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Background: Preoperative anxiety means not only patient suffering but causes also numerous perioperative complications such as increased need for medicaments, additional pain or prolonged hospital stay. Therefore, it is not only in the interest of patient but also in the interest of the healthcare system to identify, differentiate and reduce the preoperative anxiety by offering appropriate information and assistance for the patient. The prevalence of preoperative anxiety and increased preoperative anxiety vary widely in former studies. Also, the extent of anxiety intensity and the spectrum of anxiety are not clear. This issue still presents many open questions which encouraged the big cross-sectional study presented in this work.
Methods: A patient survey was conducted right before the premedication visit of the anesthesiologist in a university hospital in Hesse, Germany. It consisted in different anonymized screening questionnaires and another one to identify special fears concerning anesthesia. The first questionnaire was the German version of the validated Amsterdam Preoperative Anxiety and Information Scale (APAIS) with six statements on anesthesia (APAIS-A-An), surgery (APAIS-A-OP) and total anxiety (APAIS-A-T = APAIS-A-AN + APAIS-A-OP) and the need for information on a five-point Likert scale. It was followed by a modified numeric rating scale (mNRS) with a range of "0"-"10" to estimate the fear of anesthesia (mNRS-A-An), surgery (mNRS-A-OP) and total anxiety (mNRS-A-T = mNRS-A-An + mNRS-A-OP). The third questionnaire was used to evaluate different anesthesia-associated fears, also using the mNRS. Finally, a fourth questionnaire collected patient-related variables such as age and gender.
Results: 3200 patients from eleven departments were interviewed, of which 3087 questionnaires could be analyzed. 57% of the patients were female, 43% male. 93% of patients reported at least mild anxiety about surgery and anesthesia according to APAIS, 40.5% reported increased anxiety (APAIS-A-T> 10). Many patients showed equal anxiety levels concerning surgery and anesthesia (29% according to APAIS, 46% according to mNRS) or showed only slight differences. If there were differences, more patients reported higher surgical than anesthesia anxiety (61% according to APAIS, 42% according to mNRS). Also, the fear of surgery was generally more pronounced than fear of anesthesia (APAIS-A-OP 5.5 (SD 2.12) vs. APAIS-A-An 4.3 (SD 1.89) or mNRS-A-OP 4.3 (SD 2.77) vs. mNRS-A-An 3,5 (SD 2,64). There were some extreme cases in which both, the anxiety of anesthesia and surgery, were maximized (n=28 (0,9%) according to APAIS, n=67 (2.1%) according to mNRS). Comparing the surgical departments the biggest fears were these of gynecological/obstetric (APAIS-A-T 11.0 (SD 3.6)), neuro surgical (APAIS-A-T 10, 4 (SD 3.5)) and cardiac interventions (APAIS-A-T 10.0 (SD 3.6)). In further differentiation, the most anxiety-inducing thoughts were physician error (mNRS 3.95 (SD 3.08)), awareness during surgery (mNRS 3.82 (SD 3,09)) and dying (mNRS 3.70) (SD 3.43). The various anxieties correlated to each other to a moderate to high degree. The mNRS correlated strongly with the validated APAIS.
Conclusion: A majority of the patients is affected by preoperative anxiety, more than a third by increased preoperative anxiety. The study highlighted the importance of identifying these patients and offering them adequate help and information to reduce the hospital stay and avoid complications. A differentiation between anesthesia and surgical anxiety should take place, as it differs in many patients. Additionally, this work proves that both, APAIS and mNRS, are useful and good tools for assessing preoperative anxiety.