ABSTRACT
Background:
In patients undergoing surgical procedures, preoperative period is one of the most worrying periods. There are only few studies which revealed that increased preoperative anxiety is associated with increased requirements of doses of anesthetic agents.
Aim:
The aim of this study is to assess the prevalence of preoperative anxiety in patients posted for surgical procedures and its relation to the doses of anesthetic drugs.
Materials and Methods:
This is a cross-sectional, analytical study done between January 2021 and April 2021. A total of 100 patients undergoing surgery have given consent to participate in the study by filling self-designed questionnaire, Amsterdam Preoperative Anxiety and Information Scale (APAIS). Data analysis was done by SPSS version 24 using appropriate statistical tests.
Results:
Preoperative anxiety was noted in 21% of the patients who were undergoing surgery. The association between preoperative anxiety and need for increase in the doses of anesthetic agents during intraoperative period was found to be statistically significant (P < 0.004).
Conclusion:
A significant number of patients required increased amounts of anesthetic drugs to reduce anxiety during intraoperative period. Therefore, appropriate methods have to be introduced to address the concerns of patients undergoing surgery and thereby reducing anxiety.
Keywords: APAIS, ASA, dose of anesthetic drugs, preoperative anxiety
Anxiety is described as an unpleasant state of tension or uneasiness that may arise due to many reasons, for example, hospitalization, anesthesia, surgery. Preoperative anxiety can lead to essential procedures being postponed or cancelled, delay postoperative recovery, and increase patients’ requirements for medical intervention postoperatively.[1] The assessment of anxiety is important because patients with higher levels of anxiety show different response to effects of anesthetic drugs compared to those who are non-anxious. Excessive anxiety influences anesthetic induction and often leads to functional impairment and poorer outcome after surgery.[2,3] Preoperative anxiety is one of the most important problems for patients undergoing surgery because it causes emotional, physical, and psychological problems in the individual.[4] Most of the patients experience a significant anxiety before a planned surgery and the reasons may be due to the fear of surgery and death, loss of independence, separation from family, and postoperative pain. If these patients are not treated for a long-term period, preoperative anxiety may have adverse effects on health. It is estimated that among patients admitted for surgery 25 to 80% of them experience preoperative anxiety. The anxiety severity widely differs among patients. It differs in terms of sociodemographic factors, such as sex, age, and educational background; psychosocial factors.[5,6]
Research shows that the postoperative complications are more in patients who have higher levels of anxiety. These patients report decreased comfort and quality of life, decreased compliance, decreased ability to make appropriate treatment decisions. Such individuals also recover slowly and experience higher levels of postoperative pain. In older patient’s preoperative anxiety may lead to higher morbidity and mortality. Patients with extreme preoperative anxiety may require larger doses of induction agents and analgesics and tend to have longer hospital stay. Patients with high levels of anxiety require higher doses of aesthetic induction agents and recover poorly.[7,8] Studies have shown that preoperative anxiety is associated with increase in the doses of anesthetic agents during preoperative and intraoperative period. Research has shown the impact of various anxiety reducing interventions prior to surgery. One of the most commonly implemented interventions is provision of preoperative information and educating the patients which may reduce anxiety. Several studies have concluded that providing patients with preoperative information is beneficial and reduces anxiety but in some individuals it may sometimes increase the levels of anxiety.[9] There is currently still a paucity of research on preoperative anxiety in patients posted for surgical procedures and its relation to the doses of anesthetic drugs. Many studies did not use validated scales to measure and predict anxiety. Hence, this study was aimed to explore the preoperative anxiety and its relation to the doses of anesthetic drugs by using a validated scale for the assessment of anxiety.
MATERIALS AND METHODS
Study design and participants
This cross-sectional study included a sample of 100 patients undergoing surgical procedures in a tertiary care multi-specialty hospital attached to a medical college and was conducted between January 2021 and April 2021. Participants were consecutively selected from the surgical departments and they are explained about anesthetic and surgical procedure. All patients who gave written informed consent were included in the study; those who did not complete the questionnaire or refused to take part in the study were excluded. Patients with pre-existing psychiatric disorders and who were on psychotropic medication were excluded from the study. The study was approved by the Institutional Ethics Committee. (vide IEC Santhiram Medical College & General Hospital letter dated Jan 2, 2020).
Sample size calculation
Sample size was derived from the formula:
Variable used for sample size calculation
Mean APAIS anxiety score is considered here for calculation of sample size.
Mean APAIS anxiety score (M) 9.90.
Standard deviation of M (S) 3.60.
Set level of confidence (value <1.0) 0.95.
Z value associated with confidence 1.96.
Absolute precision (= Value < M) 0.7.
So minimum calculated sample size is 100.
Instruments
Sociodemographic and clinical questionnaire
This was applied to collect data on sociodemographic variables like age, gender, education, and clinical profile including ASA grading, history of previous surgery, awareness about surgical procedure, provision of adequate preoperative information; preoperative sleeping period.
The Amsterdam Preoperative Anxiety and Information Scale (APAIS)
APAIS is a short scale to assess patient’s preoperative anxiety. The instrument has 6 items rated by the patient on a 5-point scale, from 1 (not at all) to 5 (extremely). The anxiety score is calculated as the sum of items 1, 2, 4, and 5 and the need for information score is the sum of items 3 and 6. The score above 11 for the anxiety subscale is a sign that the patient is experiencing anxiety and the intervention to reduce anxiety is needed. The Anxiety subscale has a Cronbach’s α of 0.86. It has acceptable concurrent validity compared to State-Trait anxiety inventory and good retest reliability.[10]
Procedure
Data was collected after explaining the objectives of the study, and assuring about confidentiality. Patients were explained about their surgical and anesthetic procedures by members of the surgical and anesthetic team. Patients were also explained about the written informed consent form. Patients who agreed for the above terms and conditions were asked fill out the questionnaire. Data was collected one day before the surgery and details of anesthetic drugs used and their doses were collected from the operation notes.
Statistical analysis
The data collected were keyed into Excel for Windows and statistical analysis was carried out using the software package SPSS version 24.0 (IBM, Atlanta, USA). Descriptive analysis with measurements of frequency and mean was used to express sociodemographic variables and results from the scales and questionnaires. The association between different variables was tested using the Chi-square test. A P value of <0.05 was considered to be statistically significant.
RESULTS
Majority (40%) of the patients in the current study are between the age 40 and 60 years with 56% being the male patients and 43% being the female patients. Most of the patients (57%) had primary school education [Table 1]. Clinical variables of the patient sample are presented in Table 2. Majority (61%) of the patients belong to ASA Grade 2, 10% had previous history of exposure to surgery and anesthesia and 90% had no history of previous surgery. Majority (37%) of the patients had a preoperative sleeping period ranging from 5 to 6 hours, awareness about the surgical procedure was present in 48% of the patients. 25% of the patients used anxiolytics one day before the surgery and majority of the patients that is about 75% did not use anxiolytics before surgery. In this study, APAIS score was applied to assess preoperative anxiety where 21% had anxiety related to anesthesia and surgical procedure and 79% patients had no preoperative anxiety. Majority (52%) of the patients required optimum doses of anesthetic agents during intraoperative period whereas the remaining patients (48%) required higher doses of anesthetic drugs during intraoperative period. [Table 2].
Table 1.
Demographic variables of patients undergoing surgery
| Variable | Frequency | Percentage |
|---|---|---|
| Age | ||
| Less than 20 | 2 | 1% |
| 20-40 | 23 | 23% |
| 40-60 | 39 | 39% |
| >60 | 36 | 36% |
| Gender | ||
| Male | 60 | 60% |
| Female | 40 | 40% |
| Education | ||
| Primary school | 57 | 57% |
| High school | 31 | 31% |
| Intermediate and above | 12 | 12% |
Table 2.
Clinical profile of patients undergoing surgery
| Variable | Frequency | Percent |
|---|---|---|
| American Society of Anesthesia (ASA) physical status | ||
| 1 | 14 | 14% |
| 2 | 61 | 61% |
| 3 | 21 | 21% |
| 4 | 4 | 4% |
| History of Previous Surgery & Anesthesia | ||
| Yes | 10 | 10% |
| No | 90 | 90% |
| Preoperative sleeping period | ||
| 0 to 2 hours | 4 | 4% |
| 3 to 4 hours | 27 | 27% |
| 5 to 6 hours | 37 | 37% |
| > 7 hours | 32 | 32% |
| Awareness about surgical procedure | ||
| Yes | 48 | 48% |
| No | 52 | 52% |
| Use of anxiolysis one day before surgery | ||
| Yes | 25 | 25% |
| No | 75 | 75% |
| Amsterdam Preoperative Anxiety and Information Scale score | ||
| > 11 | 21 | 21% |
| < 11 | 79 | 79% |
| Intraoperative increase in the dose of anesthetic agents | ||
| Yes | 48 | 48% |
| No | 52 | 52% |
As shown in Table 3, Chi-square test was used to find out the association between preoperative anxiety and intraoperative increase in the dose of anesthetic doses of anesthetic agents. It is obvious that 21 patients had high preoperative anxiety out of which 76% patients required intraoperative increase in the dose of anesthetic agents. However, among 79 patients who had no preoperative anxiety, only 40% were given higher doses of anesthetic agents and most (60%) of the patients did not require higher doses of the drugs. This indicates that patients with high preoperative anxiety had significantly higher requirement of intraoperative increase in the doses of anesthetic drugs (P value of 0.004).
Table 3.
Association between preoperative anxiety and intraoperative increase in the dose of anesthetic agents
| APAIS score | Intraoperative increase in the dose of anesthetic agents | Total | Chi-square value | P | |
|---|---|---|---|---|---|
|
| |||||
| Yes | No | ||||
| >11 | 16 (76%) | 5 (24%) | 21 (100%) | 8.46 | 0.004 Significant |
| < 11 | 32 (40%) | 47 (60%) | 79 (100%) | ||
| Total | 48 | 52 | 100 | ||
APAIS – Amsterdam Preoperative Anxiety and Information Scale
Among the patients with preoperative anxiety, majority (52%) of the patients slept for 3-4 hours whereas, among the patients who had no preoperative anxiety, 77% slept for more than 5 hours. The association is statistically significant with a P value of 0.007 [Table 4]. Among 48 patients who were aware of the surgical procedure, majority (29%) had high preoperative anxiety. Among 52 patients, who were not aware of the surgical procedure only 7 (13%) had high preoperative anxiety. The association between high preoperative anxiety and awareness about surgical procedure is not statistically significant with a P value of 0.054 [Table 5].
Table 4.
Association between preoperative anxiety and preoperative sleeping period
| Preoperative sleeping period | APAIS score | Total | Chi-square value | P | |
|---|---|---|---|---|---|
|
| |||||
| > 11 | < 11 | ||||
| 0 to 2 hours | 2 (9.5%) | 2 (2.5%) | 4 | 12.226 | 0.007 Significant |
| 3 to 4 hours | 11 (52.4%) | 16 (20.3%) | 27 | ||
| 5 to 6 hours | 5 (23.8%) | 32 (40.5%) | 37 | ||
| > 7 hours | 3 (14.3%) | 29 (36.7%) | 32 | ||
| Total | 21 (100%) | 79 (100%) | 100 | ||
APAIS – Amsterdam Preoperative Anxiety and Information Scale
Table 5.
Association between preoperative anxiety and awareness about surgical procedure
| APAIS score | Total | P | ||
|---|---|---|---|---|
|
| ||||
| >11 | < 11 | |||
| Awareness about surgical procedure | ||||
| Yes | 14 (29%) | 34 (71%) | 48 (100%) | <0.054 NS |
| No | 7 (13%) | 45 (87%) | 52 (100%) | |
| Total | 21 | 79 | 100 | |
APAIS – Amsterdam Preoperative Anxiety and Information Scale
DISCUSSION
Sympathetic activity increases preoperative anxiety in humans. It may go unnoticed most of the times which results in decreased productivity. However, preoperative anxiety has been reported to be associated with poor psychosocial outcome after surgery. The goal of our study was to assess preoperative anxiety and its relation to the increase in the intraoperative doses of anesthetic agents. In this study, most of the individuals undergoing surgical procedure were males, belonging to the age group of 40-60 years. Majority of the patients undergoing surgical procedure belong to ASA Grade 2 which is consistent with the previous studies.[11] This may be due to the reason that patients who come under ASA Grade 1 and Grade 2 are favorable for doing surgical procedures with the least complications and favorable outcome after surgery.
A major finding of the present study was that on APAIS, majority (79%) of the patients had no preoperative anxiety. This is in agreement with few earlier studies though others reported much higher levels.[5,6] Previous studies have shown that anxiety one day before surgery correlates with that immediately before operation.[12] Early preoperative assessments may predict high levels of anxiety before surgery.[9] Increase in the doses of intraoperative anesthetic agents was needed in 48% of the study population. This may be due to the increase in anxiety levels due to the fear of anesthesia and surgical procedure. The association between preoperative anxiety and intraoperative increase in the dose of anesthetic agents was found to be significant in the current study. In previous study patients with higher levels of anxiety required greater amounts of propofol administration during intraoperative period to reach adequate levels of sedation.[5] Few studies found that situational anxiety immediately before surgery is not associated with intra-operative anesthetic requirements.[13] However, highly anxious patients require a greater amount of sodium thiopental to induce anesthesia than less anxious patients.[6] Similarly, assessment of state anxiety in 53 women presenting for gynecological surgery who underwent the induction of general anesthesia using alfentanil and methohexitone, revealed that preoperative anxiety seems to correlate with the amount of methohexitone required, but this relationship was not statistically significant.[7]
In our study, preoperative sleeping period in most of the patients ranged between 5 and 6 hours and only 4% of the individuals slept for less than two hours before the day of surgery. This may be due to the middle-aged patients who account for majority of the study population, in whom sleep related disturbances are less. The present study showed a significant association between preoperative anxiety and preoperative sleeping period. In the previous studies, preoperative sleeping period was not assessed, which is the novel element in this study. In the current study, only a few patients (25%) who had been posted to surgical procedures required anxiolytics which is in agreement with a randomized controlled trial.[14] In another study, higher levels of preoperative anxiety were seen in females compared to males and when they were given midazolam they experienced significant benefit of midazolam as anxiolytic.[15]
According to previous studies, the provision of preoperative information about surgical procedure creates awareness in the patients which helps in reducing at least some level of anxiety.[2] In the current study, about 48% of patients had awareness about surgical procedure. On APAIS, only a small minority (29%) of the patients who were aware about their surgical procedure had high preoperative anxiety. However, only 13% of those who were unaware of their surgical procedure had high anxiety. This difference was not statistically significant. In view of the discrepant findings, this aspect needs further detailed evaluation.
Adequate management of anxiety results in a smoother induction and a better outcome of surgery.[2] Prior knowledge of factors affecting anxiety can be used to reduce anxiety.
Strengths
The strength of the current study was that, a validated scale APAIS scale was used to assess preoperative anxiety in the study sample. This is one of the few studies which assessed the association between the preoperative anxiety and preoperative sleeping period which is statistically significant.
Limitations
This was a cross-sectional study which cannot be used to explain causal relationships. Moreover this research study was done only in one tertiary care hospital which restricts the generalizability of the results. There was an uneven distribution of study subjects among the referring departments. Anxiety was assessed only once prior to the preoperative consultation with the anesthetist. The number of patients who refused to participate and the reasons for their refusal were not recorded. In this study, consecutive sampling method was followed which can have selection bias. The type and proposed duration of surgical procedures were not assessed. The sleep period was assessed subjectively. Impact of use of anxiolytics by 25% of the patients not assessed.
CONCLUSION
The prevalence of preoperative anxiety is significantly related to the intra-operative increase in the doses of anesthetic agents. The association of preoperative anxiety with other clinical variables like preoperative sleeping period was also found to be significant. Therefore, patients need to be assessed regularly for anxiety during preanesthetic checkup and appropriate methods to reduce the anxiety should be introduced.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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