1 s2.0 S0007091217336863 Main
1 s2.0 S0007091217336863 Main
1 s2.0 S0007091217336863 Main
REGIONAL ANAESTHESIA
Effect of preoperative multimedia information on perioperative
anxiety in patients undergoing procedures under regional
anaesthesia
H. A. Jlala1, J. L. French2, G. L. Foxall2, J. G. Hardman1* and N. M. Bedforth2
1
Division of Anaesthesia and Intensive Care, University of Nottingham, Nottingham NG7 2UH, UK.
2
Department of Anaesthesia, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK
*Corresponding author. E-mail: j.hardman@nottingham.ac.uk
Background. Provision of preoperative information can alleviate patients’ anxiety. However,
the ideal method of delivering this information is unknown. Video information has been shown
to reduce patients’ anxiety, although little is known regarding the effect of preoperative multi-
media information on anxiety in patients undergoing regional anaesthesia.
Methods. We randomized 110 patients undergoing upper or lower limb surgery under
regional anaesthesia into the study and control groups. The study group watched a short film
(created by the authors) depicting the patient’s in-hospital journey including either a spinal
anaesthetic or a brachial plexus block. Patients’ anxiety was assessed before and after the film
and 1 h before and within 8 h after their operation, using the Spielberger state trait anxiety
inventory and a visual analogue scale.
Results. There was no difference in state and trait anxiety between the two groups at enrol-
ment. Women had higher baseline state and trait anxiety than men (P¼0.02). Patients in the
control group experienced an increase in state anxiety immediately before surgery (P,0.001),
and patients in the film group were less anxious before operation than those in the control
group (P¼0.04). After operation, there was a decrease in state anxiety from baseline in both
groups, but patients in the film group were less anxious than the control group (P¼0.005).
Conclusions. Preoperative multimedia information reduces the anxiety of patients undergoing
surgery under regional anaesthesia. This type of information is easily delivered and can benefit
many patients.
Br J Anaesth 2010; 104: 369–74
Keywords: anaesthetic techniques, regional; equipment, videos; stress; surgery, preoperative
period
Accepted for publication: January 4, 2010
Many patients experience substantial anxiety before oper- improve surgical outcome, shorten hospital stay, and mini-
ation,1 – 7 and this is reported to affect 60 – 80% of surgical mize lifestyle disruption.14
patients.6 8 Increased anxiety before surgery is associated Provision of preoperative information can alleviate
with pathophysiological responses such as hypertension patients’ anxiety.15 – 17 The ideal method of delivering this
and dysrrhythmias9 and may cause patients to refuse information is unknown. Written information has been
planned surgery.10 Anxiety also increases the requirement used as an effective way for delivering information to
of anaesthetic drugs to produce unconsciousness9 11 and patients,18 19 but not all patients are literate enough to read
therefore may indirectly increase the risk of awareness. and understand an information sheet; in addition, patients
Anxiety may also worsen patients’ perception of pain and will retain information to a variable extent. Multimedia
increase requirements for postoperative analgesia.3 12 information (in the form of a video) has been the subject
Anxiety may decrease patients’ overall satisfaction with of randomized controlled studies, and the value of this
perioperative care.13 Reducing preoperative anxiety may form of information in decreasing patients’ anxiety before
# The Author [2010]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
For Permissions, please email: journals.permissions@oxfordjournal.org
Jlala et al.
surgery has been demonstrated,7 15 20 21 although these at all, somewhat, moderately so, and very much so). This
effects were small and not supported by other studies.22 23 form was used at all time points of the study for both
Conflicting results may have arisen because of differences groups. Statements in the STAI-T are also rated on a
in methodology, multimedia format, measurement tools, four-point scale (almost never, sometimes, often, and
and variability in study populations. No study has almost always). This form was used twice for each partici-
addressed the patient population undergoing surgery under pant: on entering the study and on exiting the study. The
regional anaesthesia. Therefore, we developed a short film overall (total) score for STAI ranges from a minimum of
depicting the patient journey through hospital (including 20 to a maximum of 80; STAI scores are commonly
regional anaesthesia) and examined the effect of this film classified as ‘no or low anxiety’ (20 – 37), ‘moderate
on patients’ perioperative anxiety. anxiety’ (38 – 44), and ‘high anxiety’ (45 –80).25
370
Preoperative video and perioperative anxiety
discussion included a description of the SA and the (a¼0.05, power¼0.80, SD¼8.9). Data are presented as
risks involved, specifically the risk of nerve injury median and inter-quartile range (IQR). Baseline character-
(1:5000 – 10 000), block failure (5%) possibly requiring istics were analysed with Student’s t-test for continuous
conversion to general anaesthesia, headache (1:100), data and x2 test for categorical variables. STAI data were
itching and nausea (very rare), urinary retention (very lumped and tested for normality of distribution
rare), and necessity of having a urinary catheter. (Kolmogorov–Smirnov); the data demonstrated good
Discussion also included postoperative advice (wearing off approximation to normal distribution, so two-way repeated-
of the block and analgesic requirements). The next scene measures analysis of variance was used to analyse the sig-
shows the SA placement. The last scene shows the patient nificance of changes in anxiety scores over time between
being transferred to the recovery room and having a drink. groups (group vs time interaction). Statistical analysis was
The same person filmed and edited both films. The performed using SPSS 16.0 (SPSS Inc., Chicago, IL, USA).
same anaesthetist appeared in both films. In both films, the
anaesthetist provides the patient with information about
the risks, benefits, alternatives, and technical details of the
regional anaesthesia procedure. The same investigator Results
showed the films to the participants and oversaw question- Of 187 patients approached, 12 returned incomplete ques-
naire completion. tionnaires and 42 patients declined or were not suitable for
participation (12 patients because they feared viewing the
Intervention film would be distressing; 10 patients, who had had the
same operation in the past, did not think it would add any
Written informed consent was obtained in the preoperative
information; 20 patients were undergoing general anaes-
assessment clinic. On enrolment and before the patients’
thesia). Twenty-three patients were excluded for other
formal preoperative consultation with the nurse and
reasons (e.g. converted to general anaesthesia, changes to
surgeon, anxiety was assessed using STAI-S, STAI-T, and
theatre schedule, cancelled operations). In total, 110
VAS. We did not aim to separate anxiety related to anaes-
patients completed all questionnaires and were included in
thesia and surgery; therefore, we gave clear instructions to
our analysis. Random allocation resulted in 55 patients
the patients on how to rate their overall level of anxiety
assigned to the film group and 55 to the control group.
using both tests. Patients in the film group then watched the
The two groups did not differ in age, gender, weight,
film using a laptop computer equipped with headphones.
anaesthetic techniques, history and type of previous anaes-
STAI-S and VAS were then repeated after the film. Any vol-
thesia, and time from enrolment to surgery (Table 1).
unteered feedback regarding the video was recorded.
There was no difference in state or trait anxiety scores
Patients in both groups then underwent routine consultations
between the two groups at enrolment. The control group
with the admitting nurse and surgeon but not the anaesthe-
experienced an increase in state anxiety score from base-
tist; as per our normal practice, patients met their anaesthe-
line immediately before surgery (P,0.001), whereas the
tist on the day of surgery. The patients in both study arms
film group showed a non-significant increase in anxiety
received our standard care at this point (an interview with
(Fig. 1). Patients in the film group were significantly less
an anaesthetist before surgery on the day of operation).
anxious before operation than those in the control group
Three consultant anaesthetists performed all the preopera-
(P¼0.04; Fig. 1). After operation, there was a significant
tive, routine visits; they were not told specifically how to
decrease in state anxiety compared with baseline in both
explain procedures before operation, as we wished to repli-
groups; again patients in the film group were less anxious
cate our standard practice for risk disclosure and make the
than those in the control group (P¼0.005). Anxiety levels
study applicable to real practice. Patients were not specifi-
in the film group immediately after watching the film were
cally informed of the risk of rare complications (e.g. para-
reduced compared with the baseline anxiety scores, but
plegia, death). On the day of surgery, patients arrived 2–3
this did not reach statistical significance (P¼0.07; Fig. 1).
h before their surgery. All patients completed STAI-S and
VAS 1 h before surgery. Routine preoperative visits by the
patient’s anaesthetist were completed before STAI-S and Table 1 Baseline characteristics. *Time from baseline measurement to day of
surgery. Where appropriate, data are presented as median (IQR)
VAS measurement. Between 2 and 8 h after operation,
patients completed our last set of STAI and VAS. Film group (n555) Control (n555)
371
Jlala et al.
80 100
Film group
Film group 90
STAI (values range 20–80)
Fig 1 State anxiety scores (STAI). Op, operative. *P,0.05 between the Fig 2 VAS scores. Op, operative. *P,0.05 between the groups. Error
groups. Error bars represent the standard error of mean (SEM). Note: bars represent the SEM.
Twenty is the lowest possible value of STAI.
Low anxiety (STAI 37) 32 (58%) 35 (64%) 32 (58%) 21 (38%) 53 (96%) 49 (89%)
Moderate anxiety (STAI 38– 44) 12 (22%) 13 (24%) 8 (15%) 14 (25%) 1 (2%) 3 (5%)
High anxiety (STAI 45) 11 (20%) 7 (13%) 15 (27%) 20 (36%) 1 (2%) 3 (5%)
372
Preoperative video and perioperative anxiety
immediately before surgery, indicating that high anxiety (iv) Viewing an educational video about anaesthesia
levels immediately before operation may be predicted at can improve patients’ knowledge and understand-
early preoperative assessment. ing;23 33 – 35 however, we did not examine how much
There is no consensus on what constitutes a clinically information our study group retained. Such knowl-
significant change in the anxiety scoring system; however, edge acquisition may have been a mechanism in
previous studies using the Spielberger STAI have quoted reducing anxiety in our study group. This needs to be
significant changes between 3 and 5 points,7 15 33 one explored further in patients undergoing surgery under
study pointed out that an important clinical change in state regional anaesthesia.
anxiety levels is 10 points.14 We have shown a positive (v) Anaesthesia is just one cause of anxiety; we did not
effect of our intervention. We think that our intervention explore the effect of other potential sources of
(audioþvisual) is a supplementary tool and not a substi- anxiety such as surgical techniques, success of the
tute to other methods of providing anaesthetic information, operation, fear of any anticipated complications, or
for example, written information (leaflet), or verbal/spoken amount of information provided to patients.
information ( physician). (vi) Twenty-two patients who were eligible for our study
We agree that the reduction in anxiety could have been declined to participate; these patients may have been
either due to a specific effect of the film or due to the the most anxious and so our population may have
larger amount of information received; in either case, our been skewed during recruitment.
intention was to compare this process (of showing patients
Approximately one-third of patients having surgery under
a video) with our current standard of care, which is a pre-
regional anaesthesia are highly anxious before surgery,
operative assessment visit during which the patient is
with a higher incidence in women. This anxiety can affect
assessed by a nurse and seen by the surgeon, but not by an
patients’ understanding and recall of information, and their
anaesthetist. Therefore, the potential benefit of this type of
ability to give informed consent.36 – 38 Audiovisual infor-
intervention is a very efficient method of conferring infor-
mation reduces pre- and postoperative anxiety and can be
mation to patients, in addition to any visits made by an
particularly useful to those with reading, comprehension
anaesthetist.
difficulties, or both.39 40 Economic issues are a continual
There were limitations to our study.
pressure on healthcare. An information film is an efficient
and convenient way to inform patients and reduce their
(i) The pre-anaesthetic film was shown to participants in
anxiety. This can easily be carried out in the preoperative
the preoperative assessment clinic 2 weeks before the
assessment clinic, allowing adequate time for reflection
day of surgery; we could not control information
before surgery, which might make the information
received by the patients in the interval leading up to
received more effective.
surgery, which could have affected the results.
(ii) Patients undergoing upper and lower limb surgery
could differ in their anxiety responses and we chose Acknowledgements
to merge these two groups in order to provide a We thank Professor C.D. Spielberger for his advice on use of the STAI
tool. We would also like to thank Dr D.M. Levy for his contribution in
cross-section of patients undergoing regional anaes- filming and editing the films.
thesia, rather than one specific type. Despite these
possible differences between the groups, we feel that
this makes the study results more applicable to a
general population of patients undergoing procedures References
under regional anaesthesia. We did not find a signifi- 1 Johnston M. Anxiety in surgical patients. Psychol Med 1980; 10:
cant effect on patients’ anxiety after splitting patients 145 – 52
into the SA and PNB groups; however, as we had not 2 Domar AD, Everett LL, Keller MG. Preoperative anxiety: is it a
powered the study to look for this difference, the predictable entity? Anesth Analg 1989; 69: 763– 7
3 Badner NH, Nielson WR, Munk S, Kwiatkowska C, Gelb AW.
negative finding is likely to reflect the small size of
Preoperative anxiety: detection and contributing factors. Can J
these subgroups. Further studies would be required to Anaesth 1990; 37: 444 – 7
demonstrate any of these effects on anxiety. 4 Macario A, Weinger M, Carney S, Kim A. Which clinical anesthe-
(iii) We wished to include all patients attending for sia outcomes are important to avoid? The perspective of patients.
surgery and thus we did not power the study to show Anesth Analg 1999; 89: 652 – 8
the effect of previous surgical experience on anxiety; 5 Oldman M, Moore D, Collins S. Drug patient information leaflets
analysis of these sub-groups did not show a signifi- in anaesthesia: effect on anxiety and patient satisfaction. Br J
Anaesth 2004; 92: 854 – 8
cant difference. Although previous studies have
6 Norris W, Baird WL. Pre-operative anxiety: a study of the inci-
demonstrated variable effects of previous surgery on dence and aetiology. Br J Anaesth 1967; 39: 503– 9
perioperative anxiety,3 23 26 we feel that these patients 7 Doering S, Katzlberger F, Rumpold G, et al. Videotape prep-
tend to be less anxious, which would tend to produce aration of patients before hip replacement surgery reduces
a larger difference in the groups. stress. Psychosom Med 2000; 62: 365 – 73
373
Jlala et al.
8 Shevde K, Panagopoulos G. A survey of 800 patients’ knowledge, 25 Ruffinengo C, Versino E, Renga G. Effectiveness of an informative
attitudes, and concerns regarding anesthesia. Anesth Analg 1991; video on reducing anxiety levels in patients undergoing elective
73: 190 –8 coronarography: an RCT. Eur J Cardiovasc Nurs 2009; 8: 57 – 61
9 Williams JG, Jones JR. Psychophysiological responses to anesthe- 26 Kindler CH, Harms C, Amsler F, Ihde-Scholl T, Scheidegger D.
sia and operation. J Am Med Assoc 1968; 203: 415–7 The visual analog scale allows effective measurement of pre-
10 McCleane GJ, Cooper R. The nature of pre-operative anxiety. operative anxiety and detection of patients’ anesthetic concerns.
Anaesthesia 1990; 45: 153 –5 Anesth Analg 2000; 90: 706 – 12
11 Goldmann L, Ogg TW, Levey AB. Hypnosis and daycase anaesthe- 27 Holdcroft A, Parshall AM, Knowles MG, Waite KE, Morgan BM.
sia. A study to reduce pre-operative anxiety and intra-operative Factors associated with mothers selecting general anesthesia for
anaesthetic requirements. Anaesthesia 1988; 43: 466–9 lower segment Caesarean section. J Psychosom Obstet Gynaecol
12 Ip HY, Abrishami A, Peng PW, Wong J, Chung F. Predictors of 1995; 16: 167 – 70
postoperative pain and analgesic consumption: a qualitative sys- 28 Male C. Anxiety in day surgery patients. Br J Anaesth 1981; 53: 663
tematic review. Anesthesiology 2009; 111: 657 –77 29 Boker A, Brownell L, Donen N. The Amsterdam preoperative
13 Thomas T, Robinson C, Champion D, McKell M, Pell M. anxiety and information scale provides a simple and reliable
Prediction and assessment of the severity of post-operative pain measure of preoperative anxiety. Can J Anaesth 2002; 49: 792 – 8
and of satisfaction with management. Pain 1998; 75: 177 – 85 30 Millar K, Jelicic M, Bonke B, Asbury AJ. Assessment of preopera-
14 Lee A, Chui PT, Gin T. Educating patients about anesthesia: a sys- tive anxiety: comparison of measures in patients awaiting surgery
tematic review of randomized controlled trials of media-based for breast cancer. Br J Anaesth 1995; 74: 180– 3
interventions. Anesth Analg 2003; 96: 1424 –31 31 Poulton EC. Models for biases in judging sensory magnitude.
15 Bondy LR, Sims N, Schroeder DR, Offord KP, Narr BJ. The effect Psychol Bull 1979; 86: 777 – 803
of anesthetic patient education on preoperative patient anxiety. 32 Lichtor JL, Johanson CE, Mhoon D, Faure EA, Hassan SZ, Roizen
Reg Anesth Pain Med 1999; 24: 158 –64 MF. Preoperative anxiety: does anxiety level the afternoon before
16 Hughes S. The effects of giving patients pre-operative infor- surgery predict anxiety level just before surgery? Anesthesiology
mation. Nurs Stand 2002; 16: 33 – 7 1987; 67: 595 – 9
17 Klopfenstein CE, Forster A, Van Gessel E. Anesthetic assessment 33 Cassady JF, Wysocki TT, Miller KM, Cancel DD, Izenberg N. Use
in an outpatient consultation clinic reduces preoperative anxiety. of a preanesthetic video for facilitation of parental education and
Can J Anaesth 2000; 47: 511 –5 anxiolysis before pediatric ambulatory surgery. Anesth Analg 1999;
18 Olver IN, Turrell SJ, Olszewski NA, Willson KJ. Impact of an 88: 246 – 50
information and consent form on patients having chemotherapy. 34 Gaskey NJ. Evaluation of the effect of a pre-operative anesthesia
Med J Aust 1995; 162: 82 – 3 videotape. AANA J 1987; 55: 341 – 5
19 Stanley BM, Walters DJ, Maddern GJ. Informed consent: how 35 Klafta JM, Klock PA. A specialized patient education video can
much information is enough? Aust N Z J Surg 1998; 68: 788 –91 improve patients’ knowledge about anesthesia. Anesth Analg 2000;
20 Crowe J, Henderson J. Pre-arthroplasty rehabilitation is effective 90: 172
in reducing hospital stay. Can J Occup Ther 2003; 70: 88 – 96 36 Sorg BA, Whitney P. The effect of trait anxiety and situational
21 Lee A, Gin T. Educating patients about anaesthesia: effect of stress on working memory capacity. J Res Pers 1992; 26: 235 – 41
various modes on patients’ knowledge, anxiety and satisfaction. 37 Hutson MM, Blaha JD. Patients’ recall of preoperative instruction
Curr Opin Anaesthesiol 2005; 18: 205–8 for informed consent for an operation. J Bone Joint Surg Am 1991;
22 Salzwedel C, Petersen C, Blanc I, Koch U, Goetz AE, Schuster M. 73: 160 – 2
The effect of detailed, video-assisted anesthesia risk education on 38 Anderson JL, Dodman S, Kopelman M, Fleming A. Patient
patient anxiety and the duration of the preanesthetic interview: a information recall in a rheumatology clinic. Rheumatology 1979;
randomized controlled trial. Anesth Analg 2008; 106: 202 – 9 18: 18 – 22
23 Done ML, Lee A. The use of a video to convey preanesthetic 39 Williams MV, Parker RM, Baker DW, et al. Inadequate functional
information to patients undergoing ambulatory surgery. Anesth health literacy among patients at two public hospitals. J Am Med
Analg 1998; 87: 531 –6 Assoc 1995; 274: 1677 – 82
24 Spielberger CD, Lushene RE, Jacobs GA. Manual for the State-Trait 40 Luck A, Pearson S, Maddem G, Hewett P. Effects of video infor-
Anxiety Inventory, STAI (Form Y). Palo Alto, CA: Consulting mation on precolonoscopy anxiety and knowledge: a randomised
Psychologists Press, 1983 trial. Lancet 1999; 354: 2032 – 5
374