A message to your patient: if you are too anxious before surgery you will have more pain later on!!!!!

Transcription

1 A message to your patient: if you are too anxious before surgery you will have more pain later on!!!!! Gabriel M. Gurman, MD Ben Gurion University of the Negev Mayney Hayeshuah Medical Center Israel

2 A message to your patient: if you are too anxious before surgery you will have more pain later on!!!!! Do you agree with this statement? YES/NO For those who agreed with the message, a question: Do you try to find out if your patient is anxious about surgery and anesthesia?

3 If yes.. What is the proportion of your patients who benefit from this special approach? 100% 75% 50% 25% 10% 0%

4 ACUTE PAIN Reduced respiratory ability Atelectasis Hypoxia Hypercapnia Pneumonia Sympathetic activity Tachycardia Increased O2 consumption Myocardial ischemia Above everything: sleepiness, confusion, agitation, depression, delay in recovery

5 Pain and its prevention is the core of our profession This is why is absolutely normal to prepare lectures on this very important topic

6 Topics which are always included in the list of presentations about PAIN Acute pain and postop period Chronic pain and anesthesia techniques Prevention of pain by using postop regional analgesia Acute pain service Management of cancer pain Pathophysiology of acute and chronic pain

7 Here is a disclosure of my initial ignorance. Before you decide to put a patient on a postop analgesia protocol, please be sure that : *the patient is completely alert before you start it *he/she fully understood your plan *he/she has no known allergy to any analgesic drug *he/she is stable hemodynamically *there is no surgical bleeding *the surgical ward is prepared and ready to accept the patient and his postop analgesia protocol!!

8 The flowchart of postop pain management The patient is seen at the preanesthesia outpatient clinic Surgical procedure is done under general/regional anesthesia A decision is taken regarding his postop pain management Information is passed to : *the ward team *the APS team

9 One historically interesting point-factors affecting postop pain (Bonica, the 90s) Site, duration and nature of surgery Use of pre-emptive analgesia Presence of surgical complications Quality of intra-operative analgesia Quality of postoperative care and pain management

10 Once again Bonica.. Site, duration and nature of surgery Physiological and psychological patterns of the patient Pre-operative psychological preparation of the surgical patient Use of pre-emptive analgesia Presence of surgical complications Quality of intra-operative analgesia Quality of postoperative care and pain management

11 Here is a case, a rather banal A 55-year patient, heavy smoker, is scheduled for a thoracotomy because of a lung tumor BMI 32 Unable to climb one floor without a pause During the preanesthetic visit he complains of anxiety, fear of death and mainly incapacity of having a normal physical activity after surgery Two episodes of loss of conscience, each just for a couple of seconds one

12 Question for the audience: What your preanesthetic recommendations would include: *all lab analysis *respiratory functions tests *preop quick diet *Carotid Doppler examination *Cardiology advise Any other proposal?

13 So let s go to the subject: The preop anxiety and its influence on the postop course, and especially on the postop pain

14 By the way, what do we know about preoperative anxiety??

15 The origin of preop anxiety Uncertainty about the impending surgery Past experience with anesthesia and surgery Suggestions from family, friends, other patients Fear of loss of ability Marridou et al Fear of postop pain and fear of anesthesia are the most frequent causes of preop anxiety

16 There are two types of preop anxiety State anxiety =transitory emotional state that varies in intensity and fluctuates over time Trait anxiety =a personality disposition that remains relatively stable over the time Each type behaves differently in the case of danger!!!!! (you will see!)

17 But in any case, anxiety is only part of the preop emotional state, which includes: Sweating Stress Fear Crying Nightmares 20-80% of all surgical patients develop or increase the level of preop anxiety!!!

18 Did you hear about D personality? a concept used in the field of medical psychology, is defined as the joint tendency towards negative affectivity, iritability, social inhibition and lack of self assurance Letter D stands for distressed Petrovic NM 2014 *90 patients after hip replacement, 42 with a VAS score > 5 *18 pts diagnosed as belonging to the D personality group *These patients appeared to be at risk of developing severe postop pain!!

19 So, here is the axiom: Psychological/ emotional stress has a negative effect on physical recovery after surgery Weissman C, 1990: Response to stress is mediated by : *neuroendocrine system *monokines and lymphokines *factors operating at the level of the local wound level Tolson et al, 1965 Preop fear and anxiety produce elevated cathecolamines blood level

20 But more than this The impact of the preop anxiety and fear is much larger: *intraop anesthetic requirements (Kiecolt- Glaser, 1998; Kil 2012) *postop patient s satisfaction *rate of PONV *postop behavioral recovery *hospital length of stay

21 Above all, preop anxiety has to major negative effects: Increase in the level of postop PAIN Increase in the level of postop ANXIETY Scott LA et al 1983: Preop anxiety correlates well with the level of postop pain Preop anxiety is a significant linear predictor of postop pain The factors which influence postop anxiety: *ASA 3 and 4 *History of smoking *Preop anxiety *Intensity of postop pain *Minor psychiatric disorders

22 Some more data about anxiety Kain Z et al., 2000 High levels of preop anxiety indirectly predicted higher levels (VAS) of postop pain, both on hospital ward and home Rolleda G et al patients, mean age 71, orthopedic and trauma surgery Preop anxiety was present in : 90% of patients with high postop pain level 66% of patients with low level of postop pain (p<0.01) and pain One more study Alvez ML et al 2013 *112 patients operated for breast cancer *two groups: Group L low preop anxiety Group H- High preop anxiety Results: Group H has: Higher VAS up to 12 postop houts Higher tramadol consumption Higher consumption of NSAIDs Prolonged recovery

23 The vicious circle! Preop anxiety Increased postop pain Increased postop anxiety and stress (X 2.6!!) Low patient satisfaction

24 Is that really true??!! Because if is true, preventive measures are supposed to help!!!

25 Proposed preventive measures 1. Sedate the patient 2. Better attention and careful evaluation for those patients with high preoperative of state/trait anxiety 3. Psychological preparation 4. Use of antidepressants in the preop period

26 Before everything. How many of your patients get a sedative in the night before surgery? 100% 75% 50% 25% <10% How many of your patients get a benzodiazepine in the morning before surgery? 100% 75% 50% 25% < 10%

27 1.Sedate the patient Why? Kain Z et al., % of the USA anesthesiologists questionnned declared that they use sedatives in premedication for adults patients Reasons To avoid anxiety To improve pt s compliance To reduce sufferance produced by preinduction invasive procedures To reduce the anesthetic dosage To improve quality of recovery Proved +? + + +/- TO REDUCE POSTOPERATIVE PAIN We shall see!!!

28 Use of midazolam in premedication Kain Z et al., mg midazolam i-m vs placebo The study group: *significant reduction in the level of postop pain during the 1st week *less ibuprofen during the 1st week *significant reduction in the postop anxiety A=anxiety scores B= VAS in postop period Placebo group

29 Kain Z et al 2001 Patients for hysterectomy Treated patients (25): -lorazepam per os night before -midazolam i-m 30 min before surgery Placebo group (29) Results: *Less PCA consumption for the treated group, but only in the first 4 postop hours *No difference regarding first ambulation, clear fluid intake, discharge from the hospital hrs 5-8 hrs p > hrs study placebo Need for morphine (mg)

30 Do you need more information? Group A B C D Ciccozzi A et al 2007, abdominal hysterectomy,spinal Nr p < Anxios 3.5 Y/N Y Y N N Treat. Lorazepam at night and 2 hrs before surgery Pla ce bo Lorazepam at night and 2 hrs before surger y Plac ebo V A S st hr 2nd hr 3rd hr 4th hr As a result, need for Tramadol in the B group patients A B C D

31 But, as usual, some authors described what s bad with preop sedation!!! Here is a short list: Additional nurse activity Increase pharmacy cost Delays in the OR schedule and recovery after short surgical procedures (see same day surgery and ambulatory surgery) My personal opinion, unsupported by scientific data: On a whole, the advantages surpass the drawbacks

32 2.Proper evaluation and identification of high anxious patients Do not forget that one patient is not alike the other one Speak to the patient and ask about his/her fears (Alves ML et al., 2013:patients with higher anxiety scores reported higher postop pain levels) Identify the origin of anxiety Differentiate between state (incidental, temporary) anxiety and trait anxiety

33 Scott LE et al., 1983 Interesting conclusions based on studying 48 patients who had open cholecystectomy 1.State anxiety could be influenced by premedication 2. No influence of premedication on trait anxiety patients 3. Only state anxiety is highly predictive for postop pain 4.Offering simple preoperative information without adding any positive message increase the level of postop pain

34 Anderson EA 1987, cardiac surgery Both groups, information only and information + coping preparations had *reduced anxiety by increasing feelings of control * A 35% lower incidence of postop hypertension 3.Psychological preparation ( work of worrying ) Wilson J 1981 Proposals for preop preparation: *exercises for muscle relaxation *offering information about sensations the patient would experience in the postop period Results: *even aggressive patients had a decreased in the length of stay in the hospital *relaxation reduced pain level and the amount of pain treatment

35 4.Use of antidepressants The usual belief: Preop antidepressants could have negative effects on postop period, among them an increase in the length of stay (LOS) in the hospital Sutherland AM et al 2014 *3,692 patients, charts checked retroactively *7.8% took preop antidepressants *No significant difference regarding LOS

36 One additional aspect, not less important: prevention of postop infections Weissman C, 1990 Reducing preop anxiety Kepf HW, 1997 Preop anxiety Decrease hormonal response Decrease catabolic response Improved wound healing Stimulation of sympathetic vasoconstriction Increase risk for postop infection

37 Do you remember? Pain Stress Patient dissatisfaction Kiecolt-Glaser JK dental students, mouth wounds Wounds created three days before student exam healed an average 40% more slowly than those created during summer vacation!!

38 So, the time came for concluding these data

39 What can we say at the end? Anxiety is part of the preop feeling of almost every surgical patient Preop anxiety could negatively affect the postop course: *more pain *more anxiety *longer stay in the hospital *higher rate of infection *patient dissatisfaction

40 If so What can we do? 1.Recognize the importance of the topic 2.Try to identify those patients with a high level of preop fear, mainly those with state anxiety 3.Prepare the patient before surgery and anesthesia: the TEA approach talk, explain, assure 4.Use benzodiazepines the night before and in the morning of surgery 5.Do not be afraid of antidepressants, encourage the patients to go on taking them just before surgery

41 Let s finish with a nice story How can a person deal with anxiety? You might try what one fellow did. He worried so much that he decided to hire someone to do his worrying for him. He found a man who agreed to be his hired worrier for a salary of $200,000 per year. After the man accepted the job, his first question to his boss was, "Where are you going to get $200,000 per year?" To which the man responded, "That's your worry. Max Lucado Max Lucado (born January 11, 1955) is a best-selling Christian author and writer and preacher at Oak Hills Church (formerly the Oak Hills Church of Christ) in San Antonio, Texas.

42 Any question?