01 mg/kg i.m. (n = 15), in connection with spinal analgesia for elective caesarean section. In the patients receiving no premedication, the subjective estimate of the quality of the preoperative night's sleep was negatively associated with concentrations of noradrenaline (NA) and its metabolite, 3-methoxy-4-hydroxyphenylglycol (MHPG) in CSF, and with plasma adrenaline. The anxiolytic effect of diazepam was reflected as significantly lower plasma levels of another metabolite of NA, 3,4-dihydroxyphenylglycol (DHPG). Placebo and diazepam, and to a lesser extent atropine, confounded the statistical relationships between the clinical and biochemical responses found in the patients with no premedication. On the whole, the biochemical monoamine measurements were of little use in determining the clinical effects of different kinds of premedicants.

Stressful pre-operative preparation procedures. The routine removal of dentures during pre-operative preparation contributes to pre-operative distress

One hundred and twenty-four patients (76 women and 48 men) were interviewed within the first 36 hours after operation. Fifty per cent of those studied were denture wearers. They were asked to fill in a questionnaire which registered their levels of distress about the various pre-operative preparation procedures. The most common factors contributing to pre-operative distress were waiting for transfer to the operating theatre, the prohibition of fluids and the removal of dentures.

An evaluation of physiological parameters of stress in the emergency department

Seven physiological parameters previously used in stress research were studied to determine which would be able to quantitate levels of stress and study interventions in the emergency department setting. Eighteen emergency medicine personnel were prospectively studied. Sequential measurements of heart rate, respiratory rate, systolic blood pressure, diastolic blood pressure, skin temperature, serum norepinephrine, and serum epinephrine were recorded during multiple shifts in the emergency department. These parameters were assessed in repeated measures analysis of variance models with the subject's stress score of the shift and a calculated stress score of the shift. Respiratory rate demonstrated a significant association with the score of the shift over time within subjects (P = .0228). Skin temperature showed a significant trend over time (P = .0001) and in relation to how stressful the subject perceived the shift to be (P = .0006). A significant association was detected between epinephrine change over the shift and the subject's perception of the stress of the shift (P = .0217), and the stress score of the shift (P = .0009). Sequential serum epinephrine appears to be an objective measure of both perceived stressfulness of a shift and objective stress scoring of the shift. Respiratory rate changes and skin temperature changes over a shift may also be useful to measure stress in individuals in this setting.