Introduction

Anxiety is characterized as an overwhelming experience of fear, worry, stress and nervousness. It is very common to feel anxious before having a surgery, especially on the day or few days prior to the procedure which are often spent in the hospital. Signs and symptoms of anxiety include irritability, insecurity, headache, sweating, chills, respiratory-distress, tachycardia and hypertension.^[1] It is an emotional reaction associated with several pathophysiological responses accompanied by activation of the autonomous nervous system. Multiple physiological and psychological complications frequently accompany preoperative anxiety. A large amount of anaesthetic drugs are required in anxious patient for induction and maintenance of the optimum level of anaesthesia. Anxious patients also suffer from increased postoperative pain scores, delayed recovery, increased morbidity and longer hospitalisation.^[2]

Various factors that are responsible for an increased preoperative anxiety depend on age, gender, lower education level, understanding ability, economic loss, separation from their family, expenses of the medical treatment and fear of death.^[3] Increased preoperative anxiety levels can alter neuroendocrine response which can be deleterious in post-operative phase. Due to these consequences, the patient can go through prolonged wound healing and impaired immune system.

In most of the cases, the anxiety is caused because of not providing appropriate information to the patient about the anaesthetic and surgical procedures during the pre-anaesthetic visit.It commences as soon as the surgical procedure is planned and rises to maximum severity at the time of admission to a health care setting.

In adult patients, the prevalence of preoperative anxiety level ranges from 11% to 80% and also varies among different surgical groups. Anxiety plays a major role in potentially affecting various important aspects of anesthesia such as preoperative visit, induction, and recovery period.^[4,5,6,7]

The increased preoperative anxiety levels considerably affects the patient’s perception of postoperative pain control.^[8] Recovery from anesthesia can become eventful as anxiety alters the patient’s opinion about postoperative pain.^[9]

Most of the studies are done to find the association of anxiety with surgical procedures. In this study we assessed the prevalence of anxiety and the factors associated with it in relation to the anaesthesia to be administered in patients for elective laparoscopic cholecystectomy on the day and prior to the day of surgery in our hospital.

Subjects and Methods

After getting approval from the Institutional Ethical Committee and written informed consent from patients, the present study was conducted in MMIMSR, Department of Anaesthesia, Mullana, Haryana. It was a prospective, observational study which was conducted over a duration of one year (2018-2019). Patients of both genders between the age group of 20-50 years who were scheduled for elective laproscopic cholecystectomy under general anesthesia, were enrolled in the study.Preoperative patients who were not interested, with existing history of anxiety disorders or on any anti-psychotic drugs were excluded from the study.

Preoperative evaluation was done a day prior to the surgical procedure. Detailed history and vital parameters were recorded. Patients were explained and assured about the study for their approval. A total of 6 questions were asked from the standard Amsterdam Preoperative Anxiety and Inventory Scale and their scoring was done according to the Likert scale. All the patients were kept fasting overnight. Tablet alprazolam 0.25 mg and tab ranitidine 150 mg at bed time was administered to all the patients. On the day of surgery vital parameters were assessed in the preoperative room and again the questions were asked and their scores were recoded.

The study was conducted on 30 adult patients who were posted for laparoscopic cholecystectomy.

Amsterdam Preoperative Anxiety and Information Scale.^[10]

Statistical analysis

This prospective observational study was carried out on 30 patients between the age group of 20-50 years at MMIMSR, Mullana to observe the anxiety level, on the day and the day prior to surgery, in the patients undergoing laproscopic cholecystectomy. Statistical analysis was done by using SPSS 21. Data were expressed using descriptive statistics such as median and interquartile range for continuous variables and frequency and percentage for categorical variables. Chi-square test was used among categorical variables.

Results

The demographic profiles were comparable among the three groups with respect to age, gender, ASA grade and history of previous anaesthesia or surgery and there was no significant difference noted [Table 1]. Anxiety scores were not influenced by age, sex, ASA grade and history of previous anaesthesia or operation. An evident from [Table 2 & Figure 1] the percentage (%) distribution of level of anxiety a day prior to surgery were 66.7% (Mild), 30% (Moderate) and 3.3% (Severe). The percentage (%) distribution of level of anxiety on the day of surgery were 83.3% (Mild), 16.7% (Moderate) and 0% (Severe). Scoring has been done on the basis of APASIS. Scores between 6-14 were defined to have mild anxiety, 15-22 had moderate anxiety and 23-30 had severe anxiety. Most of the patients in our study had mild anxiety which was slightly on higher side on the day of surgery. Only 3.3% of the patients had severe anxiety on the day before surgery. Anxiety scores were not significant with p value> 0.05. [Table 3]

All demographic variables were compared with the prevalence of anxiety and no significant difference was found one day prior and on the day of surgery. [Table 4 & 5]

APAIS score consists of 6 questions with 4 of them depicting anxiety score and 2 depicting need for information score. Most of the patients did not report anxiety to any of the questions and did not ask for more information. Anxiety to surgical procedures were more than the anaestheticprocedure. [Table 6 & Figure 2]

Anxiety was more one day prior than on the day of surgery. [Table 7 & Figure 3] There was a significant difference between systolic and diastolic blood pressure one day prior and on the day of surgery. Heart rate was also statistically significant one day prior and on the day of surgery [Table 8 & 9].

Discussion

Patients are usually unaccustomed to the environment of operating theatre which makes the whole perioperative period a potentially unpleasant experience for them. Anxiety during the preoperative period is the most frequently encountered problem with a rise in postoperative complications such as an increase sensation of postoperative pain, delay wound healing which results in prolonged hospital stay. The level of preoperative anxiety can be influenced by psychological intervention and therefore, extra attention and information regarding the procedure from the anaesthesiologists will help in reducing patient’s anxiety.

In our study, patients in both the groups were comparable regarding age, gender, ASA grade and history of previous anesthesia / operation. Mean age of patients was 40.39 ± 8.54 years which was similar to the study conducted by Celik F et al in which the mean age of patients was 42.79 ± 4.75 years.^[11] Results of our study were similar to the study conducted by Yilmaz M et al (2012),^[12] which reveals that there was no significant correlation between age and the level of anxiety.

Erkilic E et al performed a study to find out the correlation between the preoperative anxiety and age of the patients.^[13] It was found that patients who were younger than 30 years have significant levels of anxiety in comparison to the patients who were older than 45 years. Another study conducted by Maheshwari D et al also states that patients less than age of 25 years were more prone to have higher anxiety levels which is in contrast to our study.^[14]

A study conducted by Masood Z et al reveals that prevalence of preoperative anxiety was higher in females than in males and this was also supported by a study conducted by Lee J et al, Jafar MF et al and Matthias AT et al.^[15,16,17]

In the present study, the anxiety level on both groups were higher in patients who have not experienced any previous anesthesia or operation. These study results were consistent with the study conducted by Matthias AT et al,^[17] which demonstrates that patients who have experienced a surgery before were less anxious than those who have not.

The present study shows that there is a significant difference in Systolic and Diastolic blood pressures and heart rate on a day before and on the day of surgery which is similar to the study results of Ahmetovic J et al,^[18] in which there is a marked difference in the MAP values, however, there was no statistical significance in the heart rate as found in our study.

The present study utilised a tool containing a questionnaire based scale APAIS (1996). This scale consist of six items, two each for measuring preoperative anxiety regarding anaesthesia and the surgical procedure and the remaining two for need-for-information. Each of these questions were asked from patients individually a day before and on the day of surgery, in which patients were found to be more anxious about the surgical procedure than about the anaesthesia. Based on this questionnaire it was found that the need-for-information regarding the surgical procedure was more on a day before surgery than on the day of surgery. However, most of the patients were not aware or did not like to receive the information about the anaesthetic procedure.

Many studies have been conducted around the world to find out the prevalence of preoperative anxiety. The level of anxiety have been reported to be 59.9% by Woldegerima Y.B. et al; 88% by KilincM et al; 87% by Lee J et al; 61% by Mulugeta H et al; 72.7% by Maheshwari D et al; 54% by Tulloch I et al.^{[13,14,19,20,21,22]} Berth H et al,^[23] illustrated the use of the APAIS in assessing the preoperative anxiety and concluded that it is a reliable and valid instrument, especially due to its brevity. In the present study, the preoperative anxiety levels were assessed and compared a day before and on the day of surgery and the results are found to be not-significant.

Conclusion

Results of the present study illustrated that patients did not have significant preoperative anxiety levels. On the basis of our findings, we conclude that most of the patients lack basic knowledge of anaesthesia and surgical procedure. It is required for both surgical and anaesthesia team to provide adequate information regarding operative procedure to the patients, preoperatively and to identify various patient subgroups that require additional preoperative support and help them accordingly.