This Invited Commentary accompanies the following original articles:
• Granziera E, Guglieri I, Del Bianco P, et al. A multidisciplinary approach to improve preoperative understanding and reduce anxiety: a randomised study. Eur J Anaesthesiol 2013; 30:734–742.
• Mijderwijk H, van Beek S, Klimek M, et al. Lorazepam does not improve the quality of recovery in day-case surgery patients: a randomised placebo-controlled clinical trial. Eur J Anaesthesiol 2013; 30:743–751.
In industrialised countries spending more than $1000 per head on healthcare, the estimated rate of major surgery has been reported to be approximately 11 000 per 100 000 people per year.1 Nowadays, preoperative evaluation and preparation of patients by anaesthesiologists some days before elective surgery or invasive procedure is part of the routine for most of the patients. We consider this first stage as useful for both the patient and the anaesthesiologist. Some clinical researchers consider the impact of the anaesthesiologist in this preoperative period of uncertainty as insufficient and propose to add supplementary interventions, for example, the addition of pharmacological or psychological support. In this issue of the European Journal of Anaesthesiology, two important studies investigated the impact of such preoperative intervention on patients’ wellbeing.2,3
The first prospective study investigated preoperative anxiety in a panel of 251 women with a median age of 53 years who were undergoing general anaesthesia for breast cancer surgery.2 Anxiety is an important preoperative risk factor for increased postoperative pain4 and, therefore, reduction of preoperative anxiety is a valid approach to improve outcome. Women were randomly assigned either to an anaesthetic informed consent or to a multidisciplinary psycho-oncological intervention before the anaesthesiologists’ preoperative evaluation. Anxiety was evaluated by the validated State-Trait Anxiety Inventory (STAI) questionnaire. Overall, no difference between these two groups was observed. Anxiety decreased after the preoperative evaluation and preparation by the anaesthesiologist in the same way in both groups. In a subgroup of high anxiety patients, the combined intervention seemed to have a larger effect. Therefore, overall, and this is the good news, anaesthesiologists can themselves reduce preoperative anxiety of female patients and do not need external support, except for particular patients.
The second study is a large randomised controlled trial including 400 patients with a mean age of 40 years.3 The aim was to investigate the effect of chemical premedication by lorazepam on quality of recovery and psychological manifestations such as anxiety compared with placebo in day-case surgery patients. Postoperative well being is very important in ambulatory surgery to avoid delay of discharge or rehospitalisation.5 Different postoperative outcome scores were used, including again the State-Trait Anxiety Inventory questionnaire. The result, unsurprisingly, was that there was no difference between these groups and, on the contrary, there were more postoperative side effects with lorazepam. This result is similar to another similar premedication study of patients undergoing ERCP; the side effect was a trend to greater amount of sedative drugs during the intervention.6 And again, the good news is that anaesthesiologists can themselves improve the postoperative quality of life without any external (pharmacological) support.
In both studies, the hypotheses were not confirmed; therefore, both studies can be considered as ‘negative’ studies. In general, the addition of supplementary preoperative support seems not to decrease pre and postoperative anxiety and not to improve postoperative well being. The only question is why? First, we have to wonder whether the aims of the studies are clinically relevant. Second, are the interventions used in the studies based on scientific evidence and expected to be successful? Third, do the methodological methods including power estimation allow us to conclude that the interventions were not helpful? Fourth, if all these aspects are correct, then we should change our strategy of research in preoperative care.
Both studies investigated relevant questions even though anxiety may be a surrogate endpoint for preparedness of a surgical procedure; the better the patient and the hospital system are prepared, the merrier is patient well being and satisfaction, and the quality of perioerative care including the postoperative period, which is often affected by insecurity. This central aspect will be fully discussed in the next paragraph. Both interventions are based on a certain scientific background. Psychological interventions during a prolonged period are, for example, efficient in brain-injured patients with cognitive deficits,7,8 or in patients with a posttraumatic stress disorder.8 However, drug interventions for anxiety treatment are considered more controversial.9 Both studies were powered for the investigation of a difference. The absence of a difference cannot be interpreted as absence in real life. Indeed, potentially, studies powered for absence of difference may give different results. The absence of a statistically significant difference may not mean that there is no difference in subgroups, as nicely shown in the study on anxiety in breast cancer patients.2 Finally, the absence of statistically significant difference may not mean the absence of a clinically relevant difference, in particular in the domain of subjective outcomes with a large variability. Interestingly, analyses with the concept of the minimum clinically important difference, which may be more appropriate in subjective outcomes, were used in both studies. Despite minor methodological doubts, potentially, the basic questions were too subtle and we should go back a step. The managerial slogan ‘keep it simple’ also seems to hold true for the preoperative preparation of patients, even anxious patients. When performed with high professionalism, this simple approach may increase patients’ use of coping strategies.
What do patients really want when going to a preoperative service? First, the patient or his family wants a specific check of his health situation in the perspective of a (surgical) procedure with an estimation of his physical and cognitive reserve. Second, a care plan including the preoperative, intraoperative and postoperative periods (PACU, intermediate care/high-density care, ICU) and postdischarge period has to be developed with the patient. Third, in patients with considerable physical and cognitive limitations, alternative medical treatments and potential limitations of life-sustaining treatments have to be discussed. Efficiency can be considerably improved with such a preoperative service combined with an efficient ‘back office’ coordinating the hospital clinical pathway and specific surgical and anaesthesia material availability, as shown in a systematic review.10 Surgical volume was increased (from 30 to 35%), surgical wound infection significantly decreased and cost per capita decreased (from 18 to 8%). It would be very interesting to know whether a well run preoperative service centre could reduce preoperative anxiety as well, because the patient can trust a well performing prehospital and hospital system and because all his questions around the procedure have been discussed.
Unlike the two published studies in this issue, the ‘normal’ adult population in a large and unspecialised hospital is usually older. The older population with chronic and often critical illness (ASA 3 to 5) needs particular prehospital preparation, similar to athletes, for instance, pulmonary training to improve physical fitness,11 nutritional support12 and avoidance of anaemia (iron supplementation and, perhaps, erythropoiesis-stimulating agents).13 All these measures have been shown to be effective to reduce postoperative complications and length of hospital stay in randomised controlled trials or prospective studies in particular surgeries (cardiac, abdominal and orthopaedic). We can suppose that such a preoperative preparation would be effective in this group of patients as well. Improved glycaemic14 and blood pressure control and haemostatic assessment15 may contribute further to fewer postoperative complications. Preoperative hypoxaemia may be another condition that could be improved in the preoperative period. The patient should be as strong and healthy as possible before an intervention if our purpose is to improve the 30-day mortality rate of 6% and the postoperative complication rate of 19%.16
We need urgently more research concerning this period between patient agreement for procedure and the procedure itself. This period could be crucial for further patient-relevant quality improvement in perioperative medicine with reduced length of hospital stay, postoperative complications and postoperative mortality. However, pharmacological and psychological preoperative interventions seem to have a low efficacy and research should be redirected to reduction of life-threatening postoperative complications accompanied with simple quality-of-life assessment instruments.
Acknowledgements relating to this article
Assistance with this commentary: none.
Financial support and sponsorship: BW has received support from the Swiss National Foundation (SNF; K-23K1-122264/1), Swiss Accident Company and the Bangerter-Rhyner Foundation. The founding agencies had no role in the preparation, review or approval of the manuscript.
Conflicts of interest: none.
Comment from the Editor: BW is a Deputy Editor-in-Chief of the European Journal of Anaesthesiology. The article was checked and accepted by the Editors, but was not sent for peer review.
1. Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet
2. Granziera E, Guglieri I, Del Bianco P, et al. A multidisciplinary approach to improve preoperative understanding and reduce anxiety: a randomised study. Eur J Anaesthesiol
3. Mijderwijk H, van Beek S, Klimek M, et al. Lorazepam does not improve the quality of recovery in day-case surgery patients: a randomised placebo-controlled clinical trial. Eur J Anaesthesiol
4. Caumo W, Schmidt AP, Schneider CN, et al. Preoperative predictors of moderate to intense acute postoperative pain in patients undergoing abdominal surgery. Acta Anaesthesiol Scand
5. Wu CL, Berenholtz SM, Pronovost PJ, et al. Systematic review and analysis of postdischarge symptoms after outpatient surgery. Anesthesiology
6. Weitz G, Homann N, von Jagow DC, et al. Premedication with orally administered lorazepam in adults undergoing ERCP: a randomized double-blind study. Gastrointest Endosc
7. Dams-O’Connor K, Gordon WA. Role and impact of cognitive rehabilitation. Psychiatr Clin North Am
8. McFarlane CA, Kaplan I. Evidence-based psychological interventions for adult survivors of torture and trauma: a 30-year review. Transcult Psychiatry
9. Walker KJ, Smith AF. Premedication for anxiety in adult day surgery. Cochrane Database Syst Rev
10. Lee A, Kerridge RK, Chui PT, et al. Perioperative systems as a quality model of perioperative medicine and surgical care. Health Policy
11. Hulzebos EH, Helders PJ, Favie NJ, et al. Preoperative intensive inspiratory muscle training to prevent postoperative pulmonary complications in high-risk patients undergoing CABG surgery: a randomized clinical trial. JAMA
12. Burden S, Todd C, Hill J, et al. Preoperative nutrition support in patients undergoing gastrointestinal surgery. Cochrane Database Syst Rev
2012; 11: CD008879.
13. Shander A, Van Aken H, Colomina MJ, et al. Patient blood management in Europe. Br J Anaesth
14. Dhatariya K, Levy N, Kilvert A, et al. NHS Diabetes guideline for the perioperative management of the adult patient with diabetes. Diabet Med
15. Bonhomme F, Ajzenberg N, Schved JF, et al. Preinterventional haemostatic assessment: guidelines from the French Society of Anaesthesia and Intensive Care. Eur J Anaesthesiol
16. McNicol L, Story DA, Leslie K, et al. Postoperative complications and mortality in older patients having noncardiac surgery at three Melbourne teaching hospitals. Med J Aust