Journal of Clinical Trials & Patenting

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Perioperative Anxiety

Shailendra Sigdel*

  • Division of Cardiothoracic Vascular Anesthesia, Manmohan Cardiothoracic vascular and Transplant Center, Institute of medicine, Tribhuvan University, Maharajgunj, Kathmandu, Nepal

*Address for Correspondence: Shailendra Sigdel, Assistant Professor, Division of Cardiothoracic Vascular Anesthesia, Manmohan Cardiothoracic vascular and Transplant Center, Institute of medicine, Tribhuvan University, Maharajgunj, Kathmandu, Nepal, E-mail:
Citation: Sigdel S. Perioperative Anxiety. J Clin Trials Pat 2015;1(1): 2.
Copyright © 2015 Sigdel S. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Journal of Clinical Trials & Patenting | Volume: 1, Issue: 1
Submission: 07 August, 2015 | Accepted: 15 August, 2015 | Published: 20 August, 2015
Reviewed & Approved by: Dr. D Sultan Sheriff, Associate Dean and Professor, MAI Medical Sciences, Chennai, India


Anxiety is a subjective unpleasant feeling of dread over something unlikely to happen, such as the feeling of imminent death. It is often accompanied by restlessness, fatigue, problems in concentration, and muscular tension. Perioperative anxiety is described as a vague, uneasy feeling, the source of which is often nonspecific and unknown to the individual [1] but known to cause abnormal hemodynamics as a consequence of sympathetic, parasympathetic and endocrine stimulation. Perioperative period is one of the stressful events in their lifetime. It often triggers emotional, cognitive and physiological responses. It occurs in a transient form or persists as chronic form. It has propensity to produce aggressive reactions of a patient resulting in difficult postoperative pain management and compromise quality of care [2]. The goal of perioperative care is to provide better environments and quality of life of a patient before, during and after operation.

The incidence of preoperative anxiety varies according to the setting of surgery, gender of a patient, motive of surgery and many other factors. The prevalence is high; ranging from 32% for general surgery [3] to 50% in coronary artery bypass graft surgery (CABG) [4]. Prevalence is similar or even higher in Asian population [5].

Psychological Response to Anxiety

The extent of anxiety levels varies individually. It fluctuates over time; starting prior to the surgery and persists until the late postoperative period. Different patient react perioperative periods in different ways. Some find it as relief as they are going to have a disease free life. Other considered it as a stressful life event. They are preoccupied with discomfort or concerned about the success of surgery, fear of failure of career, postoperative state of physical health and problems adapting to the changed situation. The consequences of perioperative anxiety are major cardiac events [11-13] (acute myocardial infarction, heart failure, pulmonary edema), high readmission rate (1st six month or one years), [11,14] poor quality of life and high rate of cardiac mortality. Impact of perioperative anxiety correlate with high postoperative pain, increased analgesic and anesthetic consumption, prolonged hospital stay, adverse effects on anesthetic induction and recovery, and reduction in patient satisfaction.

Reasons of increased morbidity in anxious patient are associated with the development of cardiovascular lesions as a consequences of health-related behaviors [15] (such as smoking, poor diet, poor compliance with treatment, or an inactive lifestyle) or direct influence on the myocardial perfusion, autonomic nervous system regulation, platelet activation, increased hypothalamo-pituitary-adrenal axis activity and exaggerated inflammatory processes [15-17].

Preoperative anxiety level is difficult to measure accurately. However, it can be estimated indirectly by increased blood pressure or pulse, decreased heart rate variability and patient irritability. Directly estimated with measuring the plasma cortisol or urinary catecholamine level. At present, several validated questionnaires [5] are available to measure preoperative anxiety. These include Amsterdam Preoperative Anxiety Information Scale (APAIS), the State Trait Anxiety Inventory (STAI), Hospital Anxiety and Depression Scale (HADS), Visual Analogue Scale (VAS), Multiple Affect Adjective Check List (MAACL). The APAIS is a widely accepted [5] screening tool which has been translated and used in many countries including Germany, the Netherlands, Mexico, Thailand, Turkey Korea and Japan.


All patients scheduled for surgery need to be intervened before and after surgery. Interventions before surgery include developing good rapports and doctor patient relationships, education and structured interviews, psychotherapy, and medicines like selective serotonin reuptake inhibitors or benzodiazepine. The best ways to cope with anxiety include talking their problems freely to the friends or families, and leaving everything on the god’s hand. The most effective way ofreducing anxiety as mentioned by patients is to have belief on religion [9]. The routine evaluation and effective treatment of preoperative psychological distress in patients scheduled for surgery may facilitate postoperative recovery. Early intervention in postoperative period to patients with evidence of psychological distress offers reduction of hospital length of stay, analgesic use, postsurgical morbidity and help patients to adopt more effective coping strategies in their everyday lives.


There are high degrees of preoperative anxiety in patients scheduled for surgery. Perioperative anxiety is often overlooked but it is associated with poor surgical outcome. At present several validated questionnaires are available to measure preoperative anxiety. Preoperative counseling and proper education regarding surgery will help in reducing anxiety and improving the quality of care.


  1. Klopfenstein CE, Forster A, Gessel EV (2000) Anesthetic assessment in an outpatient consultation clinic reduces preoperative anxiety. Can J Anesth 47: 511-515.
  2. Anderson KO, Masur FT (1983) Psychological preparation for invasive medical and dental procedures. J Behav Med 6: 1-40.
  3. Moerman N, van Dam FS, Muller MJ, Oosting H (1996) The Amsterdam Preoperative Anxiety and Information Scale (APAIS). Anesth Analg 82: 445-451.
  4. Koivula M, Paunonen-Ilmonen M, Tarkka MT, Tarkka M, Laippala P (2001) Fear and anxiety in patients awaiting coronary artery bypass grafting. Heart Lung 30: 302-311.
  5. Matthias AT, Samarasekera DN (2012) Preoperative anxiety in surgical patients - experience of a single unit. Acta Anaesthesiol Taiwan 50: 3-6.
  6. Thomas V, Heath M, Rose D, Flory P (1995) Psychological characteristics and the effectiveness of patient-controlled analgesia. Br J Anaesth 74: 271-276.
  7. Caumo W, Schmidt AP, Schneider CN, Bergmann J, Iwamoto CW, et al. (2001) Risk factors for postoperative anxiety in adults. Anaesthesia 56: 720-728.
  8. Sukantarat KT, Williamson RC, Brett SJ (2007) Psychological assessment of ICU survivors: a comparison between the Hospital Anxiety and Depression scale and the Depression, Anxiety and Stress scale. Anaesthesia 62: 239-243.
  9. Nigussie S, Belachew T, Wolancho W (2014) Predictors of preoperative anxiety among surgical patients in Jimma University Specialized Teaching Hospital, South Western Ethiopia. BMC Surg 14: 67.
  10. Kiyohara LY, Kayano LK, Oliveira LM, Yamamoto MU, Inagaki MM, et al. (2004) Surgery information reduces anxiety in the pre-operative period. Rev Hosp Clin Fac Med Sao Paulo 59: 51-56.
  11. Saur CD, Granger BB, Muhlbaier LH, Forman LM, McKenzie RJ, et al. (2001) Depressive symptoms and outcome of coronary artery bypass grafting. Am J Crit Care 10: 4-10.
  12. Baker RA, Andrew MJ, Schrader G, Knight JL (2001) Preoperative depression and mortality in coronary artery bypass surgery: Preliminary findings. ANZ J Surg 71: 139-142.
  13. Perski A, Feleke E, Anderson G, Samad BA, Westerlund H, et al. (1998) Emotional distress before coronary bypass grafting limits the benefits of surgery. Am Heart J 136: 510-517.
  14. Scheier MF, Matthews KA, Owens JF, Schulz R, Bridges MW, et al. (1999) Optimism and rehospitalization after coronary artery bypass graft surgery. Arch Intern Med 159: 829-835.
  15. Rozanski A, Blumenthal JA, Kaplan J (1999) Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy. Circulation 99: 2192-2217.
  16. Musselman DL, Evans DL, Nemeroff CB (1998) The relationship of depression to cardiovascular disease: epidemiology, biology, and treatment. Arch Gen Psychiatry 55: 580-592.
  17. Kubzansky LD, Kawachi I, Weiss ST, Sparrow D (1998) Anxiety and coronary heart disease: A synthesis of epidemiological, physiological, and experimental evidence. Ann Behav Med 20: 47-58.