Preoperative anxiety and endocrine response to surgery

Impact of Local Anesthetics on Cancer Behavior and Outcome during the Perioperative Period: A Review

There is a growing interest regarding the impact of the perioperative period and the application of anesthetic drugs on the recurrence of cancer metastases. Among them, the use of amide-type local anesthetics seems promising since in vitro studies and animal models have shown their potential to inhibit the Intercellular Adhesion Molecule 1 (ICAM-1) expression and Src activity, which are clearly implicated in the process of inflammation and cancer metastases. This review emphasizes the potential of amide-type local anesthetics in this context.

Direct Cytotoxic and Indirect, Immune-Mediated Effects of Local Anesthetics Against Cancer

Local anesthetics are frequently employed during surgery in order to control peri- and postoperative pain. Retrospective studies have revealed an unexpected correlation between increased long-term survival and the use of local anesthetics during oncological surgery. This effect of local anesthetics might rely on direct cytotoxic effects on malignant cells or on indirect, immune-mediated effects. It is tempting to speculate, yet needs to be formally proven, that the combination of local anesthetics with oncological surgery and conventional anticancer therapy would offer an opportunity to control residual cancer cells. This review summarizes findings from fundamental research together with clinical data on the use of local anesthetics as anticancer standalone drugs or their combination with conventional treatments. We suggest that a better comprehension of the anticancer effects of local anesthetics at the preclinical and clinical levels may broadly improve the surgical treatment of cancer.

The Effect of Preoperative Anxiety and Pain Sensitivity on Preoperative Hemodynamics, Propofol Consumption, and Postoperative Recovery and Pain in Endoscopic Ultrasonography

INTRODUCTION

The present study investigates how preoperative anxiety and pain sensitivity affect the consumption of anesthetics, time elapsed until the desired sedation level is achieved, preoperative hemodynamics, postoperative recovery time, and postoperative pain.

METHODS

The present study includes 80 ASA 1-2 patients aged between 20 and 65 who were scheduled for endoscopic ultrasonography (EUS) under sedation. Patients were instructed to fill out the Spielberger State-Trait Anxiety Inventory (STAI) and Pain Sensitivity Questionnaire (PSQ) before the procedure. For sedation, 0.03 mg  kg^-1 intravenous midazolam, 1 mg  kg^-1 lidocaine, 1 µ kg^-1 fentanyl, and then a bolus dose of 1 mg kg^-1 propofol were infused over a period of 60 s. The time elapsed until the bispectral index (BIS) value reached 75 was recorded. For anesthesia maintenance, 2 mg  kg^-1 h^-1 propofol infusion was administered. In the case of sedation failure, an additional dose of 0.1 mg  kg^-1 propofol (IV) was administered to ensure sedation depth with a BIS level of 65-75, and the propofol infusion was halted once the BIS value dropped below 65.

RESULTS

STAI-S and STAI-T scores were significantly positively correlated with PSQ minor pain and PSQ total scores. The time elapsed until reaching a BIS level of 75, propofol infusion dose used during sedation, and the need for additional doses of propofol, heart rate (HR), and duration of post-anesthesia care unit stay were significantly positively correlated with both preoperative anxiety and preoperative pain sensitivity. In terms of postoperative pain, the visual analog scale (VAS) at 1 h was more highly correlated with STAI-S and STAI-T than with PSQ. The VAS 2 h was only correlated with STAI-S and STAI-T.

CONCLUSION

The significant linear correlation between preoperative anxiety and pain sensitivity and anesthesia need can facilitate better preoperative management by predicting individual anesthetic consumption.

TRIAL REGISTRATION

The study was registered with the number NCT03114735 on ClinicalTrials.gov.

Preoperative anxiety and pain sensitivity are independent predictors of propofol and sevoflurane requirements in general anaesthesia

BACKGROUND

Psychological factors are thought to drive inter-patient variations in anaesthetic and analgesic requirements. This cross-sectional study investigated whether preoperative psychological factors can predict anaesthetic requirements and postoperative pain.

METHODS

Before total thyroidectomy, 100 consecutive women completed the Spielberger's State-Trait Anxiety Inventory (STAI) and the pain sensitivity questionnaire (PSQ). Target-controlled propofol was administered for induction of anaesthesia, and sevoflurane-oxygen-air was given to maintain equal depths of anaesthesia, as determined by bispectral index (BIS) monitoring.

RESULTS

Patients with higher anxiety scores (state and trait) required greater amounts of propofol to reach light (BIS=85) and moderate (BIS=75) levels of sedation, but only trait anxiety was significantly associated with propofol requirements in reaching a deep level of sedation (BIS=65). The MAC-hour of sevoflurane was significantly correlated only with PSQ scores. The postoperative pain intensity was significantly correlated with both STAI and PSQ.

CONCLUSIONS

Preoperative anxiety and pain sensitivity are independent predictors of propofol and sevoflurane requirements in general anaesthesia. Anaesthetic and analgesic doses could be modified based on the patient's preoperative anxiety and pain sensitivity.

The role of pre-operative state-anxiety in the determination of intra-operative neuroendocrine responses and recovery

OBJECTIVES

The psychophysiological model of adjustment to surgery predicts associations between (1) heightened pre-operative state-anxiety and intra-operative neuroendocrine responses, (2) neuroendocrine responses and complications; and (3) heightened pre-operative state-anxiety and post-operative recovery. The present study examined these associations.

METHODS

Participants were 39 patients (mean age 71.9+/-6.1 years) undergoing elective carotid endarterectomy surgery under local anaesthesia. In the week prior to surgery, patients completed baseline measures of physical and mental functioning using the MOS 36-item Short-Form Health Survey (SF-36). In addition to this, they undertook a 24-hour urine save to measure cortisol and catecholamines. Measures of state-anxiety were completed on the evening prior to surgery. A second 24-hour urine save was started at the time of anaesthetic induction. Follow-up measures of physical and mental functioning were completed 1 month following surgery. All complications were recorded during hospitalization.

RESULTS

There was a significant negative association between pre-operative state-anxiety and intra-operative cortisol (r=-.52, p<or=.001). Using hierarchical regression analysis, pre-operative state-anxiety accounted for 10% of the variance in intra-operative cortisol responses after controlling for medical and demographic factors. There were no significant associations between neuroendocrine responses and complications. Pre-operative state-anxiety was a significant determinant of poorer mental functioning following surgery, explaining 10% of the variance in scores after adjusting for baseline mental functioning.

CONCLUSIONS

Results from this study show increasing pre-operative anxiety to be associated with lower intra-operative cortisol responses and poorer mental functioning 1 month following surgery.

A double-blind study of perioperative steroid requirements in secondary adrenal insufficiency

BACKGROUND

Patients treated long-term with supraphysiologic doses of glucocorticoids experience secondary adrenal insufficiency and are routinely given large doses of steroids in the perioperative period to prevent hypotension. Because the dose of steroids required to prevent hypotension is not known, we conducted a randomized, double-blind study to determine whether patients treated long-term with glucocorticoids actually require increased steroids in the perioperative period.

METHODS

Patients who had been taking at least 7.5 mg prednisone daily for several months and had secondary adrenal insufficiency as defined by adrenocorticotropic hormone testing formed the study population. Patients were randomized to two groups. One group received perioperative injections of saline solution alone; the other received perioperative saline solution and cortisol. All patients received their usual daily prednisone dose throughout the study.

RESULTS

Six patients were in the steroid-treated group and 12 were in the saline-treated group. Most subjects underwent major operations such as joint replacements, abdominal operations, and miscellaneous other procedures. Two patients had hypotension, one in each group. Hypotension resolved with volume replacement in both patients. The average pulse rates and blood pressures were similar in both groups during the perioperative period.

CONCLUSIONS

Patients with secondary adrenal insufficiency do not experience hypotension or tachycardia caused by inadequate glucocorticoid levels when given only their daily dose of steroids for surgical procedures.

The effects of anesthesia with thiopental on T lymphocyte responses to antigen and mitogens in vivo and in vitro

In this study we show that antigen-specific lymphocyte proliferation and interleukin (IL)-2 production by peripheral blood lymphocytes from patients under thiopental anesthesia are significantly depressed. In contrast, mitogen-induced lymphocyte proliferation and IL-2 secretion are not depressed. We have also shown that tetanus toxoid (TT) specific CD4+ T cell clones, with a known cytokine production profile, were sensitive to the inhibitory effects of thiopental and exhibited decreased proliferation to TT as well as decreased secretion of IL-2. We observed no difference regarding IL-4 production by these clones. The data suggest that the immunosuppressive effect of thiopental is confined to antigen-specific responses. In addition, we have shown that whereas IL-2 and interferon-gamma production is dramatically impaired by the drug, IL-4 production is not significantly altered. This last finding has important implications regarding the type of immune response that is most affected by this anesthetic agent. In spite of the transient decrease in antigen-driven IL-2 synthesis, no clinical evidence of infection was noted in any healthy patient.

Preoperative rehearsal of active coping imagery influences subjective and hormonal responses to abdominal surgery

Existing evidence suggests that preoperative psychological preparation that is designed to reduce anxiety may sensitize cortisol and adrenaline responses to surgery. In a controlled trial of abdominal surgery patients, we therefore tested the effects of a preoperative preparation that used guided imagery, not to reduce anxiety, but to increase patients' feelings of being able to cope with surgical stress; 26 imagery patients were compared with 25 controls who received, instead, background information about the hospital. State-anxiety was similar in each group, but imagery patients experienced less postoperative pain than did the controls, were less distressed by it, felt that they coped with it better, and requested less analgesia. Hormone levels measured in peripheral venous blood did not differ on the afternoon of admission, before preparation. Cortisol levels were, however, lower in imagery patients than in controls immediately before and after surgery. Noradrenaline levels were greater on these occasions in imagery patients than controls. The results are interpreted in relation to two theories. One states that preoperative "worry" reduces surgical stress. The other concerns the influence of active and passive coping on endocrine responses to stress.

Patients' anxieties with third molar surgery

There has been little study of patients' anxieties about third molar surgery despite its widespread practice. 105 patients were invited to complete questionnaires preoperatively to assess anxieties about the procedure and to assess how well it was explained. They were also asked post operatively to assess differences from expectations, accuracy of the preoperative explanation and which aspect would worry them most should the procedure be repeated. Patients generally found their worries as expected or even better. Few found events worse with only pain (12%) and paraesthesia (13%) of note. Although 88% of patients assessed pain as better than or as expected, 43% would fear it most if the procedure was repeated. Pain is the single most feared factor despite evidence that it is usually no worse than originally feared. Reassurance and adequate pain control are the most important factors to patients in third molar surgery, and this reassurance should start at operation booking rather than on admission.

The reduction of anxiety in surgical patients: an important nursing task or the medicalization of preparatory worry?

The reduction of pre-operative anxiety in surgical patients is a routine part of nursing care, but much of the evidence which supports the view that high anxiety is related to worse recovery is based on ambiguous or unreliable indices of recovery. Instead, it has been argued that moderate levels of preoperative anxiety can help patients to prepare for surgery and reduce its stressfulness. On this basis, attempts to reduce anxiety would amount to the "medicalization" of a normal and useful state. Until recently little evidence supported this view, but research which has used hormonal changes to index surgical stress has provided evidence consistent with it. Alternative strategies for psychological preparation can be designed, which are not based on an attempt to reduce anxiety. However, attempts at psychological preparation of surgical patients pre-operatively should be regarded as experimental until more evidence is available about their effects on recovery.