Raising the Standard: Perioperative Anxiety

| March 1, 2021

by Morganne Staring, MD candidate; Anthony Petrick, MD, FACS, FASMBS; and Dominick Gadaleta, MD, FACS, FASMBS

Ms. Staring is an MD candidate at the Zucker School of Medicine at Hofstra/Northwell in Manhasset, New York. Dr. Gadaleta is Chair, Department of Surgery, South Shore University Hospital; Director, Metabolic and Bariatric Surgery, North Shore and South Shore University Hospitals, Northwell Health, Manhasset, New York; Associate Professor of Surgery, Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York. Dr. Petrick is Chief Quality Officer, Geisinger Clinic; Director of Bariatric and Foregut Surgery, Geisinger Health System in Danville, Pennsylvania.

FUNDING: No funding was provided for this article.

DISCLOSURES: The authors report no conflicts of interest relevant to the content of this article.

Bariatric Times. 2021;18(3):18–19

Perioperative anxiety is a common, yet unwelcome escort shadowing patients throughout their surgical experience. Though understandable, perioperative anxiety negatively impacts patients’ experiences and surgical outcomes and should therefore be addressed; this problem is the focus of emerging research worldwide, and new strategies have shown to improve patients’ experiences and outcomes.

Characterizing Perioperative Anxiety: Definitions, Prevalence and Causes

Anxiety can be broadly defined as an unpleasant emotional state of nervousness influencing one’s cognitions and behavior in response to anticipated threats, such as surgery.1 Comprised of physiologic components of fear (tachycardia, hypertension, nausea) paired with psychological components of worry, anxiety is common in the perioperative period. Estimates of the prevalence of perioperative anxiety range from 25 to 80 percent, peaking on the day of surgery.1,2 Sources of stress for these patients are many and varied, including such causes as anticipation of pain, separation from family, loss of independence, fear of anesthesia, and the possibility of death.3 Illness severity does not always correlate with anxiety levels; for instance, an observational study comparing perioperative anxiety symptoms in patients undergoing abdominal surgery for either benign or malignant disease found that they did not differ significantly by malignancy status.4 Sources of anxiety can differ in various phases of the surgical process. Preoperatively, distress might stem from uncertainty while awaiting test results, a negative reaction to a diagnosis, or preconceived notions surrounding treatment.5 While inpatient, people suffer heightened anxiety due to the forfeiture of privacy and unfamiliarity of the hospital environment, lack of control in timing of procedures, studies, and discharge, and fear of risks, complications, and pain associated with the procedure itself.5 Postoperatively, anxiety arises due to any mismatch in expectations and actual experience of recovery, unexpected complications, and financial strain or distressing interactions with insurance providers.4,5 Anxiety is a pervasive, multifaceted problem negatively impacting surgical patients’ experiences with many of these negative factors exacerbated in the era of COVID-19 restrictions placed on patients and their families. The good news is that many of the modalities used in standard bariatric practices and enhanced recovery programs work toward ameliorating these outcomes through education, exposure to other patients, and familiarity with the processes surrounding the perioperative period.

Effects of Perioperative Anxiety on Healing and Surgical Outcomes

Perioperative anxiety burdens not only the patient, but also providers and healthcare systems by sabotaging the physical healing process and surgical outcomes. Increased preoperative anxiety is associated with such problems as increased pain postoperatively, higher anesthetic and analgesic requirements, and poorer wound healing.1,6 Additionally, it is correlated with more canceled appointments or procedures and less effective, more frustrated communication between patients and providers.1 Negative outcomes related to perioperative anxiety have been observed across many subspecialties, including general, orthopedic, cardiac, and transplant surgery, as well as surgical oncology, and in both inpatient and ambulatory settings.3,7–10 Evidence from the field of psychoneuroimmunology suggests several mechanisms by which perioperative anxiety impairs wound healing and surgical outcomes. Stress activates the hypothalamic–pituitary axis to initiate a sympathetic response, leading to increased circulating glucocorticoid (e.g., cortisol) and catecholamine levels, which is associated with poorer wound healing.11 Increased glucocorticoid levels correlate with reduced expression of proinflammatory cytokines at wound sites, as well as downregulation of matrix metalloproteinases necessary for proinflammatory cells and molecules to enter wounds; these effects impair wound healing.11 Furthermore, elevated glucocorticoids are associated with reduced production of epidermal antimicrobial peptides, increasing risk of infection.11 Stress might also impede wound healing due to exacerbation of tissue hypoxia. In wounds, local damage to blood vessels decreases oxygen delivery while neutrophilic oxidative bursts increase oxygen demand; stress correlates with higher levels of inducible nitric oxide synthase, indicating tissue hypoxia, in animal models.11 Another mechanism by which anxiety might impair wound healing is reducing levels of stress-modulating molecules such as oxytocin, a hormone shown to correlate with faster wound healing at higher levels.11 Finally, stress might also indirectly modulate healing and recovery by behavioral mechanisms, with higher anxiety leading to greater likelihood of health-damaging behaviors such as substance use, lower physical activity, sleep disturbance, poorer diet choices, and decreased adherence.1,11 This constellation of perioperative anxiety’s biological and behavioral effects has a detrimental effect on healing, recovery, and outcomes after surgery, which strains providers and burdens healthcare systems.

Interventions to Reduce Perioperative Anxiety

The distress and negative outcomes caused by perioperative anxiety are abundantly sufficient in prevalence and scope to warrant investigation into practices that might ameliorate anxiety and therefore improve patients’ experiences and outcomes. Worldwide, research on interventions to reduce perioperative anxiety has produced diverse, nonpharmacologic, promising approaches. One such intervention is empathetic and patient-centered preoperative education. This type of educational intervention has been studied in randomized, controlled trials using providers specially trained in empathy skills, with results showing significantly reduced anxiety, lower pain, better wound healing, more physical activity, and higher patient satisfaction after surgery in the intervention group compared to standard preoperative education.3 Psychological approaches, such as cognitive-behavioral interventions and relaxation techniques, have generated some evidence, albeit of low quality, supporting its efficacy in reducing anxiety, postoperative pain, and length of hospital stay.12 Another approach is using music, which has been shown to be effective in reducing anxiety and pain in many different types of surgery, using various types of music and at different time points, though the largest effect appears to occur when the patient selects the music and listens preoperatively rather than intraoperatively.13–15 Acupuncture has been studied as an anxiety-reducing intervention, with evidence that its use correlates with lower preoperative anxiety, decreased overall use of narcotics, and less postoperative pain, nausea, and vomiting.16 Aromatherapy has also been found to correlate with lower subjective anxiety levels prior to surgery, particularly with lavender scents.17–19 

Guided imagery is a focus of much emerging research on reducing perioperative anxiety in both adults and children; a trained provider guides a patient in positive thinking and focusing their imagination to create calm, peaceful mental images involving multiple sensory modalities to reduce psychologic distress and physiologic arousal. Evidence suggests that guided imagery is effective in reducing perioperative anxiety, decreasing cortisol levels, increasing endorphins, reducing pain and use of analgesics, and reducing blood loss.20 An important consideration of these interventions is that the risk to the patient is low. One nonrandomized comparative effectiveness study of complementary and alternative medicine (CAM) intervention, consisting of either acupuncture, reflexology, or guided imagery based on patient preference, compared CAM intervention plus standard of care to the standard care alone; not only did the results show significant reduction in pain, nausea, and anxiety, but they also demonstrated no significant adverse events associated with any of the CAM interventions.21 A future direction of research into nonpharmacologic approaches for reducing perioperative anxiety involves the use of virtual reality technology to combine and augment techniques of guided imagery, meditation, and music intervention, and feasibility studies are currently underway.22 

Qualitative research has also assessed patients’ opinions on their surgeons’ involvement in reducing their anxiety. Interestingly, while patients do believe surgical teams should help them manage perioperative anxiety, they do not expect the surgeon to be primarily responsible for helping them cope; rather, they seem to prefer that surgeons focus more on the procedure itself and reduce anxiety by providing education and instilling confidence in their skill, while conveying empathy and optimism where possible.23 

Reducing perioperative anxiety through nonpharmacologic approaches, such as those described above, is an area of continued research as emerging evidence suggests tremendous potential to improve surgical outcomes and patient experiences in a meaningful way with low-risk therapeutic interventions.

Northwell Bariatric Surgery’s Patient-centered, Evidence-based Approach

The bariatric surgery team at North Shore and South Shore University Hospitals, Northwell Health, has implemented several innovative strategies aimed at reducing patients’ perioperative anxiety to improve outcomes. These practices are rooted in evidence from the literature and emphasize patient-centered care. In addition to preoperative meetings providing patients with individualized education and closed social media groups for patients to share their experiences, these programs have implemented guided imagery to address patients’ perioperative stress. Patients receive a link to user-friendly guided imagery meditation that incorporates music, positive affirmations, and relaxing images that help to promote a sense of well-being, instill positive thinking patterns, and support more restorative sleep leading up to surgery. Patients can access this guided imagery at their convenience, with the recommendation to use it once or twice daily for 20 to 40 minutes in the days before and after surgery. This practice is convenient and easy for patients to use, it is an evidence-based, low-risk, and cost-effective approach to alleviate perioperative anxiety, and improve surgical outcomes by reducing pain and analgesic requirements, and enhancing patient satisfaction. Feedback from patients indicate increased calm waiting to be brought into the operating room (OR) and at induction, better sleep before and after surgery, and continued use weeks after surgery.


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