Is preoperative anxiety adequately treated in adult patients undergoing surgery under general/regional anesthesia? A questionnaire-based cross-sectional survey

To the Editor,

Preoperative anxiety is quite prevalent with global pooled prevalence among surgical patients being as high as 48%.[1] A few factors that contribute to the preoperative anxiety are female sex, previous history of unpleasant experiences during surgery, type of surgery, and other associated co-morbidities, especially psychiatric illness.[2] Increased levels of preoperative anxiety can add to the surgical stress response, adversely affecting the perioperative physiological parameters.[3] Still routine objective assessment of preoperative anxiety is not an integral part of the preanesthetic evaluation by the anesthesiologists. We carried out a cross-sectional questionnaire-based survey with the primary objective of assessing the practice of routine assessment of preoperative anxiety levels during pre-anesthetic visits a day prior to surgery. The secondary objective was to assess the awareness among anesthesiologists regarding the various scales used for the assessment of preoperative anxiety. After approval from the Institutional Ethics Committee, the Google form-based questionnaire was circulated to anesthetists across India, through WhatsApp and other modes of electronic messaging for 45 days. The questionnaire consisted of questions, broadly classified into socio-demographics, awareness of the importance of evaluation of preoperative anxiety and its treatment. Filling and submission of forms were considered as consent for participating in the survey. Incomplete forms were not included in the analysis. Data was analyzed using SPSS ver. 24 and presented as a number (%). The reporting of the survey is done in accordance with the CHERRIES checklist. A total of 142 responses were collected over 45 days. Only one response per email ID was accepted. Availability of pre-anesthetic check-up (PAC) clinic in their hospitals was confirmed by 95.7% of the respondents. However, only 38.7% of responding anesthesiologists routinely evaluate preoperative anxiety as a part of PAC. 51% of the respondents do not use any scale for anxiety assessment. Only 53% (75/142) of the anesthetists were aware of the different anxiety assessment scales. Among the various scales used to assess anxiety, the Visual Analogue Scale is the most frequently used tool (57/142; 40.1%). Other tools used are the Amsterdam Preoperative Anxiety and Information Scale (11.2%), the Hospital Anxiety and Depression Scale (4.2%), the State-Trait Anxiety Inventory (3.5%) and the modified Yale Preoperative Anxiety Scale (1.4%). When given a choice between the two modalities, the majority (101/142; 71%) of the respondents felt that pharmacological methods are more efficacious than non-pharmacological methods (41/142; 28.9%). Counselling is the most employed non-pharmacological technique for the alleviation of preoperative anxiety (95/142; 66.9%). Being short-acting, alprazolam is the most commonly administered drug for preoperative anxiolysis (119/142; 83.8%). The other class of drugs commonly used are gabapentin and melatonin. Most anesthetists opined that preoperative anxiety is not routinely assessed (57/142; 40%) and not adequately treated (108/142; 76%).

Amongst those who responded, PAC clinics are available in most of the government teaching hospitals (101/103; 98.6%), but inclusion of routine evaluation of preoperative anxiety is higher in private hospitals (20/36; 55%) vs (35/105; 33%). This could possibly be attributed to the increased caseload in government and public hospitals, which could lead to time constraints. Malik et al.[4] assessed preoperative anxiety in patients with supratentorial tumors and found 60% of the patients to have preoperative anxiety. Lack of information regarding the procedure was a significant risk for higher levels of anxiety. Increased levels of preoperative anxiety are associated with higher postoperative pain scores and increased consumption of analgesics in the postoperative period.[5] It is also found to be a precipitating factor for postoperative delirium in elderly patients.[6] Preoperative counselling should be an integral part of the patient management. Assessing the level of anxiety and prescribing anxiolytics if required should be routinely done. In daycare surgeries, anxiolytics such as Melatonin, administered 50 min before the surgery have been shown to offer maximum benefits.[7] In our study, most of the respondents (53.3%) preferred administering anxiolytics the night before surgery. Several articles in the literature highlight the various modalities to reduce preoperative anxiety in patients. In our survey, we found that only 40% of the anesthesiologists routinely assess anxiety preoperatively. Based on our results, we advocate that there is a prime need for educational awareness among anesthesiologists about the importance of assessment and treatment of preoperative anxiety.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.