The effects of pre-operative anxiety on anesthetic recovery and post-operative pain in donor nephrectomy

Kidney transplant is the most effective choice of treatment for patients with end-stage kidney failure in terms of quality of life and longevity. Today, of all the kidney transplants performed, 20 to 25% come from living donors. Pre-operative anxiety is a preoccupying condition that stems from the prospect of being hospitalised, being administered anesthesia, undergoing surgery, or not knowing what is to be experienced after one develops any kind of illness. In the pre-operative period, the patient must be trained and informed so that she or he can be ready for the operation in psychological terms. Some studies have demonstrated that patients equipped with detailed information in the pre-operative period had lower levels of anxiety and that they had lower levels of pain and anxiety and increased recovery rates in the post-operative period. Anesthetic recovery starts at the end of the surgical process and ends when the anesthetized patient completely regains a fully-alert, responsive state, with defensive reflexes, and muscle strength completely recovered. Post-operative pain is acute pain which starts with surgical trauma and ends with tissue healing. Well-administered post-operative analgesic plays an important role in the prevention of post-operative complications. There are studies which examine the link between pre-operative anxiety and post-operative pain. Patients to undergo donor nephrectomy constitute a specific group of patients both because they are to be operated due to a health problem not of their own and because they will lose an organ at the end of the operation. No retrospective study is available regarding the effects of pre-operative anxiety on anesthetic recovery and post-operative pain in individuals who have undergone donor nephrectomy. For this reason, we have aimed to perform a prospective study about the effects of pre-operative anxiety on anesthetic recovery and post-operative pain in patients who will undergo donor nephrectomy surgery. Upon approval by the Ethics Committee, volunteers with an age range from 18 to 60 from the ASA I-II group who were considered for donor nefrectomy were prospectively included in the study in the general surgery room. After their informed consent forms were obtained and approvals granted, the patients were informed about the operation they were about to undergo, the anesthetic procedure that was to be performed, other pre-operative factors, STAI I and STAI II tests (State Trait Anxiety Inventory), the use of the patient controlled analgesic dispenser (Abbot Pain Management Provider, USA) and the visual analogous scale (VAS). In our study, where donor nephrectomy was performed on a total of 48 cases; the anxiety levels of the patients were measured and registered using STAI I (State Trait Anxiety Inventory) and STAI II scale during pre-operative period. Following vascular access, along with pre-medication (2mg midazolam iv), electrocardiography (EKG), peripheral oxygen saturation (SpO2), non-invasive blood pressure and standard monitoring were performed in the operating room. All the patients were administered 2 mg/kg propofol, 1-2 ug/kg fentanyl and 0.6 mg/kg rocuronium for the induction of anesthesia and 1-1.2% isoflurane and 0.25-1 ug/kg/dk remifentanil infusion in 40 % O2- 60% air mixture for the maintenance and 0.15 mg/kg rocuronium when needed. For the post-operative pain of the patients, a total of 0.1mg/kg morphine im. was administered half an hour before the operation ended. During the closing of the fascia after the operation, the remifentanile infusion and isofluoran inhalation was closed at the last suture and the patients were administered 0.5mg atropine and 0.04mg/kg neostigmin along with the neuromuscular block antagonism. Demographic data, level of education, level of income, use of medication, other illnesses, former history of surgery, tobacco and alcohol use, the relationship with the recipient, the duration of the operation and anesthesia process, total quantity of the opioid analgesic used in the operation, anxiety score (STAI form TX-1,STAI form TX-2), spontaneous respiration (the time at which anesthesic gases or the medications are discontinued and spontaneous respiration starts) and the start of the sufficient respiration (the length of time from the discontinuation of the medication until the rate of respiration is >/ 8/min , ETCO2 <50mmHg) as well as the extubation time(the length of time between the discontinuation of the analgesic agents and the extubation period) were all recorded on the patient chart. The modified Aldrete score (MAS) for the patients who were taken to the post-anesthetic care unit was >9. For a period of 24 hours, analgesic of all the patients was administered with the HKA instrument using 0.02mg/kg dose of morpine bolus, with a lock period of 15 minutes. During the monitoring process, an extra 2mg morphine was administered to the patients with VAS >4 and an extra 1g paracetamol iv was administered to the patients for whom effective analgesic failed to take effect in 15 minutes. The VAS, SpO2, KAH, OAB, Ramsay Sedation score, total number of button presses with HKA, total amount of analgesic administered, additional need for analgesic and side effects of the patients were recorded at the post-operative 30th minute and 1st, 2nd, 4th, 8th, 12th and 24th hours. An assessment was made as to whether there was a correlation between pre-operative STAI I and STAI II scores along with post-operative recovery parameters and VAS scores. On the post-operative second day (48th hour), the patients were asked about their state of pain (VAS) and their level of satisfaction was queried (5-point patient satisfaction scale; very dissatisfied 1, very satisfied 5), and answers were recorded. The statistical analysis of the data was done by the Biostatistics unit of Ege University. In the descriptive statistics of the data received from the scoring methods performed on the patients, average ± standard deviation, minimum and maximum , median and ratio (%) were used. The distribution of variables was controlled through Kolmogorov Simirnov testing. The relation between STAI I and STAI II scores and numerical variables was evaluated with the pearson and spearman correlation coefficient. In numerical variables with normal distribution, the significance test of the inter-group discrepancy was evaluated via t-test and the anova test. Throughout the analysis SPSS 21.0 programme was used. P <0.05 value was found to be statistically significant. A group of 48 patients aged between 21 and 60 were included in our study. During the preoperative period, the scoring of STAI I and STAI II points were calculated to be 39.8±1,1 and 45.2± 0.9. The starting time for the spontaneous respiration of the patients was on average 4±0.8 minutes, 6.2±1.2 minutes for adequate respiration, 8.3±1.5 minutes for extubation and 24.8±5.6 minutes for MAS>=9. STAI 1 score was found to be significantly correlated with spontaneous respiration time, adequate respiration time , extubation time and the modified Aldrete score (MAS)>= 9 time. There was a significant correlation between STAI 2 score and the extubation time. STAI 2 score was not correlated with spontaneous respiration time, adequate respiration time and (MAS)>= 9 time. The VAS-rest scores of the patients in the study were 7.3±1.1 at the 30th minute, 5.9± 6 in the 1st hour, 4.6± 1.4 in the 2nd hour, 3.3 ±1 in the 4th hour, 2.5 ±0.7 in the 8th hour, 1.8 ±0.6 in the 12th hour, 1.3 ±0.6 in the 24th hour. VAS-movement scores were ; 8.8± 1 at the 30th minute, 7.5± 1.7 in the 1st hour, 6.2±1.5 in the 2nd hour, 5.1±1.3 in the 4th hour, 4.2±0.8 in the 8th hour , 3.3±0.6 in the 12th hour and 2.7± 0.8 in the 24th hour. STAI I and STAI II scores were found to be significantly correlated with the VAS scores of the 30th minute ,1st hour ,2nd hour ,4th hour ,8th hour, 12th hour and 24th hour. STAI I was found to be significantly correlated with the DEL and DEM scores on the HKA instrument at the 30th minute, in the 1st hour, 2nd hour, 4th hour, 8th hour, 12th hour and 24th hour. STAI II was found to be significantly correlated with the DEL and DEM scores on the HKA instrument at the 30th minute, in the 1st hour, 2nd hour, 4th hour, 8th hour, 12th hour and 24th hour. All of the 48 patients in the study required extra analgesic at the post-operative 30th minute, 44 (91.6%) of them in the 1st hour, 32 (66.6%) in the second hour, 16 (33.3%) in the 4th hour and 2 (4.1%) in the 8th hour. None of the patients requıired extra analgesic in the 12th and 24th hours. The total amount of morphine administered to the patients in 24 hours was approximately 42.1±12.9 mg. A significant correlation was established between the STAI I and STAI II scores and the total amount of analgesic administered in 24hours. A positive correlation between the STAI I and STAI II scores and the 48th- hour VAS scores, and a negative correlation between the STAI I and STAI II scores and the satisfaction of the patients were established. Our study shows that preoperative anxiety level has a negative effect on recovery from anesthesia and that there is a significant correlation between pre-operative anxiety level and post-operative pain. We are of the opinion that the efficiency of standard analgesic protocols in patients with high levels of pre-operative anxiety should be questioned. We believe it is of crucial importance that post-operative pain treatment should be well-planned for patients with high level of pre-operative anxiety, the patient should be assessed frequently and the use of patient-controlled analgesic instrument contributes positively to pain management. Given that high levels of anxiety have negative effects upon recovery from anesthesia, surgical recovery and post-operative pain in patients to undergo surgery, we think planning is necessary so that the level of anxiety in the pre-operative period can be determined and the high level of anxiety of patients can be lowered prior to the surgery.