Musa A, Wang J, Acosta A, Movahedi R, Safani D, Hussain S, Tajran J, Gucev G. The Assessment and Management of Adult Preoperative Anxiety: A Survey of the American Society of Anesthesiologists. Anesthesiology Annual Meeting. 2019 Oct 19-23. Orlando, FL, USA.
CRediT Author Statement:
Arif Musa: conceptualization, methodology, formal analysis, investigation, resources, data curation, writing original draft, writing review and editing, supervision, coordination, funding acquisition
Rana Movahedi: conceptualization, methodology, formal analysis, writing review and editing, supervision, funding acquisition
Jeffrey Wang: conceptualization, methodology, formal analysis, writing review and editing, supervision
David Safani: conceptualization, methodology, formal analysis, writing review and editing, supervision
Christopher Cooke: formal analysis, writing review and editing, supervision Syed Hussain: formal analysis, writing review and editing, supervision Jahan Tajran: formal analysis, writing review and editing, supervision Shafi Hamid: formal analysis, writing review and editing, supervisionGligor Gucev: conceptualization, methodology, formal analysis, writing review and editing, supervision, funding acquisition
Corresponding Author: Arif Musa, MS, School of Medicine, Wayne State University, 320 East Canfield Avenue, Detroit, MI 48201, USA, Phone: (313) 577-1450, Fax: (313) 577-1457, ude.enyaw@0813mg
The publisher's final edited version of this article is available at J Clin AnesthApproximately 60% of patients experience a significant degree of anxiety prior to surgery. 1 Moreover, preoperative patient anxiety significantly predicts anesthetic consumption and postoperative pain intensity. 2 Therefore, identifying the best strategies to reduce preoperative anxiety may contribute to improving intraoperative and postoperative outcomes. Notably, patient anxiety is not routinely assessed by surgeons, who often hold anesthesiologists responsible. 3 As a result, this cross-sectional study of the American Society of Anesthesiologists (ASA) was performed to determine their preferences regarding preoperative anxiety assessment, management, and allocation of responsibility. The 11-item questionnaire was adapted from a previous survey of spine surgeons published in 2018. 3
Approval was obtained by the ASA research committees and Institutional Review Board. This research was determined to be exempt and a waiver of informed consent was granted. Respondents were asked whether they assessed their adult patients’ preoperative anxiety, how they measured it, and how they preferred to reduce it. Participation was voluntary and anonymous. A lottery incentive was offered.
A total of 3,661 individuals from the ASA membership responded to the survey constituting a 9.8% response rate (n=31,937). Most anesthesiologists asked their adult patients about preoperative anxiety (n=2332, 64.3%), either by verbal discussion by (n=2322, 99.2%) or by scale or survey (n=36, 1.5%). Methods to reduce adult preoperative anxiety according to anesthesiologists are indicated in Figure 1 .
Percentages of anesthesiologists that supported each preoperative anxiety management technique.
This findings of this survey suggest that most anesthesiologists assessed preoperative anxiety proactively, whether by verbal discussion or questionnaire. The vast majority were also willing to discuss it if raised by the patient. Nearly 60% of respondents indicated interest in surveying patient anxieties. A number of standardized scales are available for this purpose including the State-Trait Anxiety Index, Beck Anxiety Inventory, and Hospital Anxiety and Depression Scale, among others. 4
Notably, anesthesiologists endorsed a wide variety of methods to manage preoperative anxiety. Over 90% of respondents supported premedication to reduce anxiety. In fact, premedication with benzodiazepines such as midazolam have previously been reported to effectively reduce patient anxiety. 5 By comparison, more than 70% of anesthesiologists used patient education to reduce preoperative anxiety. Preoperative visits from anesthesiologists were endorsed by respondents and spine surgeons alike to reduce patient anxiety. 3 Also, most survey respondents supported the presence of family members to alleviate patient anxiety.
Preoperative tours (virtual or in-person), therapeutic nurse-patient interactions, traditional, complementary, or alternative medicine, cognitive behavioral therapy, and referral to mental healthcare providers were also used by anesthesiologists to reduce preoperative anxiety. However, several respondents indicated that their practice model did not allow for management of anxiety due to a complete lack of patient interaction with the patient prior to the procedure. Under such circumstances, it may be prudent to proactively assess preoperative anxiety (e.g. via telephone) or obtain this information from the referring physician.
One limitation of this study is the effect of non-response bias. The following strategies were used to reduce the effects of non-response bias: approval from the leadership of the ASA, dissemination of a concise questionnaire, and use of a lottery incentive. Although this was a survey of the ASA, the largest American anesthesiology professional society, responses may not be representative of all anesthesiologists in the United States.
Still, this report of the management preferences of their colleagues may help anesthesiologists make informed decisions regarding how best to assess and manage preoperative anxiety. Future research is also needed to determine if the views of anesthesiologists may differ for addressing preoperative anxiety in the pediatric population.
Anesthesiologists prefer many strategies to reduce preoperative anxiety which include medication, patient education, preoperative visits from the anesthesiologist, and permitting family presence, among others.
Bryant W Oliphant, MD, MBA, Assistant Professor, Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI 48109, USA – critical review
Frank L Acosta, MD, California Neurosurgical Institute, Valencia, CA 91355, USA – methodologyKasim Pendi, BS, School of Professional Studies, Southern California University of Health Sciences, Whittier, CA 90604, USA – critical review
• This publication was supported by SC CTSI (NIH//NCATS) through Grant UL1TR001855. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.
Potential conflict of interest:
Dr. Rana Movahedi has the following disclosures outside of the submitted work: member of the speaker bureau of Merck & Co., Inc.
Dr. Jeffrey Wang has the following disclosures outside of the submitted work: royalties from Biomet, Seaspine, Amedica, DePuy Synthes; investments/options in Fziomed, Promethean, Paradigm Spine, Nevenue, Nexgen, Vertiflex, Electrocore, Surgitech, Expanding Orthopedics, Osprey, Bone Biologics, Pearldiver; Board of Directors: North American Spine Society, North American Spine Foundation, AO Foundation, Cervical Spine Research Society; fellowship funding (paid to the institution) from AO Foundation.
There are no other financial relationships, activities, or conflicts of interest.1. Woldegrima YB, Fitwi GL, Yimer HT, Hailekiros AG. Prevalence and factors associated with preoperative anxiety among elective surgical patients at University of Gondar Hospital. Gondar, Northwest Ethiopia, 2017. A cross-sectional study . Int J Surg Open 2017; 10 :21–9. doi: 10.1016/j.ijso.2017.11.001. [CrossRef] [Google Scholar]
2. Kil HK, Kim WO, Chung WY, et al. Preoperative anxiety and pain sensitivity are independent predictors of Propofol and sevoflurane requirements in general anaesthesia . Br J Anaesth 2012; 108 ( 1 ):119–25. doi: 10.1093/bja/aer305. [PubMed] [CrossRef] [Google Scholar]
3. Musa A, Wang J, Acosta F, et al. Attitudes of spine surgeons regarding management of pre-operative anxiety: cross-sectional study . Clin Spine Surg 2019; 32 ( 1 ):E1–6. [PubMed] [Google Scholar]
4. Julian LJ. Measures of anxiety . Arthritis Care Res (Hoboken) 2011; 63 ( 011 ):10.1002/acr.20561. doi: 10.1002/acr.20561. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
5. Mui LM, Teoh AY, Ng EK, et al. Premedication with orally administered midazolam in adults undergoing diagnostic upper endoscopy: a double-blind placebo-controlled randomized trial . Gastrointest Endosc 2005; 61 ( 2 ):195–200. [PubMed] [Google Scholar]
