Increase in Operator's Sympathetic Nerve Activity during Complicated Hepatobiliary Surgery: Evidence for Surgeons' Mental Stress

Surgeon reported measures of stress and anxiety prior to and after elective gynecological surgery

INTRODUCTION

Performing surgical procedures is a recognized source of stress for surgeons. Vocational stress is an important contributor to performance, patient care, and burnout with dispositional and environmental factors contributing. Accurately assessing surgeon stress is critical to measuring effectiveness of stress reduction programs. The primary aim was to identify differences between surgeons' self-reported anticipated stress and anxiety prior to gynecological surgery, compared with their recollection of experienced stress and anxiety during surgery. Secondary aims assessed any differences by level of training, surgical type, and surgeon role.

MATERIAL AND METHODS

Attending and resident gynecologists performing routine elective surgeries completed a visual analog scale (VAS) assessing perceived stress and the State-Trait Anxiety Inventory (STAI) prior to and immediately after completing 161 elective surgeries including total laparoscopic hysterectomy, laparoscopic excision of moderate-severe endometriosis, or hysteroscopic myomectomy.

RESULTS

Eight attending gynecologists and nine residents participated. Residents commenced as primary surgeon in 62/90 (69%) procedures. Stress experienced during surgery was greater than anticipated in 92/161 (57%) surgery episodes (mean VAS increase: 3.9; 95% CI: 1.1-6.8, p = 0.009). State anxiety was greater than anticipated in 99/161 (62%) episodes (mean state anxiety increase: 4.4; 95% CI: 3.0-5.8, p < 0.001). Greater preprocedural anticipatory stress and anxiety was observed in residents vs. attending gynecologists (VAS 51.9 vs. 22.8, p < 0.001; state anxiety 38.3 vs. 28.1, p < 0.001) and in primary vs. assistant surgeons (VAS 47.2 vs. 29.9, p < 0.001; state anxiety 36.9 vs. 28.3, p < 0.001). Intraoperative stress and anxiety were greater in primary surgeons (VAS 50.4 vs. 30.5, p < 0.001; anxiety 41.3 vs. 32.5, p < 0.001) and residents (VAS 43.4 vs. 31.7, p < 0.001; anxiety 53.5 vs. 33.7, p < 0.001) compared with assistants and attending gynecologists. Perceived stress and anxiety were positively correlated at both timepoints (r = 0.68, p < 0.001; r = 0.82, p < 0.001).

CONCLUSIONS

When asked to reflect on stress experienced during surgery, our data show that stress during surgery is greater than anticipated for many surgical episodes. Self-reported stress symptoms commence prior to surgery and are more commonly reported by surgeons operating as primary surgeon and by those in training. Future research should focus on determinants of presurgical stress and examine when stressors become inhibitory to performance.

Activation of the stress response among the cardiac surgical residents: comparison of teaching procedures and other (daily) medical activities

BACKGROUND

The aim of this Pilot study was to investigate the cardiac surgical residents' workload during different surgical teaching interventions and to compare their stress levels with other working time spent in the intensive care unit or normal ward.

METHODS

The objective stress was assessed using two cardiac surgical residents' heart rate variability (HRV) both during surgical activities (32 selected teaching operations (coronary artery bypass graft n = 26 and transcatheter aortic valve implantation n = 6), and during non-surgical periods. Heart rate, time and frequency domains as well as non-linear parameters were analyzed using the Wilcoxon test.

RESULTS

The parasympathetic activity was significantly reduced during the surgical phase, compared to the non-surgical phase: Mean RR (675.7 ms vs. 777.3 ms), RMSSD (23.1 ms vs. 34.0 ms) and pNN50 (4.7% vs. 10.6%). This indicates that the residents had a higher stress level during surgical activities in comparison to the non-surgical times. The evaluation of the Stress Index during the operations and outside the operating room (8.07 vs. 10.6) and the parasympathetic nervous system index (- 1.75 to - 0.91) as well as the sympathetic nervous system index (1.84 vs. 0.65) confirm the higher stress level during surgery. This can be seen too used the FFT Analysis with higher intraoperative LF/HF ratio (6.7 vs. 3.8).

CONCLUSION

HRV proved to be a good, objective method of identifying stress among physicians both in and outside the operating room. Our results show that residents are exposed to high psychological workloads during surgical activities, especially as the operating surgeon.

Changes in saliva biomarkers during a standardized increasing intensity field exercise test in endurance horses

Salivary biomarkers could be useful to evaluate stress, fitness level, and skeletal muscle damage associated to exercise in horses in an easy and non-painful way. Therefore, this study aims to evaluate if cortisol in saliva (sCor), salivary alpha-amylase (sAMY) and butyrylcholinesterase (sBChE) and lactate (sLA) and creatine kinase (sCK) in saliva of horses can show changes during a standardized exercise test, and if they are related to heart rate variability (HRV) parameters related to sympathetic and parasympathetic tone, fitness level or skeletal muscle damage. For this purpose, ten endurance horses were submitted to a standardized exercise test in field conditions. Saliva and blood were obtained at basal time (TB), after the seven bouts of velocity (T + 01 to T + 07), and 5, 15, 30, and 45 min later (T + 5, T + 15, T + 30, and T + 45). Five endurance horses in resting condition (control group) were also enrolled. HRV and fitness level parameters, and plasma CK as a marker of muscle damage were also evaluated. Salivaryalpha-amylase increased at T + 30 (P = 0.03), sBChE at T + 5 (P = 008), and sCK at T + 07 (P = 0.009) after the exercise test, with significant differences between the exercise and control groups' results. The sCor did not show significant changes during the exercise test in the exercise group but higher concentration compared to the control horses (P < 0.001) were observed. sCor, sAMY, sBChE, and sCK showed a positive correlation (r values between 0.47 and 0.64) with the sympathetic tone and a negative correlation (r values between -0.37 and -0.56) with the parasympathetic tone. In conclusion, sAMY, sBChE, and sCK showed significant increases in ten endurance horses after an increasing intensity velocity exercise. Values of sCor, sAMY, sBChE, and sCK were associated with HRV, which is used to evaluate stress, and therefore, they could be potentially used to assess the exercise-related stress after a physical effort.

Heart Rate Complexity in US Army Forward Surgical Teams During Pre Deployment Training

INTRODUCTION

For trauma triage, the US Army has developed a portable heart rate complexity (HRC) monitor, which estimates cardiac autonomic input and the activity of the hypothalamic-pituitary-adrenal (HPA) axis. We hypothesize that autonomic/HPA stress associated with predeployment training in U.S. Army Forward Surgical Teams will cause changes in HRC.

MATERIALS AND METHODS

A prospective observational study was conducted in 80 soldiers and 10 civilians at the U.S. Army Trauma Training Detachment. Heart rate (HR, b/min), cardiac output (CO, L/min), HR variability (HRV, ms), and HRC (Sample Entropy, unitless), were measured using a portable non-invasive hemodynamic monitor during postural changes, a mass casualty (MASCAL) situational training exercise (STX) using live tissue, a mock trauma (MT) STX using moulaged humans, and/or physical exercise.

RESULTS

Baseline HR, CO, HRV, and HRC averaged 72 ± 11b/min, 5.6 ± 1.2 L/min, 48 ± 24 ms, and 1.9 ± 0.5 (unitless), respectively. Supine to sitting to standing caused minimal changes. Before the MASCAL or MT, HR and CO both increased to ~125% baseline, whereas HRV and HRC both decreased to ~75% baseline. Those values all changed an additional ~5% during the MASCAL, but an additional 10 to 30% during the MT. With physical exercise, HR and CO increased to >200% baseline, while HRV and HRC both decreased to 40 to 60% baseline; these changes were comparable to those caused by the MT. All the changes were P < 0.05.

CONCLUSIONS

Various forms of HPA stress during Forward Surgical Team STXs can be objectively quantitated continuously in real time with a portable non-invasive monitor. Differences from resting baseline indicate stress anticipating an impending STX whereas differences between average and peak responses indicate the relative stress between STXs. Monitoring HRC could prove useful to field commanders to rapidly and objectively assess the readiness status of troops during STXs or repeated operational missions. In the future, health care systems and regulatory bodies will likely be held accountable for stress in their trainees and/or obliged to develop wellness options and standardize efforts to ameliorate burnout, so HRC metrics might have a role, as well.

Perceived Surgeon Stress During No-Sedation Topical Phacoemulsification

Purpose

To determine the patient-related factors that contribute to surgeon stress during phacoemulsification cataract extraction (PCE) performed under unassisted topical anesthesia.

Methods

This is a prospective study of perceived surgeon stress during phacoemulsification by a single surgeon of consecutive patients undergoing PCE. At the conclusion of each procedure, the surgeon recorded the perceived stress according to the following three indices: surgeon score, qualitative score (yes or no), and total score (sum of itemized causes of stress). Patient variables included in the analysis included gender, age, diabetes mellitus, morbid obesity, intake of oral alpha blockers, floppy iris, laterality, pseudo-exfoliation, intraocular lens power, and initial visual acuity.

Results

During the 10-year study, 1097 eyes underwent surgery. The following patient variables were seen frequently: floppy iris syndrome (92), pseudo-exfoliation (72), and morbid obesity (36). Surgeon identified stress was reported after 250 procedures. On multivariable analysis, the following patient characteristics were associated with surgeon stress: age >80 years; morbid obesity; floppy iris syndrome; severe nuclear sclerosis; and poor baseline distance corrected visual acuity.

Conclusion

Several ocular and systemic patient-related characteristics contribute to surgeon stress during PCE.

Heart rate variability as a measure of mental stress in surgery: a systematic review

Purpose

There is increasing interest in the use of heart rate variability (HRV) as an objective measurement of mental stress in the surgical setting. To identify areas of improvement, the aim of our study was to review current use of HRV measurements in the surgical setting, evaluate the different methods used for the analysis of HRV, and to assess whether HRV is being measured correctly.

Methods

A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). 17 studies regarding HRV as a measurement of mental stress in the surgical setting were included and analysed.

Results

24% of the studies performed long-term measurements (24 h and longer) to assess the long-term effects of and recovery from mental stress. In 24% of the studies, artefact correction took place.

Conclusions

HRV showed to be a good objective assessment method of stress induced in the workplace environment: it was able to pinpoint stressors during operations, determine which operating techniques induced most stress for surgeons, and indicate differences in stress levels between performing and assisting surgery. For future research, this review recommends using singular guidelines to standardize research, and performing artefact correction. This will improve further evaluation of the long-term effects of mental stress and its recovery.

Electronic supplementary material

The online version of this article (10.1007/s00420-020-01525-6) contains supplementary material, which is available to authorized users.

Changes in Saliva Analytes Correlate with Horses' Behavioural Reactions to An Acute Stressor: A Pilot Study

Simple Summary

Emotionality is an individual characteristic defined as the propensity to respond to stress-inducing stimuli such as fear-inducing objects or social separation. Evaluation of emotionality in horses is important as it may impact their learning performance. Although emotionality is usually assessed by measuring behavioural patterns, biomarkers could provide additional information about stress response, especially with respect to its temporal dynamics. In this study, behavioural responses were measured as well as a panel of salivary biomarkers related to stress, including salivary alpha-amylase, lipase, total esterase, butyrylcholinesterase, adenosine deaminase, and cortisol, in riding horses after acute experimental stress (the sudden opening of an umbrella). We found significant changes in most of the salivary biomarkers evaluated after the induced stress, where increases in butyrylcholinesterase were more closely related to behavioural responses to acute stress and low salivary alpha-amylase values were more closely related to quietness behaviours. Therefore, this preliminary research provides information about the relationship between behaviour patterns and biomarkers of stress in saliva in horses, and opens the possibility of wider use of selected biomarkers in saliva, such as butyrylcholinesterase or alpha-amylase, for the evaluation of acute stress in horses.

Abstract

Acute stress induces an array of behavioural reactions in horses that vary between individuals. Attempts to relate behavioural patterns and physiological responses have not always given clear-cut results. Here, we measured the changes in a panel of salivary components: salivary alpha-amylase (sAA), lipase, total esterase (TEA), butyrylcholinesterase (BChE), adenosine deaminase (ADA), and cortisol, and their potential link with horses’ behaviours after acute stress. Saliva samples were collected in nine riding horses subjected to a test consisting of opening an umbrella. Saliva sampling was obtained at a basal time point in the stall (T1), in the test indoor arena (T2), at a time of stress (T3), and 30 min (T4) and 60 min (T5) later. The horses’ behaviour was recorded at T3 for 1 min. sAA, lipase, TEA, and BChE showed significant changes along time, increasing at T3 for BChE, and decreasing at T4 for sAA and BChE. Butyrylcholinesterase appeared to be the most reliable predictor of behavioural responses, as it correlated with the index of emotionality, of laterality, and the occurrence of alarm signals, while sAA decreased when horses expressed quieter behaviours. These first results bring promising lines for novel, more precise physiological markers of acute stress in horses that can bridge the gap between behaviour and physiology.

Evaluation of new biomarkers of stress in saliva of sheep

Some routine handling procedures can produce stress in farm animals, and an adequate control of these stressors is important to avoid the negative effects on animal health and production. The measurement of biomarkers in saliva can be a suitable tool for the evaluation and control of stress. In this report, lipase, butyrylcholinesterase (BChE), total esterase (TEA) and adenosine deaminase (ADA) activities in the saliva of sheep were evaluated as biomarkers of stress. For this purpose, they were measured after inducing stress by facing a dog (experiment 1) and shearing (experiment 2), and comparing them to other stress salivary biomarkers such as α-amylase (sAA) and cortisol, as well as heart rate (HR). Each analyte was measured at the basal time, and during and just after the end of the stressful stimulus, and at various times for the first hour after the period of stress induction. Values were compared with those obtained from a control group. Lipase was the only analyte that showed significant changes between the stress and the control group in both experiments. Although TEA and ADA increased after stress, no significant differences were seen compared with the control group. Lipase was correlated highly with sAA and HR, in experiment 1; and correlated moderately with cortisol and HR in experiment 2. Lipase showed the greatest percentage increase after the stressful stimuli and less overlap with the control group in the two experiments. From the results of this study it can be concluded that lipase, TEA, BChE and ADA are enzymes present in the saliva of sheep and that they can be measured by using simple and fast colorimetric methods. Further studies should be undertaken with regard to the possible application of lipase as a biomarker of stress in sheep.

Surgeons' and surgical trainees' acute stress in real operations or simulation: A systematic review

BACKGROUND AND PURPOSE

Acute stress in surgery is ubiquitous and has an immediate impact on surgical performance and patient safety. Surgeons react with several coping strategies; however, they recognise the necessity of formal stress management training. Thus, stress assessment is a direct need. Surgical simulation is a validated standardised training milieu designed to replicate real-life situations. It replicates stress, prevents biases, and provides objective metrics. The complexity of stress mechanisms makes stress measurement difficult to quantify and interpret. This systematic review aims to identify studies that have used acute stress estimation measurements in surgeons or surgical trainees during real operations or surgical simulation, and to collectively present the rationale of these tools, with special emphasis in salivary markers.

METHODS

A search strategy was implemented to retrieve relevant articles from MEDLINE and SCOPUS databases. The 738 articles retrieved were reviewed for further evaluation according to the predetermined inclusion/exclusion criteria.

RESULTS

Thirty-three studies were included in this systematic review. The methods for acute stress assessment varied greatly among studies with the non-invasive techniques being the most commonly used. Subjective and objective tests for surgeons' acute stress assessment are being presented.

CONCLUSION

There is a broad spectrum of acute mental stress assessment tools in the surgical field and simulation and salivary biomarkers have recently gained popularity. There is a need to maintain a consistent methodology in future research, towards a deeper understanding of acute stress in the surgical field.

Cholinesterase in porcine saliva: Analytical characterization and behavior after experimental stress

The purpose of this study was to measure and characterize the enzyme cholinesterase (ChE) in porcine saliva, as well as to evaluate its behavior in experimental stressful conditions. The results of ChE characterization by using different substrates and the selective inhibitors ethopropazine and physostigmine showed that the main enzyme existing in porcine saliva was butyrylcholinesterase (BChE). An automated assay using butyrylthiocholine iodide as substrate was validated providing adequate reproducibility, linearity results and limit of detection. Salivary ChE was measured using the validated assay in two models of acute stress: twenty pigs stressed for 2min with a nasal snare and other twenty pigs subjected to a short-term road transport. Salivary ChE significantly increased after restraint and transport stress in pigs, as well as the ChE to total protein ratio. In conclusion, BChE is the predominant isoenzyme in porcine saliva, it can be measured by the fast, simple and automated method described in this paper and it increases in the models of stress used in this study.