The visual analog scale allows effective measurement of preoperative anxiety and detection of patients' anesthetic concerns

Educating patients about anaesthesia: effect of various modes on patients' knowledge, anxiety and satisfaction

PURPOSE OF REVIEW

This review summarizes the current research on the effects of preoperative education about anaesthesia on patient knowledge, anxiety, and satisfaction.

RECENT FINDINGS

Misconceptions about the process and the risks of general and regional anaesthesia are common. Information leaflets should be formally assessed to ensure that patient knowledge is increased. Patients should be surveyed to see what information they want, rather than just providing what healthcare professionals think is appropriate. The amount of information requested by patients can vary considerably. Providing detailed drug information leaflets for anaesthetic drugs was not thought necessary by many patients, but was not associated with increased preoperative state anxiety. Information sessions to small groups of patients by multidisciplinary healthcare professionals were useful for patients undergoing total hip arthroplasty, with a small reduction in preoperative state anxiety, but patient satisfaction levels remained unchanged. Patient satisfaction should be measured by a valid and reliable questionnaire. When this was done, the introduction of pamphlets did not improve patient satisfaction. The evidence for better patient outcomes after patient education interventions is not convincing.

SUMMARY

Preoperative patient education should recognize that different patients have various misconceptions, expectations and needs. Multiple modes may be required to increase knowledge for informed consent and decrease patient anxiety. Patient satisfaction is generally high irrespective of the mode of patient education.

A quantitative analysis of anaesthetist-patient communication during the pre-operative visit

Previous communication research in general medical practice has shown that effective communication enhances patient compliance, satisfaction and medical outcome. It is expected that communication is equally important in anaesthesia, since patients often suffer from anxiety and lack of knowledge about anaesthetic procedures. However, little is known about the nature of communication during routine anaesthetic visits. The present study of 57 authentic anaesthetic visits provides the first results on the structure and content of communication in the pre-operative setting using the Roter Interaction Analysis System (RIAS). Patient-centred communication behaviours of anaesthetists and the extent of patient involvement were particularly investigated. From the 57 pre-operative visits, 18 267 utterances were coded. The mean (SD) [range] duration of the visit was 16.1 (7.8) [3.7-42.7] min. Anaesthetists provided 169 (68) and patients 153 (82) utterances per visit (53.5% vs. 46.5%). Physician and patient gender had no impact on the distribution of utterances and the duration of the visit. Conversation mainly focussed on biomedical issues with little psychosocial discussion (< 0.1% of all anaesthetist utterances). However, anaesthetists quite frequently used emotional comments toward patients (7%) and involved them in the conversation. The use of facilitators, open questions and emotional statements by the anaesthetist correlated with high patient involvement. The amount of patient participation in anaesthetic decisions was assessed with the Observing Patient Involvement Scale (OPTION). Compared with general practitioners, anaesthetists offered more opportunities to discuss treatment options (mean (SD) OPTION score 26.8 (16.8) vs. 16.8 (7.7)).

Comparison of morphine and butorphanol as pre-anaesthetic agents in combination with romifidine for field castration in ponies

OBJECTIVE

The aim of this study was to compare two different alpha2 agonist-opioid combinations in ponies undergoing field castration.

STUDY DESIGN

Prospective double-blind randomized clinical trial.

ANIMAL POPULATION

Fifty-four ponies undergoing field castration.

MATERIALS AND METHODS

The ponies were randomly allocated to receive one of three different pre-anaesthetic medications [intravenous (IV) romifidine 100 microg kg(-1) and butorphanol 50 micro kg(-1); romifidine 100 microg kg(-1) and morphine 0.1 mg kg(-1) IV, or romifidine 100 microg kg(-1) and saline IV] before induction of anaesthesia with ketamine 2.2 mg kg(-1) IV. Further doses of romifidine (25 microg kg(-1)) and ketamine (0.5 mg kg(-1)) were given when required to maintain anaesthesia. Quality of sedation, induction of anaesthesia, maintenance of anaesthesia, recovery, and surgical condition were assessed using a visual analogue scale scoring system and compared. The effects of the different drug combinations on heart and respiratory rate were evaluated and the recovery time was recorded.

RESULTS

Anaesthesia was considered adequate for surgery in all ponies. No anaesthetic complications were observed. Quality of sedation was significantly better in the butorphanol group compared with the control group (p = 0.0428). Overall quality of anaesthesia was better in the butorphanol group compared with morphine (p = 0.0157) and control (p < 0.05) groups. Quality of induction of anaesthesia and recovery were not significantly different between groups, nor were the surgical conditions, recovery time and the number of repeated anaesthetic doses required during the procedure. Muscle twitches were observed in both the control and morphine groups. Maintenance of anaesthesia was judged to be smoother in the butorphanol group compared with the morphine and control groups (p = 0.006). Heart rate decreased significantly (p < 0.01) in all groups after administration of sedatives but did not differ significantly between groups at any time point.

CONCLUSION

The combination of butorphanol and romifidine was found to provide better sedation compared with the other drug combinations.

CLINICAL RELEVANCE

The combination of butorphanol and romifidine provided better sedation, but morphine was found to be a suitable alternative to butorphanol. Use of morphine and butorphanol in combination with alpha2 agonists should be further investigated to assess their analgesic effects.

Visual analogue scale correlates of musculoskeletal fatigue

Visual analogue scale has been shown to reflect subjective feelings but rarely has it been used for musculoskeletal fatigue so in the present study VAS ratings were used to quantify musculoskeletal fatigue. A total of 20 students underwent a fatigue protocol (M age=21.3 yr., SD= 1.0). A series of randomized external loads at 0, 5, 10, 15, 25, 35, and 50% of the maximum voluntary contraction was generated by the BTE Primus and applied at the distal end of the dominant arm, which was sustained at the 90 degrees forward flexion position. After 60 sec. of force exertion for each loading, the subject marked the scale to reflect their extent of fatigue at the shoulder muscle. Analysis showed fatigue scores were significantly correlated with the percentages of maximum load applied (r =.73, p < or = .01). The correlation between higher external loads (25-50% maximum load) and fatigue scores was .57 (p < or = .01) and that for lower external loads (0-15% maximum load) was .44 (p < or = .01). The validity of using a visual analogue scale as a measure of musculoskeletal fatigue requires further study, particularly for a low load.

Patient experience with a urodynamic study: a prospective study in 208 patients

PURPOSE

We assessed several emotional variables, including anxiety, pain, shame and morbidity, in patients who underwent a urodynamic study.

MATERIALS AND METHODS

A total of 208 patients of 20 to 81 years old (mean age 54.3) were included in the study. Of the patients 71 (34.1%) were male and 137 (65.9%) were female. Prior to and immediately after the procedure each patient completed a self-administered questionnaire. Answers were given on a visual analog scale. All patients received an antibiotic for 3 days after the investigation and urine was collected for culture 7 days after the investigation.

RESULTS

Patient initial anxiety did not significantly depend on demographics. The mean degree of pain +/- SEM experienced by patients was higher in males than in females (3.1+/- 0.2 vs 2.4 +/- 0.2, p = 0.012). Pain scores correlated with pre-procedure anxiety scores but the relationship was weak ([pain] = 0.283[anxiety] + 1.766, r = 0.157, p = 0.024). On the other hand, female patients showed a significantly higher mean level of shame than males (3.6 +/- 0.3 vs 1.8 +/- 0.3, p <0.001). In general patients cooperated extremely well during the examination. By the stepwise method only bother was associated with tolerance ([tolerance] = 0.182[bother] + 2.753, r = 0.275, p <0.001). Seven patients (3.4%) had significant bacteriuria and received antibiotic treatment.

CONCLUSIONS

The study demonstrates that urodynamic studies are well tolerated by male and female patients in all age groups. However, emotional support depending on gender prior to the urodynamic procedure might enhance the level of patient cooperation.

Preoperative intravenous midazolam: benefits beyond anxiolysis

STUDY OBJECTIVE

To evaluate the effect of midazolam on the global perioperative experience, including patient satisfaction, postoperative nausea and vomiting, postoperative pain, and perioperative anxiety and amnesia.

DESIGN

Prospective, randomized, placebo-controlled study.

SETTING

Ambulatory surgical center affiliated with a tertiary-care hospital.

PATIENTS

88 ASA physical status I, II, and III patients scheduled for outpatient surgery.

INTERVENTIONS

Patients were randomized into two groups to receive either 0.04 mg/kg of midazolam or placebo intravenously (IV) 20 minutes preoperatively.

MEASUREMENTS

Perioperative measurements included blood pressure, heart rate, and oxygen saturation and the patient's level of anxiety; type of anesthetic administered; the anesthesiologist's guess at the treatment arm; perioperative dosages of fentanyl, morphine, and ondansetron; recovery room length of stay; frequency of nausea and vomiting, and level of postoperative pain in the 24 hours after surgery; the patient's overall satisfaction with the anesthetic, and whether the patient would recommend the premedication to a friend.

MAIN RESULTS

Patient demographics, type of surgery/anesthesia, vital signs, case duration, recovery duration, and postoperative pain were all similar between the midazolam and placebo groups. As expected, IV midazolam was an effective anxiolytic. There was no evidence of retrograde amnesia. Fewer patients in the midazolam group suffered from postoperative nausea than did those in the placebo group (25%vs. 50%;p = 0.03), despite receiving similar perioperative antiemetic and opioid administration. Similarly, fewer patients in the midazolam group experienced postoperative vomiting than placebo group patients (8%vs. 21%), although this difference did not reach statistical significance. Only 42% of patients in the placebo group would recommend their premedication to a friend, compared with 85% of patients in the midazolam group (p < 0.001).

CONCLUSIONS

In addition to the known anxiolytic effects of midazolam, midazolam premedication is an effective way to reduce the frequency of postoperative nausea, and perhaps vomiting, and increase patient satisfaction.

Beneficial Effects of Noetic Therapies on Mood Before Percutaneous Intervention for Unstable Coronary Syndromes

BACKGROUND

Many common medical, surgical, and diagnostic procedures performed for conscious patients can be accompanied by significant anxiety. Mind-body-spirit interventions could serve as useful adjunctive treatments for the reduction of stress.

OBJECTIVE

To evaluate the effects of stress management, imagery, touch therapy, remote intercessory prayer, and standard therapy on mood in patients awaiting percutaneous interventions for unstable coronary syndromes as part of the Monitoring and Actualization of Noetic Training (MANTRA) trial, which explored the feasibility and efficacy of noetic interventions on clinical outcomes in a randomized clinical trial.

METHODS

A total of 150 patients were randomized to one of the five treatment conditions. Stress management, imagery, and touch therapy were administered in 30-minute treatment sessions immediately before the cardiac intervention. Intercessory prayer was not necessarily contemporaneous with these treatments. Mood was assessed by a set of visual analog scales before and after treatment for a similar length of time for the standard therapy and prayer groups.

RESULTS

Analysis of complete data from 108 patients showed that stress management, imagery, and touch therapy all produced reductions in reported worry, as compared with standard therapy, whereas remote intercessory prayer had no effect on mood. The ratings of other similar moods were not affected, perhaps because of the relatively positive emotional state observed in the participants before treatment.

CONCLUSIONS

The results suggest that at least some noetic therapies may have beneficial effects on mood in the course of medical and surgical interventions. Administration of these interventions was feasible even in the hectic environment of the coronary intensive care unit. Given their relatively low cost and limited potential for adverse effects, these interventions merit further study as therapeutic adjuncts.

Improving anaesthetists' communication skills

The attitude, behaviour and communication skills of specialised doctors are increasingly recognised as important and they have been identified as training requirements. We designed a programme to teach communication skills to doctors in a University Department of Anaesthesia and evaluated its effect on patient outcomes such as satisfaction and anxiety. The 20 h programme was based on videotaped reviews of actual pre-operative visits and role-playing. Effects on patient satisfaction and pre-operative anxiety were assessed using a patient questionnaire. In addition, all participating anaesthetists assessed the training. We provide evidence that the training increased patient satisfaction with the pre-operative anaesthetic visit. Training also decreased anxiety associated with specific aspects of anaesthesia and surgery, but the effect was rather small given the intense programme. The anaesthetists agreed that their interpersonal skills increased and they felt better prepared to understand patients' anxieties. Communication skills training can increase patient satisfaction and decrease specific anxieties. The authors conclude that in order to better demonstrate the efficacy of such a training programme, the particular communication skills of anaesthetists rather than indirect patient outcome parameters should be measured.

Surgery information reduces anxiety in the pre-operative period

PURPOSE: Patients preparing to undergo surgery should not suffer needless anxiety. This study aimed to evaluate anxiety levels on the day before surgery as related to the information known by the patient regarding the diagnosis, surgical procedure, or anesthesia. METHOD: Patients reported their knowledge of diagnosis, surgery, and anesthesia. The Spielberger State-Trait Anxiety Inventory (STAI) was used to measure patient anxiety levels. RESULTS: One hundred and forty-nine patients were selected, and 82 females and 38 males were interviewed. Twenty-nine patients were excluded due to illiteracy. The state-anxiety levels were alike for males and females (36.10 ± 11.94 vs. 37.61 ± 8.76) (mean ± SD). Trait-anxiety levels were higher for women (42.55 ± 10.39 vs. 38.08 ± 12.25, P = 0.041). Patient education level did not influence the state-anxiety level but was inversely related to the trait-anxiety level. Knowledge of the diagnosis was clear for 91.7% of patients, of the surgery for 75.0%, and of anesthesia for 37.5%. Unfamiliarity with the surgical procedure raised state-anxiety levels (P = 0.021). A lower state-anxiety level was found among patients who did not know the diagnosis but knew about the surgery (P = 0.038). CONCLUSIONS: Increased knowledge of patients regarding the surgery they are about to undergo may reduce their state-anxiety levels.

Educating patients about anesthesia: a systematic review of randomized controlled trials of media-based interventions

In this systematic review, we compared the effectiveness of media-based patient education about anesthesia. Fifteen randomized controlled trials (n = 1506) were identified after a systematic search of electronic databases (MEDLINE, EMBASE, CINAHL, PSYCINFO, The Cochrane Controlled Trials Registry), published articles, and contact with authors. Outcomes assessed were anxiety, knowledge, and patient satisfaction. Anxiety levels before anesthesia were less intense in subjects receiving the video and printed information compared with those receiving no intervention (weighted mean difference of 3; 95% confidence interval [95%CI], 1-5 Spielberger's State and Trait Anxiety Inventory). Patients in the video group were more likely to answer all knowledge questions correctly compared with patients with no intervention (relative risk of 6.64; 95%CI, 2.05-21.52). The level of knowledge about pain management was higher in the video group compared with patients with no intervention (weighted mean difference of 17%; 95%CI, 9-25). However, the level of patient satisfaction with the intervention (expectation versus actual anesthetic experience) was similar between the groups (relative risk of 1.06; 95%CI, 0.93-1.22). This systematic review supports the use of video and printed information about general process and risks of anesthesia for patient education before surgery.

IMPLICATIONS

The effectiveness of media-based interventions for educating patients about general process and risks of anesthesia were compared in this systematic review. The use of video and/or printed information can decrease patient anxiety and increase patient knowledge. However, patient satisfaction was similar between media-based intervention and nonintervention groups.

Intrathecal fentanyl added to intrathecal bupivacaine for day case surgery: a randomized study

BACKGROUND AND OBJECTIVE

The implication of intrathecal lidocaine in neurological toxicity has made intrathecal bupivacaine the commonly used drug for local anaesthesia in ambulatory surgery. However, in high doses intrathecal bupivacaine may produce a high level of sensory and motor block, and arterial hypotension; discharge from hospital may be delayed. Intrathecal opioids added to low-dose local anaesthetics produce a synergistic effect without increasing the sympathetic block or delaying discharge. The aim of our study was to identify the minimum effective dose of intrathecal fentanyl that in combination with low-dose intrathecal bupivacaine would provide adequate surgical conditions without prolonging recovery.

METHODS

A prospective, single, blind, randomized study was conducted in 45 adult males scheduled for minor urological procedures using intrathecal anaesthesia on a day care basis. Patients were randomly assigned to one of three groups (n = 15 each). They received bupivacaine 0.17% 5 mg--with either fentanyl 7.5 microg (fenta-7.5), 10 microg (fenta-10) or 12.5 microg (fenta-12.5) intrathecally in a total volume of 3 mL. The quality of anaesthesia, haemodynamic stability, time to two-segment and S2 regression, time to micturition, and time to discharge were assessed.

RESULTS

The time to two-segment regression and S2 regression with fenta-12.5 was significantly longer than with fenta-7.5 and fenta-10 (P < 0.01). Fenta-7.5 had a significantly higher number of failed blocks (four patients) compared with fenta-12.5 (P < 0.05). The time out of bed, time to micturition and time to discharge were significantly longer with fenta-10 and fenta-12.5 compared with fenta-7.5, and also with fenta-12.5 compared with fenta-10 (P < 0.01). Haemodynamic stability did not differ for all the drug combinations.

CONCLUSIONS

Fentanyl 12.5 microg added to low-dose bupivacaine (5 mg) intrathecally provides better surgical anaesthesia and increased reliability of block than intrathecal fentanyl 7.5 or 10 microg. Haemodynamic stability was the same for all dose combinations used.

Important physical principles in anaesthesiology

The aim of this Review is to introduce anaesthesiologists to the basic physical principles that are important for their work. A better understanding of the underlying processes during anaesthesia is required for greater safety and efficiency. Relevant physical quantities are presented along with the area of anaesthesiology where they are used. This approach provides better targeting to the needs of practising anaesthesiologists. This text has been a part of a specialist course in anaesthesiology at the University of Ljubljana for some years. Current results show that both the students and the specialist anaesthesiologists now show a better understanding of the underlying physical principles required for their work and are more successful in fulfilling the needs of their practical work.

High-dose midazolam and the attenuation of the contractile response to vasoconstrictors in coronary artery segments

BACKGROUND AND OBJECTIVE

Benzodiazepines may cause hypotension and are reported to interfere with smooth vascular muscle activity. The aim was to elucidate the influence of three different benzodiazepines on the vascular reactivity of coronary arteries.

METHODS

Using the model of isolated vessels, we studied the impact of midazolam (0.15, 1.5, 15 microg mL(-1)), diazepam (0.1, 1.0, 10 microg mL(-1)) and flunitrazepam (0.01, 0.1, 1.0 microg mL(-1)) on the contractile responses to histamine (2 x 10(-5) mol L(-1)) and serotonin (3 x 10(-5) mol L(-1)) in isolated intact and denuded coronary arteries.

RESULTS

Midazolam significantly attenuated the contractile response when administered in high concentrations (15 microg mL(-1)). This effect was more pronounced in intact than in denuded preparations (histamine: -22.7 versus -7.3%, P = 0.0079; serotonin: -47.1 versus -15.9%, P < 0.0001). Diazepam and flunitrazepam exerted no significant effects on the vascular tone of coronary arteries.

CONCLUSIONS

Midazolam, but not diazepam or flunitrazepam, attenuates the contractile responses to vasoconstrictors in concentrations beyond those used in clinical practice. This effect is in part mediated by endothelial factors.

Anaesthesia for day case surgery: a survey of adult clinical practice in the UK

BACKGROUND AND OBJECTIVE

In October 2000, we conducted a national postal survey of consultant day case anaesthetists in the UK to explore the range and variation in the practice of anaesthetizing a patient for day case surgery (paediatrics, urology and orthopaedics). The survey was carried out as part of a larger study that comprised a major two-centre randomized controlled trial designed to investigate the costs and outcome of several anaesthetic techniques during day care surgery in paediatric and adult patients (cost-effectiveness study of anaesthesia in day case surgery). We report the findings of this national survey of adult urology and orthopaedic day case anaesthetic practice in the UK.

METHODS

The survey used a structured postal questionnaire and collected data on the duration of the surgical procedure; the use of premedication; the anaesthetic agents used for induction and maintenance; the fresh gas flows used for anaesthesia; the use of antiemetics; and the administration of local anaesthesia and analgesia.

RESULTS

The overall response rate for the survey was 74% (63% for urology, 67% for orthopaedics). The survey indicated the following practice in adult urology and adult orthopaedic day case surgery: 6 and 12% used premedication; propofol was the preferred induction agent (96 and 97%) and isoflurane the preferred maintenance agent (56 and 58%); 32 and 41% used prophylactic antiemetics; 86 and 93% used a laryngeal mask.

CONCLUSIONS

This survey identifies the variation in current clinical practice in adult day surgery anaesthesia in the UK and discusses this variation in the context of current published evidence.

Effect of dexamethasone on motor brachial plexus block with bupivacaine and with bupivacaine-loaded microspheres in a sheep model

BACKGROUND AND OBJECTIVE

It has been suggested that dexamethasone potentiates the sensory block produced by bupivacaine when both drugs are loaded in microspheres. The aim of the study was to evaluate the effect of dexamethasone on the brachial plexus block obtained with plain bupivacaine and bupivacaine-loaded microspheres.

METHODS

Dexamethasone alone (Group 5) or added to plain bupivacaine (75 mg) with (Groups 3 and 4) and without pH correction (Group 2) was compared with plain bupivacaine (75 mg; Group 1). The effect of a small dose of dexamethasone (0.42 mg) was then evaluated on the brachial plexus block obtained with bupivacaine (750 mg) as bupivacaine-loaded microspheres (Group 6). Dexamethasone was added either in the suspending medium (Group 7) or incorporated with bupivacaine into microspheres (Group 8). The motor block was evaluated in a plexus brachial sheep model.

RESULTS

Dexamethasone alone did not produce any motor block. When added to plain bupivacaine without pH correction, complete motor block could not be obtained. When the pH was corrected, addition of dexamethasone to plain bupivacaine seemed to delay the onset of motor block and did not prolong its duration, and it had no effect on the pharmacokinetics of bupivacaine. With bupivacaine-loaded microspheres, the duration of complete motor block was reduced when a small dose of dexamethasone was added in the suspending medium. However, the duration of motor block was significantly prolonged when dexamethasone was incorporated with bupivacaine into microspheres.

CONCLUSIONS

Despite the delayed onset of motor block, the incorporation of dexamethasone in bupivacaine-loaded microspheres dramatically increases the duration of action (700 +/- 485-5160 +/- 2136 min), which could be clinically relevant when such a drug-delivery system will be available.

Haemodynamic response to a small intravenous bolus injection of epinephrine in cardiac surgical patients

BACKGROUND AND OBJECTIVE

The aim was to study the rapid changes in cardiac output and systemic vascular resistance produced by intravenous epinephrine (5 microg) on a beat-by-beat basis.

METHODS

Ten patients were studied during cardiac surgery. Radial or brachial arterial pressure was recorded continuously during intravenous administration of epinephrine (5 microg). Cardiac output and systemic vascular resistance were derived for each beat using arterial pulse contour analysis calibrated by lithium indicator dilution. In each patient a further dose of epinephrine (5 microg) was administered during cardiopulmonary bypass with the blood flow kept constant so that changes in arterial pressure corresponded to changes in systemic vascular resistance.

RESULTS

When the patients were not on cardiopulmonary bypass, the epinephrine produced an initial increase in systemic vascular resistance to 129 +/- 15% (mean +/- SD) of control, followed by a more prolonged reduction to 57 +/- 13% of control. Cardiac output showed a small initial reduction coincident with the increase in systemic vascular resistance, followed by an increase to 152 +/- 24% of control. During cardiopulmonary bypass, the changes produced by epinephrine on systemic vascular resistance were qualitatively similar but smaller in amplitude, probably because of a greater volume of dilution in the bypass circuit.

CONCLUSIONS

Small bolus doses of epinephrine produce an initial increase in systemic vascular resistance followed by a much greater reduction that may cause hypotension.

Anaesthesia for day case surgery: a survey of paediatric clinical practice in the UK

BACKGROUND AND OBJECTIVE

In October 2000, we conducted a national postal survey of day case consultant anaesthetists in the UK to explore the range and variation in practice of anaesthetizing a patient for day case surgery (paediatrics, urology and orthopaedics). This paper reports the findings of this national survey of paediatric day case anaesthetic practice carried out as part of a major two-centre randomized controlled trial designed to investigate the costs and outcome of several anaesthetic techniques during day care surgery in paediatric and adult patients (cost-effectiveness study of anaesthesia in day case surgery).

METHODS

The survey used a structured postal questionnaire and collected data on the duration of surgical procedure; the use of premedication; the anaesthetic agents used for induction and maintenance; the fresh gas flow rates used for general anaesthesia; the use of antiemetics; and the administration of local anaesthesia and analgesia.

RESULTS

The overall response rate for the survey was 74 and 63% for the paediatric section of the survey. Respondents indicated that 19% used premedication, 63% used propofol for induction, 54% used isoflurane for maintenance, 24% used prophylactic antiemetics and 85%, used a laryngeal mask. The findings of this national survey are discussed and compared with published evidence.

CONCLUSIONS

This survey identifies the variation in clinical practice in paediatric day surgery anaesthesia in the UK.

Recollection of dreams after short general anaesthesia: influence on patient anxiety and satisfaction

BACKGROUND AND OBJECTIVE

We ascertained whether dreams during short general anaesthesia influence subsequent patient satisfaction and anxiety.

METHODS

Fifty female patients were randomized into two groups to test for a difference between intravenous and inhalational anaesthesias. In Group Propo, anaesthesia was induced and maintained with propofol; in Group Metho-Iso, anaesthesia was induced with methohexital and maintained with isoflurane. Satisfaction and anxiety with anaesthesia were evaluated using a visual analogue scale from 0 to 100. Dream incidence rate, satisfaction and anxiety were assessed from immediately after waking until 3 months later.

RESULTS

Seventeen patients (34%) dreamed during anaesthesia. There were no significant differences in satisfaction or anxiety after anaesthesia between the dreaming and non-dreaming patients (satisfaction, 92.3 +/- 21.6 versus 92.1 +/- 21.6; anxiety, 21.1 +/- 21.1 versus 30.3 +/- 32.1), or between Group Propo and Group Metho-Iso (satisfaction, 94.4 +/- 19.3 versus 90.0 +/- 23.4; anxiety, 26.0 +/- 27.6 versus 28.4 +/- 30.7). There was no significant difference in the incidence rate of dreaming with the type of anaesthesia used (Group Propo, 11 patients; Group Metho-Iso, 6 patients).

CONCLUSIONS

Dreaming during general anaesthesia is common but does not influence satisfaction or anxiety after anaesthesia.

The effect of intra-operative video on patient anxiety

We conducted a randomised controlled study to evaluate whether watching video compact discs intra-operatively using a liquid crystal display (LCD) unit decreased anxiety. Forty-four patients undergoing elective surgery under regional anaesthesia were assigned to either the LCD or control group. Anxiety was measured using the Chinese version of the State-Trait Anxiety Inventory (STAI) and visual analogue score (VAS). The mean (SD) anxiety trait scores were 46.15 (6.28) and 46.40 (7.32) in the control and LCD groups, respectively. The state anxiety of the LCD group [35.50 (7.96)] measured immediately postoperatively was significantly lower than the control group [41.50 (9.02); p = 0.03]. The median (range) reduction in VAS anxiety score was not significantly greater in the LCD group [20 (20 to 80) mm] compared with the control group [12.5 (70 to 60) mm]. Watching video intra-operatively reduces patient anxiety as measured by the STAI.

The Amsterdam preoperative anxiety and information scale provides a simple and reliable measure of preoperative anxiety

PURPOSE

To compare three anxiety scales; the anxiety visual analogue scale (VAS), the anxiety component of the Amsterdam preoperative anxiety and information scale (APAIS), and the state portion of the Spielburger state-trait anxiety inventory (STAI), for assessment of preoperative anxiety levels in same day admission patients.

METHODS

Patients completed the three anxiety assessment scales both before and after seeing the anesthesiologist preoperatively. The scales used were the STAI, the six-question APAIS, and the VAS. APAIS was further subdivided to assess anxiety about anesthesia (sum A), anxiety about surgery (sum S) and a combined anxiety total (i.e., sum C = sum A + sum S). These scales were compared to one another. Pearson's correlation (pair-wise deletion) was used for validity testing. Cronbach's alpha analysis was used to test internal validity of the various components of the APAIS scale. A correlation co-efficient (r) > or = 0.6 and P < 0.05 were considered significant.

RESULTS

Four hundred and sixty three scale sets were completed by 197 patients. There was significant and positive correlation between VAS and STAI r = 0.64, P < 0.001), VAS and APAIS r = 0.6, P < 0.001), sum C and STAI r = 0.63, P < 0.001) and between VAS and sum C r = 0.61, P < 0.001). Sum C and STAI r value were consistent with repeated administration. Cronbach's alpha-levels for the anxiety components of the APAIS (sum C) and desire for information were 0.84 and 0.77 respectively.

CONCLUSION

In addition to VAS, the anxiety component of APAIS (sum C) is a promising new practical tool to assess preoperative patient anxiety levels.

Emotional and psychological preoperative preparation in adults

Emotional and psychological surgical preparation plays an important role in many areas of nursing. However, it varies greatly in terms of its perception and delivery. The aim of this article is to familiarize the reader with the concept of emotional and psychological preparation for surgery and to explain how this may be achieved in nursing practice. It highlights that gender, age, and previous experiences are predisposing factors to preoperative anxiety, as is fear of the unknown and fear of harm. It is recommended that information should be given verbally with written supplements and that the patient should be encouraged to ask questions. Diversion therapy such as music, humour and guided imagery have been shown to be effective in reducing patients' preoperative anxiety.

Maternal pain and anxiety in genetic amniocentesis: expectation versus reality

OBJECTIVE

To investigate maternal perceptions of both pain and anxiety before and after genetic amniocentesis.

STUDY DESIGN

This prospective study of midtrimester, singleton pregnancies was conducted between March 2000 and July 2000. Study variables included patient demographics, medical and obstetric histories, indication for amniocentesis and a description of the source of information used by the patient regarding the procedure and technical degree of difficulty. Maternal pain and anxiety associated with performing amniocentesis were subjectively quantified with the use of the visual analog scale (VAS). Statistical analysis included Wilcoxon signed rank test, anova, and simple and stepwise regression analyses.

RESULTS

One hundred and eighty-three women participated in the study. Perception of pain before amniocentesis was significantly higher compared to that expressed immediately after the procedure, with a mean VAS score of 3.7 +/- 2.5 vs. 2.1 +/- 2.0 (P < 0.0001). Similarly, perception of anxiety was significantly greater prior to the procedure, with a mean VAS score of 4.6 +/- 2.8 vs. 2.8 +/- 2.4 after the amniocentesis (P < 0.0001). Perceptions of pain and anxiety were significantly and positively correlated to each other both before and after the procedure (P < 0.0001). History of a prior amniocentesis was the only variable associated with reducing expected pain and anxiety (negative correlation, P < 0.001), whereas the technical degree of difficulty was the only significant variable impacting on the actual pain and anxiety (positive correlation, P < 0.005).

CONCLUSIONS

Preamniocentesis counseling should emphasize the fact that, for most women, the actual pain and anxiety experienced during the procedure are significantly lower than expected. In fact, on a scale of 0-10, the mean level of pain was only 2.1, with a slightly higher mean level of anxiety.

A carbohydrate-rich drink reduces preoperative discomfort in elective surgery patients

We studied the effects of different preoperative oral fluid protocols on preoperative discomfort, residual gastric fluid volumes, and gastric acidity. Two-hundred-fifty-two elective abdominal surgery patients (ASA physical status I-II) were randomized to preparation with a 12.5% carbohydrate drink (CHO), placebo (flavored water), or overnight fasting. The CHO and Placebo groups were double-blinded and were given 800 mL to drink on the evening before and 400 mL on the morning of surgery. Visual analog scales were used to score 11 different discomfort variables. CHO did not increase gastric fluid volumes or affect acidity, and there were no adverse events. The visual analog scale scores in a control situation were not different between groups. During the waiting period before surgery, the CHO-treated group was less hungry and less anxious than both the other groups (P < or = 0.05). CHO reduced thirst as effectively as placebo (P < 0.0001 versus Fasted). Trend analysis showed consistently decreasing thirst, hunger, anxiety, malaise, and unfitness in the CHO group (P < 0.05). The Placebo group experienced decreasing unfitness and malaise, whereas nausea, tiredness, and inability to concentrate increased (P < 0.05). In the Fasted group, hunger, thirst, tiredness, weakness, and inability to concentrate increased (P < 0.05). In conclusion, CHO significantly reduces preoperative discomfort without adversely affecting gastric contents.

IMPLICATIONS

Discomfort during the period of waiting before elective surgery can be reduced if patients are prepared with a carbohydrate-rich drink, compared with preoperative oral intake of water or overnight fasting. Visual analog scales can provide useful information about preoperative discomfort in elective surgery patients.

Structured preoperative patient education for patient-controlled analgesia

STUDY OBJECTIVE

To investigate the effectiveness of a structured preoperative education program in patients receiving patient-controlled analgesia (PCA).

DESIGN

Randomized controlled trial.

SETTING

University-affiliated hospital.

PATIENTS

60 ASA physical status I and II women undergoing major gynecologic surgery.

INTERVENTIONS

Patients were randomly allocated to receive either standard information given during routine preanesthetic assessment (n = 30) or additional structured preoperative education on the use of PCA (n = 30).

MEASUREMENTS

All patients received standard anesthesia and PCA was provided for postoperative analgesia. Patients were reviewed bid by an independent team of pain specialists and nurses. Patient satisfaction, severity of postoperative pain, nausea, dizziness, and morphine consumption were measured at discharge from recovery room, 24, and 48 hours after operation. Recovery characteristics of patients were also measured.

MAIN RESULTS

Pain scores and morphine consumption decreased over time (p < 0.01), but there was no significant difference between groups. The overall analgesic efficacy, side effects, and recovery times was not affected by the education program. Patient satisfaction in the education group was better than control during early recovery (p= 0.03), but there was no additional benefit in the remaining postoperative period.

CONCLUSIONS

Structured preoperative PCA education did not affect patient outcome. The early improvement in patient satisfaction was minimized by continued education and pain team supervision during the rest of the postoperative period.

Risk factors for postoperative anxiety in adults

We identified risk factors for postoperative anxiety and quantified their effect on 712 adults between 18 and 60 years of age (ASA I-III physical status) undergoing elective surgery under general anaesthesia, neural blockade or both. The measuring instruments were a structured questionnaire, a pain visual analogue scale, the McGill Pain Questionnaire, the State-Trait Anxiety Inventory, the Montgomery-Asberg Depression Rating Scale, a Self-Reporting Questionnaire-20, and a Self-Perception of Future Questionnaire. Multivariate conditional regression modelling taking into account the hierarchical relationship between risk factors revealed that postoperative anxiety was associated with ASA status III (OR = 1.48), history of smoking (1.62), moderate to intense postoperative pain (OR = 2.62) and high pain rating index (OR = 2.35), minor psychiatric disorders (OR = 1.87), pre-operative state-anxiety (OR = 2.65), and negative future perception (OR = 2.20). Neural block anaesthesia (OR = 0.72), systemic multimodal analgesia (OR = 0.62) and neuroaxial opioids with or without local anaesthesia (OR = 0.63) were found to be protective factors against postoperative anxiety.

The effect of anxiety and personality on the pharmacokinetics of oral midazolam

We investigated the relationship between the pharmacokinetic variables of oral midazolam and patients' state/trait anxiety and personality. Twenty-six patients received the standard 15-mg oral dose for anxiolysis on the evening before otorhinolaryngological surgery. Blood samples were taken over a 9-h period after the administration, and the samples were analyzed for concentrations of midazolam and its two main metabolites by using a gas chromatography-mass spectrometry procedure. The pharmacokinetic variables maximum concentration, time to reach the maximum concentration, the elimination half-life, and the area under the curve were calculated from these data. When the patients were divided into groups with respect to their anxiety and personality scores, no significant differences in the pharmacokinetic variables of midazolam could be found. Only small, insignificant changes in the maximum concentrations were found with respect to nervousness and emotionality. We conclude that personality traits and anxiety levels had no effect on the pharmacokinetic variables of midazolam.

IMPLICATIONS

We conclude that personality traits and anxiety levels had no effect on the pharmacokinetic variables of midazolam. Therefore, it is not necessary to obtain anxiety or personality scores to find the proper midazolam dose for the individual patient.

Risk factors for preoperative anxiety in adults

BACKGROUND

Patients who undergo surgery experience acute psychological distress in the preoperative period. The objective of this study was to identify and quantify the effect of risk factors for preoperative anxiety in adults.

METHODS

A cross-sectional study was performed with 592 inpatients scheduled for elective surgery. Age ranged from 18 to 60 years (ASA physical status I-III). Demographic information was collected using a structured questionnaire. The measuring instruments were a visual analog scale, the State-Trait Anxiety Inventory; the Montgomery-Asberg Depression Rating Scale, the WHO Self-Reporting Questionnaire-20, and the future self-perception questionnaire. Multivariate conditional regression modeling was used to control confounding factors and to determine independent predictors of preoperative anxiety, taking into account the hierarchical relationship between risk factors.

RESULTS

High preoperative anxiety was associated with history of cancer (odds ratio (OR)=2.26) and smoking (OR=7.47), psychiatric disorders (OR=5.93), negative future perception (OR= 2.30), moderate to intense depressive symptoms (3.22), high trait-anxiety (3.83), moderate to intense pain (2.12), medium surgery (OR=1.52), female gender (OR=2.0), ASA category III (OR=3.41), up to 12 years of education (OR=1.36), and more than 12 years of education (OR=1.68). Previous surgery (OR= 0.61) was associated with lower risk for preoperative state-anxiety.

CONCLUSIONS

History of cancer and smoking, psychiatric disorders, negative future perception, moderate to intense depressive symptoms, high trait-anxiety, moderate to intense pain, medium surgery, female gender, ASA category III, up to 12 years of education and more than 12 years of education constituted independent risk factors for preoperative state-anxiety. Previous surgery reduced the risk for preoperative anxiety.