Sedative Premedication for Surgical Anxiety
Many patients anticipating an upcoming surgical procedure experience considerable stress and anxiety as a result.1 Such anxiety has been identified as a leading risk factor for patients undergoing cardiovascular surgery and as being correlated with altered neuroendocrine responses leading to worse postoperative outcomes.2,3 Due to these factors, using sedative premedication for surgical anxiety has become relatively commonplace. Several different classes of medication are used for this purpose, including benzodiazepine, barbiturates, and α-2-agonists and are most commonly administered orally, rectally, or intranasally.4
Despite these clinical efforts to curb pre-procedure anxiety symptoms, treating preoperative anxiety is not necessarily correlated with a better perioperative experience for the patient.5 Furthermore, sedative medications to resolve surgical anxiety have been associated with certain dangerous and unintended effects. For instance, preoperative benzodiazepine administration with the goal of alleviating anxiety has been associated with delayed time to extubation, prolonged recovery postoperatively, and a higher risk of agitated emergence from sedation, without a marked improvement in patient experience.5–7 A reduction of the practice of administering benzodiazepines to alleviate preoperational anxiety was also suspected to be responsible for the reduction of post anesthesia care unit (PACU) delirium, a type of postoperative delirium (POD), in patients older than 60 between 2015 and 2018.
However, a very recent study in Perioperative Medicine by Stuff et al. found through secondary analysis of prospectively collected data that the use of midazolam for sedative premedication for surgical anxiety was not significantly associated with PACU delirium, suggesting that the reduction of the rate of PACU delirium in these patients might better be associated with factors outside of benzodiazepine use, such as improvements in perioperative management.8 Furthermore, the research on these medications is rife with conflicting data, with an earlier review by Walker et al. cautiously reporting, after a review of randomized controlled trials comparing anxiolytic drug(s) with placebo before general anesthesia in adult day surgery patients, that premedication for anxiety in adult day surgery does not delay the discharge of patients, though they warned that, due to the heterogenicity of their dataset, this result should not necessarily be considered conclusive.9 What is clear, given both the potential deleterious effects of preoperative anxiety on surgical outcomes as well as the potential risks of employing sedative premedication for surgical anxiety, is that more considered research and trials are likely necessary before guidelines on the use of such medications can be created with confidence.
It may be useful to note that this need for caution does not remove a provider’s ability to alleviate anxiety altogether. People have a variety of techniques to alleviate stress and anxiety in their daily lives, and these techniques can be employed to help patients facing a nerve-wracking surgery stave off overwhelming anxiety. For instance, some patients may find it useful to have detailed information about their surgery as early on as possible so that they feel as informed and as prepared as possible. For other patients, listening to relaxing music, reading, or participating in guided meditation or breathing exercises may prove beneficial.10 Although these techniques may not be as effective as sedative medication in addressing severe anxiety, thoughtfully applying them may at least partly empower healthcare professionals to help their patients alleviate surgical anxiety and, hopefully, reduce the risk of delayed or impaired postoperative recovery.
References
(1) Navarro-García, M. A.; Marín-Fernández, B.; de Carlos-Alegre, V.; Martínez-Oroz, A.; Martorell-Gurucharri, A.; Ordoñez-Ortigosa, E.; Prieto-Guembe, P.; Sorbet-Amóstegui, M. R.; Induráin-Fernández, S.; Elizondo-Sotro, A.; Irigoyen-Aristorena, M. I.; García-Aizpún, Y. Trastornos del ánimo preoperatorios en cirugía cardiaca: factores de riesgo y morbilidad postoperatoria en la unidad de cuidados intensivos. Revista Española de Cardiología 2011, 64 (11), 1005–1010. https://doi.org/10.1016/j.recesp.2011.06.009.
(2) Kumar, A.; Dubey, P. K.; Ranjan, A. Assessment of Anxiety in Surgical Patients: An Observational Study. Anesth Essays Res 2019, 13 (3), 503–508. https://doi.org/10.4103/aer.AER_59_19.
(3) Ai, A. L.; Kronfol, Z.; Seymour, E.; Bolling, S. F. Effects of Mood State and Psychosocial Functioning on Plasma Interleukin-6 in Adult Patients before Cardiac Surgery. Int J Psychiatry Med 2005, 35 (4), 363–376. https://doi.org/10.2190/2ELG-RDUN-X6TU-FGC8.
(4) Kröll, W.; Gassmayr, S. E. 11 Pre-Operative Anxiety, Stress and Pre-Medication. Baillière’s Clinical Anaesthesiology 1998, 12 (3), 485–495. https://doi.org/10.1016/S0950-3501(98)80065-2.
(5) Maurice-Szamburski, A.; Auquier, P.; Viarre-Oreal, V.; Cuvillon, P.; Carles, M.; Ripart, J.; Honore, S.; Triglia, T.; Loundou, A.; Leone, M.; Bruder, N. Effect of Sedative Premedication on Patient Experience After General Anesthesia: A Randomized Clinical Trial. JAMA 2015, 313 (9), 916. https://doi.org/10.1001/jama.2015.1108.
(6) Lepousé, C.; Lautner, C. A.; Liu, L.; Gomis, P.; Leon, A. Emergence Delirium in Adults in the Post-Anaesthesia Care Unit. British Journal of Anaesthesia 2006, 96 (6), 747–753. https://doi.org/10.1093/bja/ael094.
(7) Radtke, F. M.; Franck, M.; Hagemann, L.; Seeling, M.; Wernecke, K. D.; Spies, C. D. Risk Factors for Inadequate Emergence after Anesthesia: Emergence Delirium and Hypoactive Emergence. Minerva Anestesiol 2010, 76 (6), 394–403.
(8) Stuff, K.; Kainz, E.; Kahl, U.; Pinnschmidt, H.; Beck, S.; von Breunig, F.; Nitzschke, R.; Funcke, S.; Zöllner, C.; Fischer, M. Effect of Sedative Premedication with Oral Midazolam on Postanesthesia Care Unit Delirium in Older Adults: A Secondary Analysis Following an Uncontrolled before-after Design. Perioper Med 2022, 11 (1), 18. https://doi.org/10.1186/s13741-022-00253-4.
(9) Walker, K. J.; Smith, A. F. Premedication for Anxiety in Adult Day Surgery. Cochrane Database Syst Rev 2009, No. 4, CD002192. https://doi.org/10.1002/14651858.CD002192.pub2.
(10) What can help relieve anxiety before surgery? – InformedHealth.org – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK279557/ (accessed 2022-06-26).