Anxiety in Anesthesiology

Introduction

Anxiety is a common concern in anesthesiology, particularly in the perioperative setting. As a Canadian medical student preparing for the MCCQE1, understanding the management of anxiety in surgical patients is crucial. This guide will cover key concepts, Canadian guidelines, and provide practice questions to help you ace your MCCQE1 exam.

Pathophysiology of Perioperative Anxiety

Anxiety in the perioperative period is characterized by:

• Increased sympathetic nervous system activity
• Elevated cortisol levels
• Heightened pain perception
• Potential for increased anesthetic requirements

Assessment of Perioperative Anxiety

Preoperative Evaluation

Management of Perioperative Anxiety

Non-Pharmacological Interventions

1. Patient Education: Provide clear, concise information about the surgical procedure and anesthesia process.
2. Psychological Techniques:
   • Deep breathing exercises
   • Progressive muscle relaxation
   • Guided imagery
3. Music Therapy: Offer calming music in the preoperative area.
4. Acupuncture: Consider as an adjunct therapy where available and appropriate.

Pharmacological Interventions

Canadian Guidelines for Perioperative Anxiety Management

The Canadian Anesthesiologists' Society (CAS) provides guidelines for perioperative anxiety management:

1. Conduct thorough preoperative assessment, including anxiety evaluation.
2. Implement a multimodal approach, combining non-pharmacological and pharmacological interventions.
3. Tailor interventions to individual patient needs and preferences.
4. Consider cultural factors and language barriers in anxiety management strategies.
5. Involve family members or support persons when appropriate and with patient consent.

Key Points to Remember for MCCQE1

• Understand the physiological and psychological effects of perioperative anxiety
• Know how to assess anxiety using validated tools like APAIS
• Be familiar with both non-pharmacological and pharmacological interventions
• Recognize the importance of patient education and clear communication
• Understand the pharmacokinetics of common anxiolytics used in anesthesiology
• Be aware of Canadian guidelines for perioperative anxiety management
• Consider cultural competence in anxiety management strategies

Sample Question

A 35-year-old woman is scheduled for laparoscopic cholecystectomy. During the preoperative assessment, she appears visibly anxious, with a heart rate of 110 bpm and blood pressure of 150/90 mmHg. She reports no previous surgeries and is concerned about the anesthesia. Which of the following is the most appropriate initial management for this patient's anxiety?

• A. Administer 2 mg of intravenous midazolam
• B. Provide detailed information about the anesthesia process
• C. Recommend postponing the surgery
• D. Start propranolol for heart rate control
• E. Initiate cognitive behavioral therapy

Explanation

The correct answer is:

• B. Provide detailed information about the anesthesia process

Explanation: In this scenario, the patient's anxiety is likely due to lack of information and unfamiliarity with the surgical and anesthesia processes. The most appropriate initial management is to provide clear, detailed information about the anesthesia process. This aligns with the Canadian guidelines emphasizing patient education and non-pharmacological interventions as first-line approaches. It addresses the patient's expressed concern about anesthesia and may help alleviate anxiety without immediately resorting to medication.

Options A (midazolam) and D (propranolol) are pharmacological interventions that may be considered, but they should not be the first step before attempting non-pharmacological approaches. Option C (postponing surgery) is not appropriate unless there are medical contraindications to proceeding. Option E (cognitive behavioral therapy) is a long-term intervention not suitable for immediate preoperative anxiety management.

This question tests the candidate's understanding of perioperative anxiety management, prioritizing non-pharmacological interventions, and the importance of patient education in the Canadian healthcare context.

References

1. Canadian Anesthesiologists' Society. (2021). Guidelines to the Practice of Anesthesia - Revised Edition 2021. Canadian Journal of Anesthesia, 68, 92-129.

2. Maranets, I., & Kain, Z. N. (1999). Preoperative anxiety and intraoperative anesthetic requirements. Anesthesia & Analgesia, 89(6), 1346-1351.

3. Moerman, N., van Dam, F. S., Muller, M. J., & Oosting, H. (1996). The Amsterdam Preoperative Anxiety and Information Scale (APAIS). Anesthesia & Analgesia, 82(3), 445-451.

4. Pritchard, M. J. (2009). Managing anxiety in the elective surgical patient. British Journal of Nursing, 18(7), 416-419.

5. Wilson, C. J., Mitchelson, A. J., Tzeng, T. H., El-Othmani, M. M., Saleh, J., Vasdev, S., ... & Saleh, K. J. (2016). Caring for the surgically anxious patient: a review of the interventions and a guide to optimizing surgical outcomes. The American Journal of Surgery, 212(1), 151-159.