Current status and influencing factors of anxiety in patients with malignant tumors after anesthesia recovery

Abstract

BACKGROUND

General anesthesia is essential for maintaining adequate sedation, minimizing intraoperative stimuli, and ensuring smooth surgery completion. However, when faced with invasive procedures and anesthetic risks, patients often exhibit nonspecific physiological and psychological responses.

AIM

To investigate the occurrence of agitation and the prevalence of anxiety during anesthesia recovery in patients with malignant tumors (MTs) and to analyze their influencing factors, providing a theoretical basis for clinical management.

METHODS

An analysis was performed on 168 patients who underwent surgery for MTs and recovered from anesthesia between April 2022 and October 2023. Based on the presence or absence of agitation during general anesthesia recovery, patients were divided into agitation and non-agitation groups. The Self-Rating Anxiety Scale was distributed to patients who recovered from anesthesia for a questionnaire survey, and based on the results, they were further categorized into anxiety and non-anxiety groups. Clinical data were compared to identify factors influencing agitation and anxiety.

RESULTS

Agitation occurred in 41 (24.4%) of the 168 patients during recovery from general anesthesia. Compared with the non-agitation group, patients with agitation were older, had higher rates of preoperative anxiety, alcohol consumption, diabetes, operations or anesthesia lasting > 3 hours, intraoperative hypothermia, and higher Visual Analog Scale (VAS) scores during recovery (P < 0.05). Logistic regression analysis identified age, operative duration of > 3 hours, preoperative anxiety score, and intraoperative hypothermia as independent risk factors for agitation. The mean anxiety score among all patients was 7.23 ± 2.67, with anxiety symptoms confirmed in 59 cases (35.1%). Univariate and multivariate analyses revealed significant associations between groups with age, preoperative anxiety score, education level, annual income, and VAS score during recovery (P < 0.05). Preoperative anxiety score, education level, annual income, and VAS score during recovery were key factors influencing anxiety in patients who underwent MT surgery during general anesthesia recovery.

CONCLUSION

Anxiety is common among patients recovering from anesthesia after MT surgery. Preoperative anxiety score, education level, annual income, and VAS score during recovery are major influencing factors for anxiety, whereas preoperative anxiety represents a risk factor for agitation.

Core Tip: Surgical resection remains the primary treatment method for malignant tumors, with general anesthesia playing a pivotal role in ensuring smooth intraoperative management. Agitation during recovery is a common postoperative complication, and patients’ emotional states critically affect recovery outcomes. This study highlights the prevalence and determinants of postoperative anxiety in patients undergoing anesthesia recovery who underwent malignant tumor surgery to alleviate adverse physiological and psychological reactions, reduce discomfort, and promote optimal physical and mental recovery.

INTRODUCTION

Malignant tumors (MTs), characterized by invasive growth and metastasis, remain a major threat to human health[1]. As a severe stressor, MTs show increasing prevalence each year, inflicting significant physical and psychological trauma on patients[2,3]. Data from 2020 indicate approximately 4.57 million new cancer cases and approximately 3 million deaths in China[4]. Surgical treatment, the most traditional therapeutic approach, is often clinicians’ first choice[5]. General anesthesia is essential for the smooth conduct of surgery, maintaining an appropriate anesthetic depth, reducing intraoperative stimulation, and facilitating a successful procedure[6]. Perioperative patients represent a vulnerable population; when faced with invasive surgery and potential anesthetic risks, they often develop nonspecific physiological and psychological responses, such as mental tension, tachycardia, dyspnea, hypertension, and even stress syndromes that exacerbate their condition. One common complication of general anesthesia is agitation during recovery[7,8], manifested by restlessness, disorientation, and excitement. Patients may cry, struggle, or move involuntarily. If not promptly managed, agitation can compromise surgical outcomes and hinder recovery[9]. In addition, MT-related fear and adverse reactions after anesthesia recovery are typically more intense than those arising from other diseases, often leading to a poorer prognosis. Emotional status, therefore, plays a crucial role in postoperative recovery.

Understanding the causes of agitation during general anesthesia recovery and implementing timely preventive or therapeutic measures are of great clinical importance. Additionally, investigating postoperative anxiety among patients recovering from anesthesia who underwent MT surgery and identifying its influencing factors can help reduce adverse physiological and psychological reactions, minimize discomfort, and promote optimal psychological, physiological, and emotional stability during the peri-anesthesia period. Accordingly, this study retrospectively analyzed the clinical data of 168 patients with MTs who experienced agitation and anxiety during anesthesia recovery. The findings are presented below.

MATERIALS AND METHODS

Research population

An analysis was conducted on the clinical data of 168 patients with MTs who underwent anesthesia recovery between April 2022 and October 2023. Inclusion criteria: (1) Definite diagnosis of MTs and surgical treatment; (2) General anesthesia use and normal coagulation function; (3) American Society of Anesthesiologists (ASA) grade I-II; (4) Karnofsky Performance Scale score ≥ 70, indicating tolerance for surgery and postoperative treatment; (5) Clear consciousness, no cognitive or speech impairment, accurate understanding of the questionnaire, and normal communication ability; and (6) Complete clinical data. Exclusion criteria: (1) Mental disorders or cognitive impairments; (2) History of substance or drug abuse; (3) Preoperative auditory or visual impairment; (4) Severe cardiac, renal, or other organ dysfunction; (5) Coagulation abnormalities; and (6) Incomplete clinical data.

Methods

(1) Preoperative and postoperative anxiety assessment: Patient anxiety was assessed the day before surgery and after postoperative anesthesia recovery using the 14-item Hamilton Anxiety Scale administered by clinical professionals. Total scores of < 7, 7-14, 14-21, 21-29, and > 29 indicated no, possible, definite, obvious, and severe anxiety, respectively. Patients with postoperative Hamilton Anxiety Scale scores < 7 were assigned to the non-anxiety group, whereas those with scores ≥ 7 were included in the anxiety group; and (2) Evaluation of agitation during postoperative recovery: Agitation was assessed during recovery using the Riker Sedation-Agitation Scale, which ranges from 1 to 7. Scores ≤ 4 indicated no agitation, and scores > 4 indicated agitation.

Patient data collection

(1) General information: Data on sex, age, ethnicity, education level, body mass index (BMI), smoking and drinking history, comorbidities, marital status, medical payment method, family income, and tumor stage were collected; (2) Preoperative conditions: Tumor stage, ASA classification, and preoperative anxiety status were recorded; (3) Intraoperative indicators: Operative and anesthesia durations were documented; and (4) Postoperative indicators: Visual Analog Scale (VAS) scores during recovery, extubation complications, and catheter indwelling status were recorded.

Statistical analysis

All data were analyzed using SPSS version 25.0. Continuous variables following a normal distribution are expressed as mean ± SD and compared using the independent-samples t-test. Categorical variables are summarized as counts and percentages and analyzed using the χ² test. Variables with significant univariate differences were included in the multiple regression analysis. Multivariate logistic regression was used to identify factors influencing postoperative anxiety and agitation during postoperative recovery. Multicollinearity was assessed using the variance inflation factor. A two-tailed P < 0.05 was considered statistically significant.

RESULTS

General data

Among 168 patients with MTs, 95 were male, and 73 were female, aged 28-78 years, with a mean age of 62.74 ± 7.42 years and a mean BMI of 22.99 ± 2.63 kg/m². Seventy-two patients had a smoking history, 83 had a drinking history, 81 had diabetes, and 70 had hypertension. Detailed demographic and clinical data are presented in Table 1.

Table 1.

General information of 168 patients

Characteristic	n = 168
Gender
Male	95
Female	73
Age (years old)	62.74 ± 7.42
Body mass index (kg/m2)	22.99 ± 2.63
Ethnicity
Han	139
Ethnic minorities	29
Education level
Junior high school or below	94
Senior high school or above	74
Marital status
Married	103
Single/divorced/widowed	65
Annual income (in ten thousand yuan)
< 5	100
≥ 5	68
Smoking history	72
Drinking history	83
Diabetes	81
Hypertension	70
Medical payment method
Medical insurance	128
Self-funded	40
Operative duration
≤ 3	82
> 3	86
Tumor staging
I-II	94
III-IV	74
American Society of Anesthesiologists grading
I	67
II	101

Univariate analysis of postoperative agitation

Of the 168 patients, 41 (24.4%) experienced agitation during anesthesia recovery, whereas 127 (75.6%) did not. Univariate analysis revealed statistically significant differences between the agitation and non-agitation groups in age, drinking history, diabetes, operative duration, preoperative anxiety score, anesthesia duration, VAS score during recovery, anesthesia mode, and intraoperative hypothermia (P < 0.05). No significant differences were found in sex, ethnicity, education level, BMI, marital status, annual income, smoking history, hypertension, medical payment method, tumor stage, ASA classification, extubation complications, or catheter indwelling status (P > 0.05) (Table 2).

Table 2.

Univariate analysis of postoperative agitation in patients

Characteristic		Agitation group (n = 41)	Non-agitation group (n = 127)	χ 2/t	P value
Gender				0.627	0.429
Male	95	21	74
Female	73	20	53
Age		66.05 ± 4.95	61.68 ± 7.77	3.382	0.0009
Body mass index		22.49 ± 2.80	23.15 ± 2.56	1.397	0.164
Ethnicity				0.835	0.361
Han	139	32	107
Ethnic minorities	29	9	20
Education level				0.555	0.456
Junior high school or below	94	25	69
Senior high school or above	74	16	58
Marital status				1.115	0.291
Married	103	28	75
Single/divorced/widowed	65	13	52
Annual income (in ten thousand yuan)				0.774	0.379
< 5	100	22	78
≥ 5	68	19	49
Smoking history	72	19	53	0.269	0.604
Drinking history	83	26	57	4.259	0.039
Diabetes	81	27	54	6.759	0.009
Hypertension	70	20	50	1.129	0.288
Medical payment method				0.273	0.602
Medical insurance	128	30	98
Self-funded	40	11	29
Operative duration				8.289	0.004
≤ 3 hours	82	12	70
> 3 hours	86	29	57
Tumor staging				0.555	0.456
I-II	94	25	69
III-IV	74	16	58
American Society of Anesthesiologists grading				0.744	0.388
I	67	14	53
II	101	27	74
Preoperative anxiety score		12.85 ± 2.34	9.94 ± 2.56	6.458	< 0.0001
Anesthesia duration (hours)				9.849	0.002
≤ 3 hours	89	13	76
> 3 hours	79	28	51
Visual Analogue Scale score during recovery		6.24 ± 1.11	5.57 ± 1.17	3.268	0.001
Mode of anesthesia				5.949	0.015
Intravenous anesthesia	101	18	83
Intravenous-inhalation combined anesthesia	67	23	44
Intraoperative hypothermia				5.022	0.025
With	73	24	49
Without	95	17	78
Extubation complications				0.226	0.635
With	21	6	15
Without	147	35	112
Indwelling catheter				0.039	0.844
With	22	5	17
Without	146	36	110

Multivariate analysis of postoperative agitation

Multivariate logistic regression analysis (Table 3) identified age, operative duration, preoperative anxiety score, and intraoperative hypothermia as independent risk factors for postoperative agitation (P < 0.05). Drinking history, anesthesia duration, diabetes, VAS score during recovery, and anesthesia mode were not independent predictors (P > 0.05).

Table 3.

Multivariate logistic analysis of postoperative agitation in patients

Variable	Assignment	β	SE	Wald	P value	HR	95%CI
Constant	-	-19.485	3.797	26.332	0.000	0.000	-
Age	Continuous variable	0.102	0.047	4.767	0.029	1.108	0.846-6.863
Drinking history	1 = with, 0 = without	0.880	0.534	2.713	0.100	2.410	0.847-6.774
Diabetes	1 = with, 0 = without	0.873	0.530	2.712	0.100	2.395	0.847-6.774
Operative duration	1: ≥ 3 hours, 0: < 3 hours	1.310	0.562	5.434	0.020	3.706	1.232-11.151
Preoperative anxiety score	Continuous variable	0.603	0.132	20.941	0.000	1.827	1.411-2.365
Anesthesia duration	1: ≥ 3 hours, 0: < 3 hours	0.505	0.533	0.898	0.343	1.657	0.583-4.709
Visual Analogue Scale score during recovery	Continuous variable	0.293	0.235	1.563	0.211	1.341	0.847-2.124
Mode of anesthesia	1 = intravenous-inhalation combined anesthesia, 0 = intravenous anesthesia	0.723	0.529	1.871	0.171	2.060	0.731-5.806
Intraoperative hypothermia	1 = with, 0 = without	1.544	0.536	8.305	0.004	4.682	1.639-13.380

SE: Standard error; HR: Hazard ratio; CI: Confidence interval.

Univariate analysis of postoperative patient anxiety

Among the 168 patients, 59 (35.1%) experienced anxiety during postoperative recovery, whereas 109 (64.9%) did not. The mean postoperative anxiety score in the anxiety group (10.29 ± 2.25) was significantly higher than that in the non-anxiety group (5.58 ± 0.67). Univariate analysis (Table 4) revealed significant inter-group differences in age, education level, annual income, preoperative anxiety score, VAS score during recovery, and extubation complications (P < 0.05). Differences in sex, ethnicity, BMI, marital status, smoking, tumor stage and drinking history, diabetes, and hypertension were not significant (P > 0.05).

Table 4.

Univariate analysis of postoperative patient anxiety

Characteristic	Anxiety group (n = 59)	Non-anxiety group (n = 109)	χ 2/t	P value
Postoperative anxiety score	10.29 ± 2.25	5.58 ± 0.67	20.300	< 0.0001
Gender			0.594	0.441
Male	31	64
Female	28	45
Age	64.37 ± 6.14	61.86 ± 7.91	2.116	0.035
Body mass index	22.58 ± 2.27	23.20 ± 2.79	1.464	0.145
Ethnicity			0.603	0.438
Han	47	92
Ethnic minorities	12	17
Education level			5.176	0.023
Junior high school or below	40	54
Senior high school or above	19	55
Marital status			0.520	0.471
Married	34	69
Single/divorced/widowed	25	40
Annual income (in ten thousand yuan)			17.991	< 0.0001
< 5	48	52
≥ 5	11	57
Smoking history	28	44	0.786	0.375
Drinking history	30	53	0.076	0.783
Diabetes	33	48	2.169	0.141
Hypertension	27	43	0.628	0.428
Medical payment method
Medical insurance	41	87	2.250	0.134
Self-funded	18	22
Operative duration			0.067	0.797
≤ 3	28	54
> 3	31	55
Tumor staging			2.663	0.103
I-II	28	66
III-IV	31	43
American Society of Anesthesiologists grading			0.255	0.614
I	22	45
II	37	64
Preoperative anxiety score	11.56 ± 2.46	10.17 ± 2.86	3.154	0.002
Anesthesia duration			0.534	0.465
≤ 3	29	60
> 3	30	49
Visual Analogue Scale score during recovery	6.08 ± 0.97	5.54 ± 1.25	2.880	0.004
Mode of anesthesia			0.024	0.877
Intravenous anesthesia	35	66
Intravenous-inhalation combined anesthesia	24	43
Intraoperative hypothermia			0.043	0.836
With	25	48
Without	34	61
Extubation complications			5.109	0.024
With	12	9
Without	47	100
Indwelling catheter			1.187	0.276
With	10	12
Without	49	97

Multivariate analysis of postoperative anxiety

As shown in Table 5, multivariate logistic regression identified preoperative anxiety score, annual income < 50000 yuan, and VAS score during recovery as independent risk factors for postoperative anxiety in patients with MTs. Conversely, education level (high school or above) was a protective factor (P < 0.05). Age and extubation complications were not independent predictors of postoperative recovery (P > 0.05).

Table 5.

Multivariate logistic analysis of postoperative anxiety in patients

Variable	Assignment	β	SE	Wald	P value	HR	95%CI
Constant	-	-7.517	2.309	10.596	0.001	0.001	-
Age	Continuous variable	0.023	0.032	0.490	0.484	1.023	0.960-1.090
Preoperative anxiety score	Continuous variable	0.188	0.074	6.517	0.011	1.207	1.079-4.789
Education level	1 = senior high school or above, 0 = junior high school or below	-0.782	0.388	4.068	0.044	0.458	0.214-0.978
Annual income (in ten thousand yuan)	1: < 5, 0: ≥ 5	1.395	0.430	10.504	0.001	4.035	1.079-4.789
Visual Analogue Scale score during recovery	Continuous variable	0.399	0.169	5.562	0.018	1.491	1.070-2.077
Extubation complications	1 = with, 0 = without	0.555	0.555	1.000	0.317	1.742	0.587-5.172

SE: Standard error; HR: Hazard ratio; CI: Confidence interval.

DISCUSSION

Patients with MTs frequently undergo surgery, radiotherapy, or chemotherapy. Preoperatively, most patients experience varying degrees of anxiety due to limited disease understanding, surgical fear, and treatment concerns[10]. Mild anxiety may represent an adaptive psychological response that aids surgical preparedness and can positively influence postoperative recovery[11]. However, severe anxiety can disrupt endocrine function, elevate catecholamine and glucocorticoid levels, reduce lymphocyte counts, and delay postoperative wound healing[12]. During surgery, anesthetic agents act on the central nervous system to induce anesthesia. During emergence, residual drug effects can transiently impair cortical and reticular activating system function, causing abnormal sensations and behaviors that manifest as agitations during recovery[13].

In this study, 41 of the 168 patients with MTs experienced agitation during recovery from general anesthesia. These patients were older and had higher rates of preoperative anxiety, alcohol use, diabetes, prolonged operative and anesthesia duration ( > 3 hours), intraoperative hypothermia, and higher VAS scores during recovery than the non-agitation group. Logistic regression analysis identified age, operative duration of > 3 hours, preoperative anxiety score, and intraoperative hypothermia as independent risk factors for agitation during general anesthesia recovery in patients undergoing MT surgery. Individuals aged ≥ 60 years are considered elderly; with increasing age, tolerance to surgery and anesthesia declines, and comorbidities heighten the likelihood of agitation during recovery. Longer operations cause greater surgical trauma and physiological stress, which can also precipitate agitation. Studies have shown a significant correlation between preoperative anxiety and postoperative agitation. Preoperative anxiety triggers physiological responses - tachycardia, hypertension, sleep disturbance, and heightened pain sensitivity - that complicate surgery and delay recovery[14,15]. Excessive preoperative anxiety before anesthesia may further promote excessive secretion of pain mediators in the early postoperative period, amplify inflammatory cascades, and disturb coagulation, predisposing to systemic neuropsychiatric disorders and thrombosis-related complications, thereby increasing agitation risk during general anesthesia recovery. Body temperature is a vital physiological indicator essential for normal metabolic and life activities[16]. During the perioperative period, 20%-70% of patients experience hypothermia (core temperature < 36 °C)[17], which contributes to infection, prolonged hospitalization, higher medical costs, and coagulation dysfunction[18,19]. Because thermoregulatory capacity is impaired under anesthesia, the body cannot maintain temperature solely through autonomic regulation of heat production and dissipation[20]. Notably, studies show that intraoperative hypothermia is associated with postoperative cognitive decline, potentially mediated by changes in cerebral perfusion, energy metabolism, stress responses, and protein deposition in cerebrospinal fluid[21,22]. It has also been identified as a risk factor for postoperative delirium (POD), a common central nervous system complication following surgery[23]. POD manifests as acute disturbances of attention and cognition, including confusion, disorientation, cognitive impairment, personality or mood changes, and even delusions and hallucinations[24]. Therefore, effective recognition and management of intraoperative hypothermia may improve patient recovery, reduce postoperative complications, enhance overall outcomes, and lessen the financial burden on patients.

The mean postoperative anxiety score among the 168 patients was 7.23 ± 2.67, with anxiety symptoms identified in 59 cases. Univariate and multivariate analyses identified preoperative anxiety score, education level, annual income, and VAS score during recovery as key factors influencing postoperative anxiety in patients undergoing general anesthesia for MT surgery. Patients with preoperative anxiety often remain anxious postoperatively, although some without preoperative anxiety develop anxiety after invasive surgery. Higher education acts as a protective factor, as individuals with greater educational attainment generally exhibit stronger coping skills, stress management, and problem-solving abilities. Fahey et al[25] found that higher education among Indian women enhanced coping and stress management, while Bonanno et al[26] reported that greater adaptability is associated with higher education - suggesting that better-educated patients may experience less anxiety due to a clearer understanding of their condition. Economic status also plays an important role in disease management. The financial strain and instability caused by MTs impose a greater psychological burden on patients with lower annual incomes, making them more prone to anxiety. A United States study reported that over 80% of surgical patients experience immediate postoperative pain, and approximately 75% describe it as moderate to severe[27]. Moreover, preoperative anxiety is a known predictor of postoperative pain, independent of demographic or clinical variables[28]. Our findings show that postoperative pain during recovery is also a risk factor for postoperative anxiety, indicating that preoperative anxiety, postoperative pain, and postoperative anxiety interact dynamically.

CONCLUSION

In summary, most MT patients experience postoperative anxiety from anesthesia. Preoperative anxiety score, education level, annual income, and VAS score during recovery are key influencing factors of anxiety, whereas preoperative anxiety itself is a risk factor for postoperative agitation. Clinically, optimizing surgical procedures - such as adopting fast-track anesthesia techniques to shorten anesthesia duration - may help mitigate these effects. For patients with preoperative anxiety, tiered psychological intervention should be implemented based on educational level (e.g., simplified visual aids for less-educated patients and detailed disease guides for highly educated patients). In addition, maintaining normothermia during surgery can reduce the incidence of POD. Proactive assessment and timely intervention for these risk factors before surgery are essential for minimizing anxiety and agitation during recovery and improving overall patient outcomes.

Data sharing statement

No additional data are available.