MEASUREMENT OF PREOPERATIVE ANXIETY AND DETECTION OF PATIENTS’ ANESTHETIC CONCERNS USING VAS

Abdullah S. Alqefari, Abdullah A. alyami, Abdulmagid G. alenezi, Sultan A. Alsaleh, Tarik M. Almowald, Faisal M. Alturi, Mousa R. Alhokail, Mohammed A.Alqhtani, Jamal A.Alghamdi, Naif S.Alotaibi, Maha A. Alenezi, Mohammed A.Alkahmous, Abdulaziz A. Alkahmous and Omar A.Ahmed. GPs, College of Medicine, Jordanian University of Science and Technology (JUST), Riyadh, KSA. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History

Surgery is associated with patient anxiety. Anxiety is known as unpleasant feeling which may leads to avoidance of patient to perform planned operation (Yilmaz et al, 2011). Anxiety is a result of anticipation of threatening event (Hernández-Palazón et al, 2015), here operation is the event. Patients consider that day of surgery is the most threatening day in their lives (Nigussie et al, 2014). The time prior to operation is critical and it is a provoking cause for anxiety for patients (Johnston, 1989;Domar et al, 1989). Preoperative anxiety is a tension secondary to many events such as surgery, disease and hospitalization (Yilmaz et al, 2011). Preoperative anxiety represents 11 % to 80% in adults (Maranets et al, 1999) it has higher effect on women especially young and it affects candidates of major surgery (Roomruangwong et al, 2012),patients without previous exposure to operations (Kim et al, 2010) and it differs according to type of surgery (Maranets et al, 1999). It was found that anxiety incidence in patients of  Pochard et al, 1996;Underwood et al, 1993)reported that incidence rate of anxiety ranged from 20% to 35%. Preoperative anxiety ranges from 60-90% in western population (Saini et al, 2016). Most candidates of surgery experience preoperative anxiety (Johnston, 1989;Domar et al, 1989;Badner et al, 1990).Actually preoperative anxiety is not unusual reaction of patient waiting for surgery (Yilmaz et al, 2011). Once the surgery is planned and determined, patients , anxiety begins and it increases by entering hospital (Klopfenstein et al, 2000). There are many factors that can affect the degree of patients' anxiety including prior exposure to surgery, age, gender and education (Badner et al, 1990). Anxiety cause changes in sympathetic, parasympathetic and endocrine stimulation (Matthias et al, 2012). Preoperative anxiety is related to many adverse events such as delayed jaw relaxation, autonomic fluctuations, coughing during induction of anesthesia, increased pain, nausea and increased risk for infection (Nigussie et al, 2014). Anxious and non-anxious patients respond variously to anesthesia. Larger dosesof anesthesia andpostoperative drugs are required for anxious patients (Jafar et al, 2012), also they may need to stay longer in hospital (Matthias et al, 2012)because they experienced delay in recovery as a result of anxiety (Nigussie et al, 2014). Prolongation of mechanical ventilation also was mentioned (Hernández-Palazón et al, 2015), for all these reasons it is important to measure anxiety for those patients waiting for surgery. Visual Analogue Scale is one of many ways to evaluate anxiety (Jafar et al, 2012). It is used to evaluate anxiety preoperatively and it is a useful and easy method to be applied, also it allows determination of anxiety level in different surgical patients [Kindler et al, 2000;Boker et al, 2002;Millar et al, 1995;Oddershede et al, 2014;Perks et al, 2009;Shafer et al, 1996]. So the aim of this study is to measure preoperative anxiety before operation and describes the quantity of anxiety that patients experience preoperatively using visual analogue scale.

Materials and Methods Subjects:-
This cross sectional observational study was performed on 190 patients in the period from 20 th January 2017 to 7 th February 2017 from Yamama Hospital in Riyadh, an approval from the hospital was obtained to perform this study. This study was performed after operation, participants were asked to answer the questions they all agreed and welcomed. There was no exclusion in this study where all participants answered all questions.

Patient Questionnaire:-
A scored visual analogue scale questionnaire containing 10 questions was established to record the answers of patients and quantify anxiety. The score scale ranged from 0 to 10, zero= no anxiety while 10= extreme anxiety. A very good reliability and internal consistency of the items in thequestionnaire were obtained according to the Cronbach's alpha at 0.833.
Statistical analysis:-Data were analyzed by using Statistical Package for Social Studies (SPSS 22; IBM Corp., New York, NY, USA). Continuous variables were expressed as mean ± standard deviation and categorical variables were expressed as percentages. The t-test was used for continuous variables. The Cronbach's alpha was used to assess reliability and internal consistency of the items in the questionnaire, the Cronbach's alpha was scored at 0.833. P-value <0.05 was considered statisticallysignificant.

Results:-
This study was conducted on 190 patients after performing their operations; the females were dominant in this study than males where the male number was 85 (44.74%) while female number was 105 (55.26%). The mean age of participantswas33.10 ± 9.81, most of them were Saudi 176 (92.63%) and only 14 (7.37%) were non Saudi. Most of individuals were from Urban areas 185 (97.37%) and high educational level 126 (66.32%) while those from rural areas were 5 (2.63%) only and secondary school education or less level was 64 (33.68%). The results of questions were represented by mean± SD. Anxiety scoring started from zero which means no anxiety ascending to reach 10 which mean the maximum anxiety, the mean of each question for this study did not exceed 5. In the present study, no awaking was the more concern in patients (mean =4.91)followed by fearing of physical and mental harm after operation (mean=4.78) then awareness during anesthesia (mean=4.58), the next concern was post-operative pain (mean=4.54), however the last fearing was being at mercy of medical stuff (mean=3.11), while post-operative nausea and vomiting (mean=3.97) was higher than waiting for surgery (Mean=3.56). The results of questionnaire are summarized in table 1 for all subjects and regarding sex. An assessment for anxiety score was performed to investigate the anxiety level of patients before surgery. Sever anxiety at a range of 76-100 represents 58 (30.53%) of individuals in this study, while higher percent of persons experienced a moderate anxiety 72 (37.89%) at rang of 51-75 of scores, mild anxiety at arrange of 25-50 was in 60 (31.58%) of participants, all subjects suffered from anxiety with different degrees, table2.  (Kindler et al, 2000), they found that waiting for the operation, being at the mercy of medical staff, result of the operation and postoperative pain were the first to fourth respectively in order as causes of anxiety, however in our study these four reasons ranked in different order. No awaking, physical and mental harm after operation, awareness during anesthesia and post-operative pain were the top reasons of anxiety respectively in our patients, while being at the mercy of medical staff was the last one. The concern about not awaking was the first reason for anxiety in our study, this may be due to low level of awareness of patients about operation nature and the development in operation techniques. In a study of United States (Bondy et al, 1999), it was reported that the 1859 preoperative anxiety was reduced by giving information to the patients about procedures. Kiyohara et al (2004)study showed that patients, who received information about the surgical procedure, had lower anxiety levels. Also a study in India (Vandana et al, 2009), reported the same results about developing less preoperative anxiety from patients who received information about surgery than those who were not informed, so providing patients with information about disease and operation will decrease preoperative anxiety. Awareness during anesthesia was one of the 4 top concerns causing anxiety, actually it was the third in order, so it is important to increase patient awareness about anesthesia technique and safety by visiting anesthesiologist before surgery to decrease their fearing. The last reason in the presentstudywasbeingatthe mercyofmedicalstaff, whilestudy by Kindler et al (2000) showed that last concern was awareness during anesthesia, this differences in results may returns to differences in culture, public awareness and education levels, although there is difference in ordering of anxiety reasons, preoperative anxiety still exist whatever its cause. In a study by Jawaid et al (2007)and MacClean et al (1990), they reported that patient's highest concern was post-operative pain, while in the present study its order wasnumberfour. The 7 th concern in our patients was the results ofoperation, while in a study by Akinsulore et al (2015), this reason was the first in their patients and the third in Jawaid study (Jawaid et al, 2007). A study in Port Harcourt Teaching Hospital in southeastern Nigeria (Ebirim et al, 2010)and a study by Nigussie et al (2014), they found that Worrying about postoperative nausea and vomiting was the last concern of patients, this is near to our findings in the current study where this concern ranked the 8 th one of 10 concerns. Many studies (Saini et

Conclusion:-
In conclusion, preoperative anxiety is very common in candidates of surgery but with different degrees. Females are more anxious than males, so it is important to decrease patient anxiety before operation.