Surgery-induced immunosuppression and postoperative pain management

Surgery is well-known to result in the suppression of some immune functions; however, the role of perioperative pain has only recently been studied. Pain-relieving anesthesia techniques and perioperative analgesia provide some protection against surgery-induced immune suppression and infectious surgical sequelae, although few studies also assess postoperative pain. Attributing a biological consequence to the observed immune alterations remains an issue in human studies, and the use of immune sensitive tumor models in animals enables the linking of immune changes with disease and a means by which to explore causal relationships among surgery-related pain, immune function, and metastatic development. There is strong evidence in animals that pain-relieving interventions significantly reduce the tumor-enhancing effects of undergoing and recovering from surgery. It cannot be assumed that animal findings are directly applicable to the human condition; however, if such relationships hold in humans, perioperative pain management becomes an important strategy for reducing postoperative sequelae.     

The use of pre-, intra-, and posthypnotic suggestion in anesthesia and surgery

While under hypnosis, patients can be taught to alter their psychophysiological functions. With this ability to alter these functions, patients can overcome the anxiety associated with surgery. Patients with high anxiety often experience more depression, can have increased complications, need more anesthesia and medication, have suppressed immune function, and often take longer to heal. The purpose of this article is to review the research literature related to the use of hypnosis in preparing the patient for surgery and to present 2 approaches used by the authors to prepare patients for surgery. The first approach is used when there is enough time to condition the patient, and the second approach is used when the anesthetist meets the patient shortly before the surgery is to begin and there is no time to induce formal trance.     

The effect of music on preoperative anxiety in day surgery

AIM: This paper reports a study to test the hypothesis that day surgery patients who listen to music during their preoperative wait will have statistically significantly lower levels of anxiety than patients who receive routine care. BACKGROUND: Although previous day surgery research suggests that music effectively reduces preoperative anxiety, methodological issues limit the generalizability of results. METHODS: In early 2004, a randomized controlled trial design was conducted to assess anxiety before and after listening to patient preferred music. Participants were allocated to an intervention (n=60), placebo (n=60) or control group (n=60). Pre- and post-test measures of anxiety were carried out using the State-Trait Anxiety Inventory. RESULTS: Music statistically significantly reduced the state anxiety level of the music (intervention) group. No relationships were found between socio-demographic or clinical variables such as gender or type of surgery. CONCLUSION: The findings support the use of music as an independent nursing intervention for preoperative anxiety in patients having day surgery.     

Differences in anxiety and role experiences between three age groups of women with heart disease

Anxiety and role experiences in women may be related to age, developmental changes, social roles, and life circumstances such as cardiac disease. One hundred fifty-five women participated in a cross sectional survey on anxiety and role experiences in early middle-age, midlife, and elderly women after heart surgery. MANOVA analysis revealed significant differences for anxiety and role experiences by age. Compared with older women, early middle-age women had lower balance between role rewards and concerns and a poorer match between ideal and actual role function, which may be a contributing factor for their increased anxiety.     

手术患者麻醉前应激状态的研究

目的通过观察和描述手术患者在进入手术室进行麻醉前等待手术、完全清醒时的应激状态，探讨手术患者麻醉前应激反应的程度。方法采取方便抽样法对60例采用脊椎硬膜外联合麻醉的患者分别在手术前1d和手术麻醉前（进入手术室后休息10min）进行焦虑、血压、心率的测量并分析。结果①不同性别、既往有无手术史、麻醉史、过敏史对麻醉前焦虑指数的影响均无统计学意义（P〉0．05）；②患者术前访视时的焦虑指数、血压和心率与进入手术室麻醉前比较差异具有统计学意义（P〈0．01）；③术前访视和麻醉前焦虑指数与各项生理指标均有相关性（P〈0．01）。结论手术患者麻醉前的应激反应水平明显高于术前访视时的应激水平；患者的生理指标可明确反映焦虑程度。     

诱导等待期间接台手术患者焦虑水平与信息需求的调查分析

目的:调查诱导等待期间接台手术患者的焦虑水平与信息需求,并分析其相关影响因素。方法:采用方便抽样,利用阿姆斯特丹焦虑与信息需求量表(APAIS),对2018年7至9月在复旦大学附属中山医院行择期全身麻醉手术的97例接台患者在诱导等待期间进行问卷调查。结果:诱导等待期间接台手术患者严重焦虑的发生率为11.3%。信息需求与焦虑正相关(r=0.535,P<0.001)。家庭关系欠佳、既往有痛苦麻醉经历是发生术前焦虑的危险因素,低手术级别手术是术前高信息需求的影响因素。结论:诱导等待期间接台手术部分患者呈焦虑状态。建议医护人员评估、筛选高危患者,尤其对家庭关系欠佳、既往有痛苦麻醉经历的患者实施心理干预,手术信息优先给予手术级别较低患者。     

The Use of Tablet Computers to Reduce Preoperative Anxiety in Children Before Anesthesia: A Randomized Controlled Study

PurposeChildren undergoing surgery and general anesthesia often experience preoperative anxiety (POA) with related negative short-, medium- and long-term consequences. Anxiolytic premedication has negative side effects, and nonpharmacologic interventions are often resource demanding and not always readily available in a busy clinical setting. The use of an age-appropriate game on a tablet computer may reduce POA, postoperative pain, and occurrence of emergence delirium (ED).DesignChildren aged 3 to 6 years scheduled to undergo elective minor surgery were randomly assigned to play a game on a tablet computer while in the holding area before anesthesia (n = 30) or prepared as per departmental standard only (n = 30).MethodsPOA, ED, and levels of pain were assessed by the modified Yale Preoperative Anxiety Scale, Pediatric Anesthesia Emergence Delirium, and Face, Legs, Activity, Cry, Consolability scale, respectively.FindingsA total of 60 children were randomized to either the intervention group or the control group. Gender, bodyweight, duration of anesthesia and surgery, and fentanyl dosages were comparable between the two groups. Tablet-gaming children tended to be less anxious than control subjects at the time of anesthesia induction (modified Yale Preoperative Anxiety Scale, 55.7 vs 65.8; 95% confidence interval, ?0.63 to 20.8; P = .066). There was no difference in occurrence of ED or pain 20 minutes after arrival in the postanesthesia care unit.ConclusionsAlthough not statistically significant, the use of an age-appropriate tablet computer game may reduce the level of anxiety at the anesthetic induction in 3 to 6 years old children undergoing elective day-case surgery. However, the occurrence of ED and levels of pain appeared unaffected. Standardization of nonpharmacologic interventions to reduce perioperative anxiety and pain is required.     

Surgery, pain, and immune function

Research findings have demonstrated that surgery negatively affects immune function. Pain also has deleterious effects on immune function. Most research in this area has been conducted on animals. Psychoneuroimmunology provides the framework for this article. Psychoneurological phenomena, such as stress, depression, and pain, can influence immune system functioning through neuroendocrine pathways. Biological and behavioral processes appear to be closely related and need to be jointly considered when planning and providing anesthesia care. The anesthesia planning process increasingly involves aggressive assessment and treatment of postoperative pain, which may benefit immune function.     

The effects of handholding on anxiety in cataract surgery patients under local anaesthesia

AIM OF THE STUDY: To assess the effectiveness of handholding on the anxiety of patients undergoing planned cataract surgery under local anaesthesia. BACKGROUND: Anxiety concerning anaesthesia, pain, physical injuries, isolation, prognosis, possibilities of deformity, or loss of self-control may be stressful to patients undergoing surgery. Anxiety activates the sympathetic nervous system, characterized by an increase in catecholamine concentration, heart rate and blood pressure and increased glucocorticoid levels; it also affects immune responses. Therefore, there is a need for nursing interventions to reduce the anxiety of patients under local anaesthesia who are conscious. METHODS: An untreated control group design with pre and post-test was used. Among 62 patients, 30 were randomly assigned to the handholding group and 32 to the control group. Handholding was provided to subjects of the handholding group during surgery. Visual analogue scales and interviews were used to measure anxiety, and pulse rate and systolic and diastolic blood pressure were used as physiological measures of stress. Blood was taken for analysis of levels of epinephrine, norepinephrine, cortisol, neutrophils, lymphocytes and natural killer cells. RESULTS: The number of subjects who reported decreased anxiety during operation was significantly higher in the handholding group compared with the control group and most of the subjects reported that handholding during operation was very helpful in reducing anxiety. Epinephrine levels in the handholding group were significantly lower than in the control group. CONCLUSIONS: Results suggest that this noninvasive intervention has potential for reducing anxiety in patients having cataract surgery under local anaesthesia.     

Measuring patient anxiety in coronary care. Part 1.

Patient anxiety is a common problem identified by nurses. However, the difficulty of assessing the level and significance of the anxiety is problematic. This paper discusses the issue of measuring patient anxiety, specifically in Coronary Care. As well as discussing physiological measures, three appropriate psychometric instruments are identified (the State-Trait Anxiety Inventory--STAI; the Hospital Anxiety and Depression Scale--HAD; a Linear Analogue Anxiety Scale--LAAS), along with a review of the relevant literature. Systematic anxiety measurement, and management of maladaptive anxiety would appear to be appropriate and meaningful nursing functions within the provision of holistic patient care in Coronary Care.     

Stress: an overview of the literature with emphasis on job-related strain and intervention

Maintained stress produces a constellation of neurochemical and hormonal changes that involve both the hypothalamic-pituitary-adrenal axis and a variety of brain regions. Long-term stress can produce psychological and physiologic consequences including anxiety, depression, hypertension, impaired immune system function, and an increased risk of cancer and coronary heart disease. Negative responses to perceived job-related stress usually occur when an individual has relatively little control over the means to meet high job demands. Among the approaches to reduce workplace stress, changing the coping strategies of challenged employees, particularly by increasing decision latitude, can significantly relieve both the psychological and physiologic consequences. Nevertheless, behavioral intervention is not invariably successful, and benzodiazepines are often prescribed to manage inadequately alleviated anxiety. Evidence that excessive serotonergic neurotransmission may underlie anxiety has prompted the use of compounds such as buspirone. This partial agonist of the 5-HT1A receptor has been demonstrated to be as effective as benzodiazepines in controlling generalized anxiety symptoms and to have a more favorable side-effect profile.     

Anxiety among clients for plastic surgery.

A beautiful face, lithe body, and appealing genitalia are alluring in Western Society. Plastic surgery to repair a defect or improve sexual appeal often elicits the patient's anxiety as well as excitement. The health care professional's empathic and therapeutic support is essential to improving post surgical recovery. The effectiveness of outcome and patient satisfaction often rest on how well the surgery meets the patient's needs. Anxiety is a major factor that influences whether patients have realistic expectations for surgery and whether the patient needs constant reassurance and support from the nurse. The nurse needs to use scientific knowledge and strategies for screening, assessment, and management of anxious patients. Depending on their level of anxiety, patients benefit from diverse nursing interventions to treat anxiety, provide resources, and recommend referrals for those with anxiety disorders.     

Effect of adrenal function on gastrointestinal peptide release in experimental cardiac arrest

Pancreatic polypeptide (PP), neurotensin, substance P, and vasoactive intestinal polypeptide (VIP) are peptides that modify various autonomic and neural functions. These substances are secreted into the blood in response to physiologic stimuli affecting the gastrointestinal tract. To determine the effect of adrenal hormones on gastrointestinal peptide release we measured blood levels of PP, VIP, substance P, and neurotensin in adrenalectomized and intact dogs undergoing cardiac arrest and cardiopulmonary resuscitation (CPR), a condition associated with maximal adrenal stimulation. One hour after completion of abdominal surgery consisting of bilateral adrenalectomy or exposure of the adrenal glands (sham operation), ventricular fibrillation was induced in 19 dogs by direct ventricular discharge. Despite marked elevations of plasma epinephrine and norepinephrine, CPR was associated with minimal endocrine gastrointestinal involvement, restricted to increased VIP levels in sham-operated dogs. No specific gastrointestinal peptide response to cardiac arrest was seen in adrenalectomized animals, but their plasma PP and VIP levels were higher than those of sham-operated dogs. Therefore, acute maximal adrenal stimulation is associated with selective VIP release. In addition, the higher level of the vagally controlled plasma PP in adrenalectomized animals suggests a tonic inhibitory effect of adrenal secretions on the release of this peptide.     

Temperature effect of a disinfectant in operative field during surgery under local anesthesia

Abstract There are few reports on the efforts made by nursing staff to improve the operating environment so as to alleviate the anxiety of patients during surgery under local anesthesia. We examined the effect of applying a warm disinfectant over the operative field in reducing the anxiety and stress of patients. In experiment 1, we conducted a preliminary study in healthy subjects to investigate the psychosomatic effects of different temperatures of fluid applied to the skin. Experiment 2 was conducted in patients who were undergoing surgery under local anesthesia, and we studied the differences in the psychosomatic influences caused by disinfectants at different temperatures. A preliminary study revealed significant differences in the surface temperature of the skin immediately after application of 'cold water', 'regular water' and 'warm water'. There were significant differences in feeling after application of the various temperatures. In experiment 2, the scale points for anxiety in the State–Trait Anxiety Inventory condition increased significantly before and after disinfecting with a cold disinfectant (15°C). Moreover, a significant difference was observed in the feeling of coldness compared with 'warm' (40°C) disinfectant. In conclusion, the temperature of a disinfectant to be used on an operative field for a patient under local anesthesia should be 'warm'. This is useful for reducing the anxiety and stress of the patient.     

Anxiety and quality of recovery in day surgery: A questionnaire study using Hospital Anxiety and Depression Scale and Quality of Recovery Score

The aims of this study were (i) to examine the association between preoperative and postoperative anxiety, and (ii) to examine the association between preoperative anxiety and postoperative recovery, following day surgery under general anaesthesia. Day surgery has become more commonplace owing to advances in pharmacology, anaesthetic and surgical techniques, as it has recognized benefits, such as lower costs and reduced incidence of infection. Recent years have seen increased complexity of day surgery undertaken on a broader range of patients, but with reduced pre-surgery contact with the hospital environment. These recent service changes might have had an effect on the preparation of patients for day surgery, and this in turn might have affected their postoperative recovery. This pilot study used survey methods to examine potential associations between preoperative and postoperative anxiety, and between preoperative anxiety and postoperative recovery. Data were collected in 2008 from a convenience sample of 54 day surgery patients. The instruments used were the Hospital Anxiety and Depression Scale (HADS) and the Quality of Recovery Score (QoR-40). There was a statistically significant relationship between preoperative and postoperative anxiety (χ(2) =11.899, d.f.=1, P=0.001). The T-test showed a statistically significant difference in the mean scores for QoR-40 score for gender, and for the postoperative anxiety and QoR-40. A relationship between preoperative anxiety and postoperative recovery was not shown. Although challenging to implement in view of restricted timescales, appraisal and revision of pre-assessment processes to incorporate an anxiety measurement tool, such as the HADS, should be considered.     

Using Guided Imagery to Relieve the Anxiety of Preschool Children Undergoing Dental Procedures

PurposeNegative experiences in dental clinics can induce anxiety in patients, and the effects are particularly pronounced in children. When behavior guidance methods (eg, direct observation, tell-show-do, and ask-tell-ask) fail, general anesthesia is an important alternative; however, the procedure of anesthesia can also induce fear and anxiety. This study assessed the effectiveness of guided imagery in relieving the anxiety associated with dental surgery in children and caregivers.DesignA prospective randomized trial with two groups.MethodsThe guided imagery in this study was meant to establish a rapport between the medical team and the patient, by encouraging the child to imagine having an adventure while riding in a spacecraft. Anxiety levels and behavior were measured using five well-established scales: the modified Yale Preoperative Scale-Short Form, the State-Trait Anxiety Inventory-6 items, the Watcha score, the Pediatric Anesthesia Emergent Delirium scale, and the Posthospitalization Behavioral Questionnaire-Ambulatory Surgery.FindingsThe results indicate that the guided imagery had no significant effects on anxiety levels.ConclusionsGuided imagery is a low-cost, easy-to-implement, interesting exercise capable of enhancing interactions between nursing staff and children. It may also help to condition children to the environment and thereby assist them in overcoming their fears.     

腹腔镜诊疗不孕症患者的心理状态调查与护理对策

目的:对行腹腔镜手术的不孕症患者的心理状态进行调查并探讨相应的护理对策,以提高治愈率及妊娠率。方法:采用医院焦虑及抑郁量表(HAD)及自行设计的不孕基本情况调查问卷,对2011年1～9月我院生殖中心行腹腔镜手术的128例不孕症患者进行问卷调查,了解其主要心理问题及影响其心理的相关因素,并进行针对性护理,比较护理前后患者焦虑及抑郁量表得分情况。结果:通过调查发现行腹腔镜手术的不孕症患者均有抑郁、焦虑不安等不良心理,经心理护理后较护理前焦虑及抑郁量表(HAD)分值明显降低,差异有统计学意义(P<0.05)。影响其心理状态的相关因素有年龄、经济状况、不孕时间、文化程度、患者对腹腔镜手术相关知识的了解程度以及来自家庭、社会的压力等。结论:对行腹腔镜手术的不孕症患者在诊治过程中应当重视心理健康问题,找出影响其心理的相关因素,采取相应的心理护理措施,以缓解患者的心理压力、提高治疗效果。     

Decrease in pulmonary artery pressure after administration of thoracic epidural anesthesia in a patient with Marfan syndrome awaiting aortic valve replacement procedure

Thoracic epidural anesthesia is an adjunct to general anesthesia in cardiac surgery. Decrease in heart rate and blood pressure are frequently seen beneficial effects. There are several other hemodynamic effects of thoracic epidural anesthesia such as decrease in systemic vascular resistance, cardiac index, left ventricular stroke work index among others. However, the effect of thoracic epidural anesthesia on pulmonary artery pressure (PAP) has not been studied extensively in humans. Thoracic epidural anes-thesia decreased pulmonary artery pressure in experimen-tally induced pulmonary hypertension in animals. The mechanisms involved in such reduction are ill understood. We describe in this report, a significant reduction in PAP in a patient with Marfan’s syndrome scheduled to under-go aortic valve replacement. The possible mechanisms of decrease in pulmonary artery pressure in the described case are, decrease in the venous return to the heart, decrease in the systemic vascular resistance, decrease in the right ventric-ular function and finally, improvement in myocardial contraction secondary to all the above. The possibility of Marfan’s syndrome contributing to the decrease in PAP appears remote. The authors present this case to generate discussion about the possible mechanisms involved in thoracic epidural anesthesia producing beneficial effects in patients with secondary pulmonary hypertension. Thoracic epidural anesthesia appears to decrease pulmonary artery pressure by a combination of several mechanisms, some unknown to us. This occurrence, if studied and understood well could be put to clinical use in pulmonary hypertensives.     

患者主导提问式健康教育模式在老年全麻手术患者中应用

目的比较由老年患者主导的提问式健康教育模式和传统的健康教育,对老年患者全麻手术围手术期焦虑及术后疼痛的影响。方法630例非恶性肿瘤需要全麻手术的老年患者,按住院顺序随机分成研究组315例和对照组315例。研究组采用研究小组设计的由老年患者主导提问、干预人员解答的术前综合健康教育;对照组采用传统的术前健康教育。测量两组老年患者的干预前后的焦虑,入手术室时的恐惧、血压及心率、术后疼痛、术后镇痛药的使用次数,以及两组患者对术前健康教育的满意程度,并进行统计学分析。结果健康教育后研究组患者为焦虑评分为（41．12±3．16）分,对照组为（56．43±4．26）分,组间比较差异具有统计学意义（t=4．65,P〈0．01）。研究组患者术后疼痛评分为（6．12±1．35）分,对照组组为（9．76±1．57）分,组间比较差异具有统计学意义（t=6．35,P〈0．05）。观察组患者对健康教育满意度评价为（12．53±1．09）分,对照组为（7．24±1．12）分,组间比较差异具有统计学意义（t=4．78,P〈0．05）。结论由患者主导的提问式健康教育模式有助于缓解全麻患者的术前焦虑和术后疼痛,值得临床研究推广。