You've decided to take the plunge and start offering surgical procedures in your office. Following the previous article, you have made the appropriate selection of patients and procedures to perform. However, you may find that even the best patients are anxious about procedures performed in the office. In this segment, I will offer some tips on how to anticipate a patient who may have anxiety related to surgery, and how to prevent it so that office-based surgery can be performed successfully. At the end of this article, I will touch on another topic, postoperative nausea and vomiting.
On the Lookout
The first task is recognizing that patients undergoing any invasive procedure can have anxiety. Patients may not be able to completely describe what they are feeling, but often describe a feeling of uneasiness or fear. This sensation is associated with an adrenergic response, leading to increased blood pressure and pulse, and dryness of the mouth. This sensation can be exacerbated by pain or hyperstimulation.
When interviewing a patient for a possible surgical procedure, it is important to prescreen the patient for anxiety. Factors that may be a sign of risk for anxiety around surgery include previous intolerance to surgical procedures or sitting still, history of pain intolerance, medical history of anxiety or other mental illness, or a medical condition leading to lability of blood pressure or heart rate. Patients whom you feel are at risk for anxiety may benefit from techniques to reduce anxiety, or may be better candidates for surgery outside the office setting.
Whether at risk for anxiety or not, all patients will benefit from techniques (medical and non-medical) to prevent anxiety during surgery. Non-medical techniques are the easiest and should become a part of your standard operating procedure. The most important is probably the attitude of the surgeon and staff. If you exude confidence, and talk with a calm and friendly voice before, during and after the procedure, this will go along way to keeping a patient calm and relaxed during surgery.
Likewise, if the environment of the office and staff is calm and comfortable, the patient will be more at ease. Nothing makes a patient more nervous than a distracting office environment and a hyperkinetic staff. The surgical suite, whether an examination lane or dedicated procedure room, should also be comfortable. Playing soft music, ensuring the temperature is comfortable and the patient is at ease in the chair can make a procedure go much smoother.
However, pharmacologic intervention, when used properly, can make a case easily tolerable for the patient. In these instances, the ideal medication or "silver bullet" to treat anxiety around surgery would have a fast onset and resolution with no "hangover," be anxiolytic and a sedative, prevent pain, stabilize hemodynamic lability, and be amnestic. No magic pill exists, but selecting certain drugs for these characteristics can treat anxiety effectively and safely.
There are three main classes of drugs used to help prevent anxiety in the office setting: opioids, benzodiazepines and anti-adrenergics. The classic opioid is morphine, which acts as an analgesic and sedative. Valium is the classic benzodiazepine, which works as a sedative. The characteristics of clonidine, which is known for its antihypertensive properties, also include analgesic and sedative. These are summarized in Table 1. Recall that the ideal anxiolytic has many of these characteristics, so you can choose one drug or more than one class of drugs and have the characteristics augment each other.
Once you select a medication to pretreat the anxiety, you need to consider when to give the medication. For patients who are particularly nervous about a procedure, you may choose to administer the night before surgery. This will allow the patient to have a restful night. It is also reasonable to administer the medication the morning of surgery, but its effects may wear off before surgery time. My preference is to have the patient show up about 30 minutes before surgery, check the vital signs and then administer the medication. Then you can ask a patient if he feels the medication and, if so, commence surgery. If during the surgery, the patient needs more sedation, you can augment with a tablet given sublingually. It will dissolve and act quickly. Table 2 summarizes the common medications used for office-based procedures. Note that short-acting drugs have a faster onset; therefore, Xanax or Versed is perfect for short office procedures.
If used appropriately, these drugs should never cause a reaction or oversedation. However, you should always be prepared for that possibility. To treat a benzodiazepine reaction, flumazenil can be given, 0.2 mg IV over 15 seconds, then 0.2 mg every minute for a total of 1 mg, as needed. Nalaxone is used for an opioid overdose, 0.4 to 2 mg IV/IM/SC and can be repeated every two to three minutes for a total dose of 10 mg.
During surgery you should continue to monitor whether the patient has any discomfort or anxiety. If so, assess the cause—pain, discomfort, etc. Assure the patient during the surgery, and even have a staff member hold the patient's hand. Consider augmenting sedation as needed.
PONV
In addition to anxiety, postoperative nausea and vomiting (PONV) can turn a surgical experience into a miserable one. Besides the objecting retching and vomiting a patient may experience, the patient will feel the subjective sensation of nausea. It is important to anticipate PONV because it is associated with up to 30 percent of all procedures and the consequences, including wound dehiscence, hematoma and aspiration, can be serious.
As with anxiety, there are certain factors for which you can prescreen patients. These factors include a history of anxiety, motion sickness, past problem with PONV and surgical issues such as pain during surgery, surgeries longer than three hours, and any procedure around the eye or face.
Although there are many medications to prevent and/or treat PONV, many non-medical interventions work well. The first is preoperative fasting at least six hours for solid meals and two hours for liquids. Furthermore, reducing anxiety, whether by limiting the description of the surgery or covering the eyes during the surgery, helps prevent PONV. Also, controlling pain during and after surgery is important. Finally, limiting position changes during surgery, i.e., sitting the patient up and down, can help prevent PONV.
However, if a patient seems a higher risk for PONV or if you have to treat it after surgery, there are many medications available. These are summarized in Table 3. All of these drugs are quite effective at treating PONV. However, all except Zofran have the risk of extra-pyramidal symptoms in which patients develop involuntary muscle contractions as a side effect of the medication. If a patient has a history of this side effect, use of these drugs is contraindicated.
With the pearls described in this article, you can anticipate and treat anxiety and PONV in patients you offer surgery. Although the discussion in this article pertains to surgery performed in the office setting, these same skills work well in the ambulatory or hospital setting as well. In the final installment of this series, I will discuss controlling pain during and after surgery, and then give a basic algorithm tying all these facets of office-based surgery together.
Dr. Bernardino is an associate professor of ophthalmology and director of Ophthalmic Plastics and Orbital Surgery at Yale Eye Center/Yale University School of Medicine. Contact him at (203) 785-2020; fax: (203) 785-5909; e-mail: robert.bernardino@ yale.edu.
