Rev. Bras. Anestesiol. vol.67 número4

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REVISTA

BRASILEIRA

DE

ANESTESIOLOGIA

Publicação Oficial da Sociedade Brasileira de Anestesiologia

www.sba.com.br

SCIENTIFIC

ARTICLE

The

relationship

between

preoperative

anxiety

levels

and

vasovagal

incidents

during

the

administration

of

spinal

anesthesia

Mürsel

Ekinci

a,∗

,

Birzat

Emre

Gölboyu

a

,

Onur

Dülgero˘

glu

b

,

Murat

Aksun

c

,

Pınar

Karaca

Baysal

a

_,

_Erkan

_Cem

_C

_¸elik

d

_,

_Ays

_¸e

_Nur

_Yeksan

e

a_Kars_State_Hospital,_Department_of_{Anesthesiology}_and_Reanimation,_Kars,_Turkey b_Kars_State_Hospital,_Department_of_General_Surgery,_Kars,_Turkey

c_Katip_Celebi_School_of_Medicine,_Department_of_{Anesthesiology}_and_{Reanimation, ˙Izmir,}_Turkey d_Palandoken_State_Hospital,_Department_of_{Anesthesiology}_and_Reanimation,_Erzurum,_Turkey e_Kafkas_University_School_of_Medicine,_Department_of_{Anesthesiology}_and_Reanimation,_Kars,_Turkey

Received15January2016;accepted29July2016 Availableonline9September2016

KEYWORDS

Anxiety;

Spinalanesthesia; Syncope;

Vasovagal

Abstract

Background: Itwas aimedtoinvestigate therelationshipbetween preoperativeanxietyand vasovagalsymptomsobservedduringtheadministrationofspinalanesthesiainpatients under-goingsurgeryintheperianalandinguinalregions.

Methods:Thestudyincludedpatientswithplannedsurgeryforinguinalherniarepair,anal fis-sure,hemorrhoidandpilonidal sinusexcision.The studyincludedatotalof210patientsof ASAI---II,aged18---65years.Patientswereevaluatedinrespectofdemographiccharacteristics, smokingandalcoholconsumption,ASAgradeandeducationallevel.Correlationswere evalu-atedbetweenthenumberofattemptsatspinalanesthesiaandanesthesiahistorywithvasovagal symptomsandeducationallevel,gender,smokingandalcoholconsumptionandanesthesia his-torywithanxietyscores.Theinstant(transient)stateanxietyinventorypartoftheTransient State/TraitAnxiety Inventory(State Trait AnxietyInventory ---STAI) was used todetermine theanxiety levelsofthe participants.Clinical findings ofperipheral vasodilation, hypoten-sion,bradycardia andasystoleobservedduringtheadministrationofspinal anesthesiawere recorded.

Results:Vasovagal incidences during the administration of spinal anesthesia were seen to increase incasesofhighanxietyscore,malegender, andanabsenceofanesthesiahistory. Educationallevelandthenumberofspinalneedlepunctureswerenotfoundtohaveanyeffect onvasovagalincidents.

∗_{Corresponding}_author.

E-mail:murselek@mynet.com(M.Ekinci).

http://dx.doi.org/10.1016/j.bjane.2016.07.017

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Conclusion: Thedeterminationofcausestriggeringvasovagalincidentsseenduringthe applica-tionofspinalanesthesia,betterpatientinformationofregionalanesthesiaimplementationsand anxietyreliefwithpreoperativeanxiolytictreatmentwillhelptoeliminatepotentialvasovagal incidents.

http://creativecommons.org/licenses/by-nc-nd/4.0/).

PALAVRAS-CHAVE

Ansiedade; Raquianestesia; Síncope; Vasovagal

Arelac¸ãoentreosníveisdeansiedadenoperíodopré-operatórioeosincidentes vasovagaisduranteaadministrac¸ãoderaquianestesia

Resumo

Justificativa: Oobjetivo desteestudofoiinvestigar arelac¸ãoentreaansiedadenoperíodo pré-operatórioeossintomasvasovagaisobservadosduranteaadministrac¸ãoderaquianestesia apacientessubmetidosàcirurgianasregiõesperianaleinguinal.

Métodos: Oestudoincluiupacientescomcirurgiasagendadasparacorreçãodehérniainguinal, fissuraanal,hemorroidaseexcisãodefístulapilonidal.Foramincluídos210pacientesentre 18-65anoseestadofísicoASAI-II.Aavaliaçãodospacientescompreendeuhistóriadetabagismo econsumodeálcool,classificaçãoASAeníveldeescolaridade.Ascorrelaçõesforamavaliadas entreonúmerodetentativasdeaplicaçãodaraquianestesiaehistóriadeanestesiacomsintoma vasovagal,níveldeescolaridade,sexo,tabagismoeconsumodeálcool,históriaanestésicae escoresdeansiedade.Oinventáriodoestado(transitório)deansiedade,partedoInventário deAnsiedadeTraço-Estado(StateTraitAnxietyInventory-IDATE),foiusadoparadeterminaros níveisdeansiedadedosparticipantes.Achadosclínicosdevasodilataçãoperiférica,hipotensão, bradicardiaeassistoliaobservadosduranteaadministraçãodaraquianestesiaforam registra-dos.

Resultados: Observamos aumento dos incidentes vasovagais durante a administrac¸ão da raquianestesia emcasoscomescoreselevadosdeansiedade,pacientesdosexomasculinoe pacientessemhistóriaanestésica.Oníveldeescolaridadeeonúmerodepunc¸õescomagulha espinhalnãomostraramterqualquerefeitosobreosincidentesvasovagais.

Conclusão:Determinar as causas que desencadearam os incidentes vasovagais observados duranteaaplicac¸ãodaraquianestesia,fornecerboainformac¸ãoaopacientesobreaanestesia regional epromover alívioda ansiedadecom tratamentoansiolítico nopré-operatório con-tribuirãoparaeliminarpossíveisincidentesvasovagais.

http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Vasovagal syncope, which is also known as vasodepressor

syncope, of neurocardiogenic originsis thought tobe the

resultofabnormalinteractionsoftheneurocardiovascular

mechanismcomplexwhichisnecessaryforthemaintenance

ofsystemicandcerebralperfusion,isoneofthemost

fre-quentlyseensyncopetypes.1

Clinically,syncopehasfourmainparameterswhichmay

beindicators;lossofconsciousness,lossofposturaltonus,

spontaneousrecoveryandcardiovascularfindingsadditional

tomultiple etiologies. In theclassic formof

neurocardio-genicsyncope,cardiovascularfindingssuchashypotension,

bradycardia,palenessandsweatingareseentogetherwith

theclassicsyncopefindings.Eachparameterof

neurocardio-genicsyncopeisrelatedtoanincreaseinvasovagalactivity

andisevaluatedasavasovagalsymptom.2

Although the etiology is not fully known, an increase

in afferent signals to the central nervous system, when

thevagus dorsal motornucleus andthe nucleus ambiguus

responsible for parasympathetic activity in the medulla

arestimulated,inhibitionofsympatheticactivityfollowing

suppressionof the rostral ventromedial and ventrolateral

nucleiresponsibleforsympatheticactivityandthe

activa-tionofparasympatheticactivitycausesyncopebycreating

bradycardiaand/orhypotension.3---7_In_syncope_of

neurocar-diogenic origin, severe anxiety may be the origin of the

syncope.

Anxiety is a spontaneous and ambiguous low mood

feeling,thereasonforwhichisunknownandmaybe

expe-riencedwiththesensesoffear,distressandimpendingbad

events.Itisanaturalreactionthatpeopledevelopagainst

situations where they do not feel secure and a kind of

feelingof alertness when a situation is perceived as

life-threatening.Theanxietyincidenceamonghospitalpatients

isbetween 10%and 30%in general.8 _Preoperative_anxiety

incidenceinadult patientshasbeen reportedasbetween

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Anxietyis healthyandfunctionaluptoacertainlevel.

Therefore, the target related to anxiety in patients

pre-paredpreoperativelyisa‘‘medium’’or‘‘healthy’’levelof anxiety.9

Preoperative anxiety is a situation characterized by

unrest and concern arising from any illness,

hospitaliza-tion, anesthesia and surgery or not knowing what is to

happen.10_Anxiety_increases_the_stress_response_by

activat-ingthereleaseofneuroendocrinemediatorsinpatients.This

hasanegativeeffectonsurgery,anesthesiaand

postopera-tiverecovery.11

Although bradycardia and cardiac arrestdependent on

vagalreflexesarerarelyconfrontedingeneralandregional

anesthesia, the seriousness of these rare complications

requiresmaximumprecautionstobetaken.

Inpreviousstudies,syncopehasbeenreportedtooccur

atleastoncein3%ofthegeneralpopulationandthisrate

increasesto6%intheelderly.12,13_Syncope_has_been

deter-minedin3%ofallemergencypolyclinicpresentationsandin

1%ofhospitalizedpatients.14 _However,_with_the_exception

ofcase reports,tothebestofourknowledge,therehave

beennostudiesinliteratureonpreoperativeor

periopera-tivesyncopeandtheetiologyhasnotbeencomprehensively

researched.

Inthisstudy,itwasaimedtoinvestigatethefactors

caus-ing reflex bradycardia, seen during the administration of

regionalanesthesiainpatientsundergoingplannedelective

surgeryintheperianalandinguinalregions,andtoevaluate

therelationshipwithpreoperativeanxiety.

Material

and

method

Thestudyincluded210ASA I---IIpatientsaged18---65 years withplannedsurgeryforinguinalherniarepair,analfissure,

hemorrhoid andpilonidal sinus excision. Approval for the

study was granted by the hospital ethics committee and

informed consent was obtained from all patients. Any

patientswhowereilliterateorcouldnotunderstandTurkish

or hadsightandhearingproblems orpsychiatricdisorders

wereexcludedfromthestudy.Theinstant(transient)state

anxietyinventorypartoftheTransientState/TraitAnxiety

inventory(StateTraitAnxietyInventory---STAI)whichis

vali-datedforTurkishpeoplebyÖmerandLeComptein1976was

usedtodeterminetheanxietylevelsoftheparticipants.15

This test comprisestwodifferent subunits,each involving

20itemsthatmeasuretraitandstateanxietiesseparately.

Thetraitanxietysectionwasdesignedtomeasurefeelings

withinthelast7days,andtheothersubunitwasdesigned

to measure current feelings. Participants were requested

to mark one of the options of ‘‘never’’, ‘‘sometimes’’,

‘‘frequently’’ or ‘‘almost always’’, for each item in the

survey.Positivescoresweregivenforitems3,4,6,7,9,12,

13,14,17and18,andnegativescoresweregivenforitems

1,2,5,8,10,11,15,16,19and20inthesurvey.Thescores

weremarkedbyhand.Scoresbetween1(or−1)and4(or

−4)weregivenforeachitemaccordingtothepositiveand

negativecharacteristicsand50wasaddedtothetotalscores

obtained.Thehighestandlowestscoreswereacceptedas

80and20respectively(Fig.1).Thepatientswereevaluated

tohavelow,moderateandhighanxietywhentheyhadSTAI

valuesof20---37as,38---44asand45---80,respectively.

Inthepremedicationroom,beforetheadministrationof

premedication,theSTAIanxietyscalewasappliedtoallthe

patients by an anesthetist and the results were noted. A

recordwasmadeofthepatientage,gender,height,weight,

historyofsmokingandalcoholconsumption,ASAgradeand

educationallevel. An intravascular route wasopened and

the patient wastransferred to the operating theatre.On

Spielberger state trait anxiety inventory Never

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1. Calmed down 2. Safe 3. Tense 4. Annoyed 5. Comfortable 6. Upset

8. Relaxed 9. Anguished 10. At ease

12. Nervous 13. Restless 14. Downhearted 15. Rested 16. Satisfied 17. Concerned 18. Stunned 19. Happy 20. I fell good 11. Self-confidence 7. Concerned with future misfortunes

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Frequently Sometimes

(4) Almost always

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Table1 Demographicfeaturesofthepatients.

Vasovagalsymptom present(n=40)

Vasovagalsymptom absent(n=170)

pvalue

Age 28±3.5 34±6.4 0.091

Height(cm) 170±14.3 172±11.2 0.166

Weight(kg) 72±12.4 70±13.4 0.657

Operationtime(min) 46±14.8 49±13.4 0.541

Female/male 3/37 51/119 0.003

Smokers,n(%) 21(52.5) 70(41.2) 0.324

Alcoholabusers,n(%) 20(50) 81(47.6) 0.421

ASAI/II 28/12 114/52 0.268

Primaryeducation/highschool/furthereducation 22/8/10 84/49/37 0.527

Independentt-test,Pearsonchi-squaretest. SD,standarddeviation.

the operating table, heart rate and rhythm were moni-toredwithelectrocardiography,non-invasivebloodpressure (NIBP)andperipheral oxygensaturation(SpO2)monitoring

were applied. After the monitorization, the patient was moved into a sitting position and the lumbar area was cleaned3timeswithpovidoneiodinethensterile draped. Entry was made with a 26G pencil point spinal needle betweenL4---L5or L3---L4,located withpalpation,and the numberof entriesattemptedfor theapplication ofspinal anesthesiawasrecorded.Thespinalanesthesiawasapplied to all the patients in a sitting position and no anxiolytic wasappliedtoanypatient.Duringtheprocedure,systolic pressure observed <90mmHg and diastolic <60mmHg was evaluatedashypotension,<60bpmasbradycardiaand0bpm as asystole and these values were recorded. In cases of bpm<40,1mgatropinewasadministered.

Statisticalmethods

Thepowerofthestudywasdeterminedas0.99ina confi-dence interval of 95% and at significance level of 0.05. Thisfindingindicatedthatthesamplewassufficient(effect size=0.27).

SPSS 15.0 program wasused in the data analysis. The Shapiro---WilkandLeneve testswereused respectivelyfor theconformityofthedatatonormaldistributionand vari-ancehomogeneity.Parametricandnonparametricmethods wereusedintheanalysisofthevariableswithandwithout homogeneousvarianceandnormaldistributionrespectively. The independent-samples t-test wasusedinthe compari-sonof 2 independentgroups. The Pearsonchi-squaretest was used in the comparison of categorical data. Quanti-tative data were expressed as mean±standard deviation (SD)inthetables.Categoricaldatawereexpressedas num-ber(n)andpercentage(%).Thedatawereanalyzedat95% confidenceintervalandavalueofp<0.05wasacceptedas statisticallysignificant.

Results

Atotalof210patientswereincludedaged18---65yearsof ASA grade I---II. No statistically significant difference was

determinedbetween thoseshowingandnotshowing vaso-vagalsymptomsinrespectofage,height,weight,smoking, alcoholconsumptionorASAgrade(p>0.05)(Table1).

Vasovagal symptoms were observed in a total of 40

patients.Preoperatively,vasovagalsymptomswereseenin

mean19%ofthepatients(Table1).

Therewerenocasesineithergroupwhowereilliterateor hadnotreceivedanyeducation.Nostatisticallysignificant

differencewasseenbetweenthegroupsinrespectof

vaso-vagalsymptomsandlevelofeducation(p>0.05)(Table1).

Themostfrequentlyobservedvasovagalsymptomswere

sweating and dizziness. Cardiogenic origin findings were

observedin27patientsandinoneoftheseanasystolictable

formed.Insomepatients,severalsymptomswereobserved

atthesametime(Table2).

Ofthe40patientsshowingvasovagalsyncopesymptoms,

onehad a history of spinal anesthesia and six of general

anesthesia.Astatisticallysignificantdifferencewas

deter-minedbetweenthegroups inrespectofhistoryofgeneral

andspinalanesthesia(p<0.05)(Table3).

Typeofsurgeryandnumberofspinalpunctureattempts

did not have statistically significant effect on vasovagal

symptomoccurrence(p>0.05)(Table3).

Thepatientshavingvasovagalsymptomshadhighdegree

ofanxiety(STAI>45)atasignificantlyhigherratethanthe patientshavingnosymptoms(p<0.001)(Table4).

A statistically significant relationship was determined

betweenhighanxiety scoresandgender andnohistoryof

spinalorgeneral anesthesia(p<0.05).Nostatistically

sig-nificantrelationshipwasdeterminedbetweenhighanxiety

scoresandeducationallevel,smokingandalcohol

consump-tion(p>0.05)(Table5).

Table2 Vasovagalincidentsseeninpatients.

Typeofsymptom n(%)

Sudation 30(75%)

Hypotension/dizziness 16(40%)

Bradycardia 10(25%)

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Table3 Comparisonofpatient’spreviousanesthesiaexperience,operationtype,numberofspinalpunctureattempts.

pvalue

Spinalanesthesiahistory,n(%) 1(2.5) 64(37.6) <0.001

Generalanesthesiahistory,n(%) 6(15) 84(49.4) <0.001

Operationtype

Inguinalhernia 12 42 0.398

Pilonidalsinus 14 80

Analfissure 6 34

Hemorrhoid 8 16

1trial/>1trials 16/24 156/14 0.051

Pearsonchi-squaretest.

Table4 Degreeofanxietyinvasovagalsymptomoccurringandnonoccuringpatients.

pvalue

STAI20---37(lowdegreeofanxiety) 2(5%) 106(62.3%) <0.001

STAI38---44(moderatedegreeofanxiety) 8(20%) 44(25.8%) STAI45---80(highdegreeofanxiety) 30(75%) 20(11.9%)

STAI,StateTraitAnxietyInventory. Pearsonchi-squaretest,n(%).

Discussion

In the current study, factors causing vasovagal incidents whichareoftenencounteredduringspinalanesthesiawere investigatedand the relationship withanxiety was evalu-ated.In literature, although thereare many case reports ofpreoperativevasovagalincidentsandvasovagalincidents observedduringregionalanesthesiainterventions,the cur-rentstudypresentsawidercaseseries.16,17

Anxiety is the first response when people confront a

problemandthemostfrequentreactionincasesofillness.

Anxietydevelopsinhospitalpatients,especiallythosewho

aretoundergoanysurgicalintervention.9_In_addition_to

sur-gicalinterventions,allanesthesiaapplicationsareperceived

asdangerousbypatientsandbothpreoperativeand

postop-erativestressandtensiondevelopwiththisperception.18

While different tests have been used in the

evalua-tionof preoperativeanxietyinliterature,theuseof STAI,

whichincludesbothastateandtraitanxietyscaleiswidely accepted.19

Preoperative anxiety incidence has been reported

between 11%and92%in varioussurgicalpatientgroups.20

WhileSTAI-Sthreshold,whichisusedforthestateofanxiety withclinicallydistinctivesymptoms,isacceptedas39---40,

it has been determinedas 44---45for patientsin a

preop-erativeperiod.Thereasonfor thisisthatSTAI-Sindicates

howpeoplefeelindependentlyofthepresentsituationsand

circumstances.20

Inthecurrentstudy,patientswithSTAI-Sscores>45were

classifiedashighdegreeanxietyandthesepatients

consti-tuted23%(50)ofthetotalpatientgroup.

Anxietylevelshavebeenreportedtobehigherinfemales

in many studies.20---22 _As _the _hospital_where _the_study _was

conductedservesamilitarybase,therewasagreater

num-berofmalesinthecurrentstudypopulation.Contrarytothe

generalliteratureinformation,anxietyinfemaleswaslower

Table5 Relationshipsofeducationlevel,gender,smoking,useofalcoholandanesthesiaexperiencewithanxietyscores.

STAI45---80high degreeof anxiety(n=50)

STAI38---44medium degreeofanxiety (n=52)

STAI20---37low degreeofanxiety (n=108)

pvalue

GenderF/M 9/41 20/32 25/83 0.021*

EducationPS/HS/FE 26/11/13 28/13/11 52/33/23 0.069

Spinalanesthesiahistory,n(%) 10(50) 15(28.8) 40(37.03) 0.032*

Generalanesthesiahistory,n(%) 10(50) 20(38.4) 60(55.5) 0.049*

Smokers,n(%) 21(42) 26(50) 47(43.5) 0.365

Alcoholabuser,n(%) 25(50) 26(50) 50(46.2) 0.348

Pearsonchi-squaretest*p<0,05.

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thanthatofmalesinthisstudy.Thesignificantlyhigher num-berofmalesinthestudypopulationmaybethereasonfor thisdifference.Whiletheanxietyconnectedwithbeing sep-aratedfromthefamilywasreportedtobehigherinfemales, someresearchershavealsostatedthatfemalesexpresstheir anxietiesmoreeasilythanmales.23

Itwasconsideredthatthisdifferencecouldbeconnected

withlevelsofexpressedemotion beingmorerestrictedin

malesinoursociety.Inthecurrentstudy,itwasdetermined thattheanxietylevelsofmaleswerestatisticallyhigherin

thepreoperativeperiodcomparedtothoseoffemales.

Somestudieshavereportedthatprevioussurgical

experi-encereducedpreoperativeanxietyandthisisexplainedwith

theconditional learningmodel, inwhich an unconditional

fearstimulusisencounteredatshortintervals.22

Whiletherearestudieswhichhavestatedthatthe

anes-thesiaexperiencedidnotchange thepreoperativeanxiety

level,therearealsostudieswhichhavesuggestedthatthe

anesthesiaexperiencereducedanxietyinmen,whileitdid

notaffectanxietyinwomen.23,24 _There_are_also_studies_in

literature,whichhavereportedthatpatientswithan

anes-thesia experience of more than 10 years previously had

fewer anesthesia-dependent anxieties compared to those

whohadundergonesurgerywithinthelast10years.10_In_the

currentstudy,regionalandgeneralanesthesiaexperiences

were questioned separately, and a statistically significant

differencewasdeterminedinvasovagalincidencesbetween

thepatientswithandwithoutanesthesiaexperience.

Ithasbeenreportedinliteraturethataphysical status

ofASAIIandaboveandthesizeofoperationaffectedthe

levelofanxiety.Insomestudies,theASAstatuswasreported

to be a determinant of the preoperative anxiety level.22

ThecurrentstudywasappliedtopatientswithASAI---II

sta-tusundergoingoperationswithdischargeonpostoperative

day1attheverylatest, consideringtheexpectedamount

ofbleeding,operationtimeandpostoperative

hospitaliza-tionduration.Nosignificantdifferencewasdeterminedin

termsofASAstatusbetweenthegroupsparticipatinginthis

study.

Someresearchershavestatedthatagewasnotafactor

affecting the anxiety level,12,23,24 _although _Ramsay

deter-minedthattherateofanxietywashigherinamiddle-aged

patientgroupandconnectedthat withthe family

respon-sibilities of these patients. There is a greater sense of

pre-destinyin olderpatientsandyoungerpatientsmaybe

better informed about health-related negative incidents

throughmediatechnology.10_In_the_current_study,_the_patient

population with observed vasovagal incidents was mostly

comprisedofyoungerpatients,whichconformswith

liter-ature, although no statistically significant difference was

determinedbetweentwogroups.

Whileithasbeenreportedinsomestudiesthatanxiety

increasedwithanincreasinglevelofeducation,other

stud-ieshaveshownthattheeducationleveldidnotaffectthe

degreeofanxiety.25,26_It_was_stated_in_one_study_that

preop-erativeanxietylevelswerehigherinthosewhohadreceived

educationformorethan12years.22_In_the_current_study,_no

relationship wasdetermined between the level of

educa-tionandanxiety.Thelevelofanxietywashigherinpatients

withaprimaryschoollevelofeducationandlowerinthose

whohadattended highschool butthe differencewasnot

statisticallysignificant.

Preoperativenicotine replacementtreatment has been

shownnottohaveany effectonthepreoperative anxiety

levelsofsmokersandthesymptomsdevelopingconnected

todeprivationin smokers didnot clinically create a

seri-ousproblemintheperioperativeperiod.27,28_In_the_current

study, no difference was observed in the anxiety levels

betweensmokersandnon-smokers.

This study had some limitations, including the

imple-mentationofspinalanesthesiaonly,thatmostofthestudy

populationwasmaleandthe limitednumberofoperation

types.Futurestudiescouldinvestigatevasovagalsymptoms

seenduringtheimplementationofregionalanesthesiaand

peripheralnerveblocks.

Conclusion

The determination of the factors causing vasovagal

inci-dents during spinal anesthesia application has a place in

bothdiagnosis andtreatment astheyshouldbeknownby

both patients and anesthetists. The prevalence of

vaso-vagal incidences increases with high anxiety scores and

absenceofanesthesiahistory.Evaluationoftheanxiety

lev-elsofpatients,reducingunwantedvasovagalproblemswith

preoperativeanxiolyticmedication andinformingpatients

abouttheapplicationofregionalanesthesiawillbehelpful

ineradicatingvasovagalincidents.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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