11 Pre-operative anxiety, stress and pre-medication

The preoperative period means for the majority of patients a distressing situation, which is characterized by anxiety and fear. This is not only uncomfortable for the patient, but the simultaneously occurring activation of the sympathetic nervous system is potentially dangerous for a predisposed patient. Therefore, the primary goal for the patients preoperatively is to reduce anxiety and to induce sedation. Furthermore, if indicated, premedication should minimize the risk of an aspiration syndrome, prevent postoperative nausea and vomiting (PONV), provide analgesia, reduce secretions and control infections.

Besides fear and anxiety, stress may even cause an adaptation syndrome or depression. Physiological reactions of all organ systems to epinephrine and norepinephrine result from the stimulation of the sympathetic nervous system. To quantify these effects physiological and biochemical parameters are used. Fears may be recognized consciously or may be masked; for anxiety there is a differentiation between trait-anxiety and state-anxiety, which are of differing importance. It can be stated that the perioperative anxiety influences the patient's outcome.

For the preoperative medication both the individual patient, due to the physical and psychological status and to their history, and the desired goals have to be considered. The most commonly used ways of administration are oral, rectal or intranasal. We can choose our pharmaceutical premedication for anxiolysis and sedation from different substance classes as benzodiazepine, barbiturates, α-2-agonists, being aware of specific effects and side effects and also the possibility of antagonization. On the other hand, the anaesthesiologist has to know the meaning of the psychological premedication too.

Other unpleasant experiences for patients postoperatively are nausea and vomiting, which are to be treated prophylactically in patients with a known history of PONV. Anticholinergics are no longer routinely used for premedication, and from a legal point of view this is no longer recommended.