Prevalence of pre-operative anxiety among serving military personnel undergoing elective abdominal surgery: an observational study

Surg Lt Cdr Deep J Chaudhuri(PI)¹, Gp Capt Ameet Kumar (Corresponding author)², Dr Subhashis Sharma³, Maj Sidharth Gautam⁴, Maj Naveen Tiwari⁵, Col Animesh Vats⁶, Brig Alok Bhalla^7, Sharayu Dattatreya Gaikwad⁸

1,3,4,5,8: Residents of Surgery, AFMC Pune

2: Professor of Surgery, AFMC Pune and Head, Dept of GI Surgery, CHSC Pune

6: Professor of Surgery, AFMC Pune and Prosthetic Surgeon

7: Head, Dept of Surgery, AFMC Pune

INTRODUCTION:

Preoperative anxiety is a prevalent issue affecting 60-85% of patients undergoing elective surgery, with potentially adverse effects on patient outcomes (Sarah & Lynn, 2019). Multiple studies have investigated this phenomenon, its impacts, and potential interventions. Research indicates that high levels of preoperative anxiety can lead to increased postoperative pain, lower quality of life, poorer cognitive performance, longer hospitalization, and increased physical disability (Cutrona et al., 2016; Oteri et al., 2021; Vaughn et al., 2007). Pre-operative anxiety dysregulates the neurogenic component of surgical stress response and has been recommended to be addressed in the ERAS 2018 protocol.

Interestingly, the prevalence of preoperative anxiety varies widely across studies, ranging from 17% to 89%, with higher rates observed in female patients (Oteri et al., 2021). Factors contributing to preoperative anxiety include concerns about surgical procedures, complications, symptoms, recovery process, and the organization and delivery of care (King et al., 2017). Additionally, temperament has been found to play a role in preoperative anxiety, particularly in pediatric patients (Chow et al., 2019).

Several interventions have shown promise in reducing preoperative anxiety. These include the use of multi-media technology (Cutrona et al., 2016), acupuncture, music therapy, virtual reality, and pharmacological support (Oteri et al., 2021). Notably, a randomized controlled trial found that patient-preferred music significantly reduced state anxiety levels in day surgery patients (Cooke et al., 2005). Another study suggested that the essential oil lavandin could be a simple, low-risk, and cost-effective intervention for reducing preoperative anxiety (Braden et al., 2009). However, the most important intervention remains priming the patient about the plan of surgery including timelines for expected post operative recovery (RA: Roshan Lall 18^th ed). Given the prevalence and impact of preoperative anxiety, early detection, prevention, and optimal management are crucial for achieving better patient care and outcomes in surgical settings (Bryan, 2021; Oteri et al., 2021; Wizano & Kurnia, 2022).

Military population is a special demography that has frequent exposure to stressors and anxiety situations. Often, armed forces personnel need to serve at war zones or areas of conflict. Besides, gruelling during training and maintenance of physical fitness on priority basis shape the behaviour of a military person. However, it is yet unknown how prevalent pre-operative anxiety is among the military population and its’ interplay with socio-demographic and military service profiles as some occupational profiles in the military, like the Commando training, are believed to wean away fear and anxiety permanently in the very few who have the mental robustness to complete the training.

AIMS & OBJECTIVES:

Study Setting: Department of Surgery and GI Surgery, Command Hospital, Pune.

Study Population: All serving personnel undergoing abdominal surgery.

Study Duration: September 2024 - November 2024.

Aim: To estimate the  prevalence of pre-operative anxiety among serving military personnel undergoing elective abdominal surgery and asses their relationship with other factors.

Objective 1: To evaluate the grades and asses the prevalence of pre-operative anxiety by evaluating the responses to a validated questionnaire based instrument.

Objective 2: To evaluate the roles of socio-demographic and military service profiles in determining pre-operative anxiety

METHODOLOGY:

INCLUSION CRITERIA: 

All patients undergoing abdominal surgery at CHSC, Pune between September 2024 - November 2024

EXCLUSION CRITERIA:

1. Patients undergoing emergency abdominal surgery (acute abdomen)

2. Patients undergoing abdominal surgery for trauma

3. Patients who had undergone any previous laparotomy/ laparoscopy or surgical intervention under general or spinal anesthesia

4. Patients who are not serving military personnel (dependents of military personnel, military veterans, civilians, non-entitled patients)

5. Patients who would not consent to participation/ withdraw consent

SAMPLE SIZE:

Monthly Surgical Audits have revealed that nearly 80 exclusively abdominal operations are performed each month by the Departments of Surgery and GI Surgery. Over a three month duration, the population expected to undergo abdominal surgery are: 240. After applying the Incl and Excl criteria, ~ 150 serving soldiers are expected to undergo elective abdominal surgeries. With the literature showing maximum 80% prevalence of pre-operative anxiety, the sample size is calculated by the formula:

Sample size n = [DEFF*Np(1-p)]/ [(d²/Z²_1-α/2*(N-1)+p*(1-p)]  

where

By this formula, for 95% confidence level, a sample size of 94 is calculated.

SAMPLING: A convenient sampling of all patients getting admitted for elective abdominal surgery will be taken

STUDY DESIGN: This will be a descriptive observational study.

STUDY PROCEDURE: After obtaining consent, the study population will be handed out printed proforma containing the Amsterdam Preoperative Anxiety and Information Scale (APAIS), a validated questionnaire for this purpose, and their responses will be collected. Data on their socio-demographic and military service profiles will also be collected, along with data of their blood pressures and pulse rates on the pre-operative evening in a relaxed state.

ETHICAL ISSUES: All data will be collected in the form of a single printed proforma for individual patients. Safety of the data, including confidential information, will be ensured by personal custody by the PI. For all analysis and publication purpose, the data will be de-identified.

References 

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Vaughn F, Wichowski H, Bosworth G. Does Preoperative Anxiety Level Predict Postoperative Pain? AORN Journal. 2007;85(3):589-604. doi:10.1016/s0001-2092(07)60130-6

Oteri V, Martinelli A, Gigli F, Crivellaro E. The impact of preoperative anxiety on patients undergoing brain surgery: a systematic review. Neurosurgical Review. 2021;44(6):3047-3057. doi:10.1007/s10143-021-01498-1

Chow CHT, Buckley N, Rizwan A, et al. Association of Temperament With Preoperative Anxiety in Pediatric Patients Undergoing Surgery. JAMA Network Open. 2019;2(6):e195614. doi:10.1001/jamanetworkopen.2019.5614

King A, Johanson DL, Bartley J, Broadbent E. Components of preoperative anxiety: A qualitative study. Journal of Health Psychology. 2017;24(13):1897-1908. doi:10.1177/1359105317709512

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Cooke M, Hiratos M, Chaboyer W, Schluter P. The effect of music on preoperative anxiety in day surgery. Journal of Advanced Nursing. 2005;52(1):47-55. doi:10.1111/j.1365-2648.2005.03563.x

Wizano Y, Kurnia D. Assessment of Anxiety Before Surgery In Cardiac Surgery Patients Who Have No History of Anxiety: Supporting Factors and Postoperative Morbidity. Devotion : Journal of Research and Community Service. 2022;3(13):2270-2277. doi:10.36418/dev.v3i13.277

Bryan JP. Concerns Related to Preoperative Anxiety in the Total Joint Arthroplasty Patient. JBJS Journal of Orthopaedics for Physician Assistants. 2021;9(4). doi:10.2106/jbjs.jopa.21.00020

Sarah S, Lynn S. Is the Amsterdam Preoperative Anxiety and Information Scale (APAIS) a Valid Tool in Guiding the Management of Preoperative Anxiety in Adult Patients? A Literature Review. Journal of Nursing and Practice. 2019;3(1). doi:10.36959/545/368