A multicenter survey of perioperative anxiety in China: Pre- and postoperative associations

https://doi.org/10.1016/j.jpsychores.2021.110528Get rights and content

Highlights

  • Surgical invasiveness influences association between pre- and postoperative anxiety.

  • Preoperative anxiety is positively correlated with postoperative poor sleep quality.

  • Preoperative anxiety has no significant correlation with nausea and vomiting.

Abstract

Objectives

To describe patient characteristics associated with preoperative anxiety and subsequently assess the relationship between preoperative anxiety and postoperative anxiety, pain, sleep quality, nausea and vomiting.

Methods

The study collected data from patients undergoing elective operation from 12 hospitals in China. The State-Trait Anxiety Inventory (STAI) and the Athens Insomnia Scale (AIS) were used to assess anxiety and sleep quality before surgery. Evaluations of anxiety, pain, sleep quality, nausea and vomiting were quantified using the Visual Analogue Scale on postoperative days 1 and 2.

Results

Data from 997 patients were analyzed. Preoperatively, 258 (25.9%) patients had high anxiety (STAI-State>44). Multivariate analyses showed a significant relationship between high anxiety and female gender (OR: 1.66, 95% CI: 1.08–2.57, p = 0.02), highly invasive surgery (OR: 2.29, 95% CI: 1.29–4.06, p = 0.005), higher trait anxiety (OR: 1.24, 95% CI: 1.20–1.28, p < 0.001) and insomnia (AIS ≥ 6, OR: 1.79, 95% CI: 1.17–2.76, p = 0.008). Preoperative anxiety demonstrated a negative correlation with postoperative anxiety following highly invasive surgery; this became a positive relationship following less invasive surgery. Preoperative anxiety was also positively related to postoperative pain and poor sleep quality. The correlation between preoperative anxiety and postoperative nausea and vomiting was not statistically significant.

Conclusion

Female gender, highly invasive surgery, higher trait anxiety and insomnia are independent risk factors for high preoperative anxiety. Surgical invasiveness influences association between pre- and postoperative anxiety. Higher preoperative anxiety is related to poorer sleep quality and more severe pain postoperatively.

Introduction

Surgery is a significant event in the initiation of anxiety. An observational study in over 15,000 patients suggested that one of the burdensome experiences related to surgical procedure was anxiety [1]. Preoperative anxiety has a high incidence, ranging from 11% to 80% in different clinical disciplines [2]. Moreover, worldwide, it is estimated that 266–360 million operations are performed annually [3]. And as the number of surgeries continues to rise, the number of patients experiencing anxiety will as well. This is a serious public health problem.

Preoperative anxiety has been described as one negative factor in anesthesia management and surgical outcome. It is associated with many adverse physiological manifestations, such as hypertension, tachycardia, and even arrhythmia [4]. According to recent studies results, anxiety was associated with hypotension after spinal anesthesia and shivering during cesarean delivery [5,6]. These reactions may increase adverse events, requiring the anesthesiologists to adjust the dose of anesthetics and vasoactive drugs [7]. Some studies suggest that preoperative anxiety has a positive correlation with postoperative pain [8] and nausea and vomiting (PONV) [9], and in rare circumstances may be an independent risk factor for postoperative mortality [10,11]. Therefore, anesthesiologists need to explore risk factors for preoperative anxiety to identify mitigation strategies.

This is the most extensive study to date to evaluate preoperative anxiety in China. Our principal objective was to describe patient characteristics associated with preoperative anxiety. Secondly, we aimed to assess the relationship between preoperative anxiety and postoperative anxiety, pain, sleep quality, nausea and vomiting.

Section snippets

Methods

Ethical approval was obtained from the Institutional Review Board of the Aviation General Hospital of China Medical University (approval number HK2019-01-13). The survey was carried out only after the patients signed an informed consent, which met the requirements of the Helsinki Declaration. All subjects had the right to withdraw from this study at any time. All personal information was kept confidential.

Demographic and surgical information of patients

Despite the plan to include 1200 patients, we received 1146 (95.5%) survey results. Excluding 149 patients with missing data of preoperative anxiety, a total of 997 subjects were included in the final analysis. The median (interquartile range: 25th–75th percentile) of age of participants was 51 (39–61). The proportion of female patients was 55.9%. Further demographic and clinical information are provided in Table 1, Table 2 respectively. Additionally, the specific surgical types from head-neck,

Discussion

In the present study, 258 (25.9%) patients were in high anxiety preoperatively (STAI-S>44). Their median score (interquartile range: 25th–75th percentile) of the STAI-S was 50 (48–55). However, this prevalence was lower than previously reported [29]. This could be due to differences in the assessment tools of anxiety. Since there are more than 40 million surgical procedures performed annually in China [3], this means that the presence of a high anxiety state exists in at least 10.4 million

Limitations

There are several limitations to this investigation. Firstly, we cannot conclude that there is any causal and temporal relationship between high preoperative anxiety and insomnia. Further, we only roughly analyzed the correlation between preoperative anxiety and postoperative status (anxiety, pain, sleep quality nausea and vomiting) with regard to the level of invasiveness of surgery and we cannot exclude other confounding factors.

Conclusion and clinical implications

Results of our study suggest that high preoperative anxiety is common for patients scheduled to undergo an elective surgery. The independent risk factors for high preoperative anxiety included female gender, highly invasive surgery, higher trait anxiety and insomnia. Identifying modifiable factors may help to plan a proper intervention. Most patients regarded surgical effects, postoperative pain and anesthesia safety as their most significant concerns before surgery. This suggests that

Funding statement

This survey was funded by the National Natural Science Foundation of China, Beijing, China (81671076).

Declaration of Competing Interest

The authors declare no competing interests.

Acknowledgement

This research was supported by the National Natural Science Foundation of China. (81671076). We expressed the deepest gratitude to the anonymous reviewers for their careful work and thoughtful suggestions.

References (48)

  • D.A. Kalmbach et al.

    Insomnia and short sleep predict anxiety and worry in response to stress exposure: a prospective cohort study of medical interns

    Sleep Med.

    (2019)
  • M. Viens et al.

    Trait anxiety and sleep-onset insomnia: evaluation of treatment using anxiety management training

    J. Psychosom. Res.

    (2003)
  • A.M. West et al.

    The effects of preoperative, video-assisted anesthesia education in Spanish on Spanish-speaking patients’ anxiety, knowledge, and satisfaction: a pilot study

    J. Clin. Anesth.

    (2014)
  • I. Tulloch et al.

    Assessment and management of preoperative anxiety

    J. Voice

    (2019)
  • V. Andersson et al.

    The impact of preoperative patient anxiety on postoperative anxiety and quality of recovery after orthopaedic surgery

    J. Perianesth. Nurs.

    (2020)
  • E. Walker et al.

    Patient reported outcome of adult perioperative anaesthesia in the United Kingdom: a cross-sectional observational study

    Br. J. Anaesth.

    (2016)
  • B.K. Madsen et al.

    Melatonin for preoperative and postoperative anxiety in adults

    Cochrane Database Syst. Rev.

    (2020)
  • T.G. Weiser et al.

    Size and distribution of the global volume of surgery in 2012

    Bull. World Health Organ.

    (2016)
  • I.A. Kelmanson

    High anxiety in clinically healthy patients and increased QT dispersion: a meta-analysis

    Eur. J. Prev. Cardiol.

    (2014)
  • B. Wódarski et al.

    Risk factors for shivering during caesarean section under spinal anaesthesia. A prospective observational study

    Acta Anaesthesiol. Scand.

    (2020)
  • A.İ. Uysal et al.

    The effect of preoperative anxiety level on mean platelet volume and propofol consumption

    BMC Anesthesiol.

    (2020)
  • R. Laufenberg-Feldmann et al.

    Is ‘anxiety sensitivity’ predictive of postoperative nausea and vomiting?: a prospective observational study

    Eur. J. Anaesthesiol.

    (2019)
  • S. Nigussie et al.

    Predictors of preoperative anxiety among surgical patients in Jimma University Specialized Teaching Hospital, South Western Ethiopia

    BMC Surg.

    (2014)
  • D.M. Stamenkovic et al.

    Preoperative anxiety and implications on postoperative recovery: what can we do to change our history

    Minerva Anestesiol.

    (2018)
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    Xi-Rong Li and Wen-Hao Zhang are co-first authors. They contributed equally to the work.

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