By Mindy Clancy, RN-BSN
Patients waiting in preoperative care areas before surgery typically have large variations of anxiety levels. The surgical team strives to relieve patients of these symptoms and create an environment to increase a patient’s well-being and satisfaction. Oftentimes, pre-medication preoperatively can be provided to combat this anxiety. This practice offers a myriad of successes towards positive patient outcomes; however, there are also many contraindicating concerns.
About 80% of patients experience preoperative anxiety.2 Depending on the patient’s medical and mental condition, it can be imperative to provide these measures to provide safe and effective care. Particularly for patients with severe autism or varying mental health disorders.
Premedication before anesthesia has existed since the 1850s and has evolved in many ways.2 Historically, it was standard practice to premedicate every patient; however, throughout the evolution of anesthesia, the approach has changed.
The initial goals were to be able to provide the patients with a sense of lessened anxiety, comfort, aid in shortening induction times, prevention of movement intraoperatively, and for the reduction of secretions.2 As medications have advanced through time, the use of various medications has improved to provide shorter induction times, and an overall better physiological response to the anesthetics. Since induction times have been reduced significantly, we are now able to provide anxiolytics, such as Midazolam and Ketamine, specifically for the use of combatting anxiety levels.
It is understandable that providing relief of the overwhelming anxiety that can occur before surgery would be a large priority as a health care provider; however, it is also important to note that there are some contraindications including issues postoperatively such as cognitive dysfunction, drowsiness, amnesia, delirium and irritability.1 Other issues include physiological complications upon emergence from anesthesia, such as issues with breathing, swallowing and pharyngeal dysfunction.1
In order to avoid issues postoperatively, and anxiety preoperatively, providing patients with education of what to expect from their surgery is paramount to their success. Studies have found significant success in reducing patient anxiety after receiving education regarding the anesthesia process via a direct in-person communication from the anesthesiologist, compared to not speaking with them at all, or reading about the information through a brochure.2 Therefore, ensuring that the patient has had an ample amount of time with the surgeon, anesthesiologist and circulating nurse prior to going back to the operating room would aid in the success of reducing anxiety, or risking any ethical compromise. Information that should be communicated would entail the surgical plan, details regarding the entire process and what to expect, and postoperative pain and expectations.
It is a patient’s right to fully understand and agree with their plan of care. This is where we are presented with ethical issues regarding pre-medicating patients. In the most ideal situation, the patient and surgeon have communicated a plan for the surgical procedure, as well as the risks and the benefits. It is the goal of the surgical team to provide care exactly as anticipated; however, there are a plethora of situations that can cause a delay or change in the plan of care come the day of surgery. Delays in the OR can be related to changes in timing of surgical cases, equipment issues or changes because of imaging or laboratory results.
It is imperative that the provider administering these mind-altering medications not give these to patients until the plan of care is established, the patient has confirmed understanding, all documents have been signed, and there is no possibility for change in the plan of care that would require further conversations and understanding. If these medications are administered too early, and a change in the plan has occurred, then it is not ethical or appropriate to consider their consent as legally withstanding. This is why it is paramount to have communication boundaries in place with the surgical team.
In order to provide the highest level of care possible for patients, a standard of care should be established. This can only be ensured by a surgical team that has high levels of communication in which the circulator, surgeon and anesthesiologist are all in understanding of the plan, and the progression in the steps that have been completed in the preoperative areas thus far. The circulating nurse will be the last line of communication with the patient prior to bringing the patient back to the operating room. It is at this time, that the nurse will conduct a handoff with a fellow nurse to ensure that all necessary documents have been signed, pertinent medical history has been obtained, and check for the patient’s understanding and consent.
A proposed plan for the surgical team to follow would be close coordination with the nurse and anesthesiologist that once the final handoff has occurred, the anesthesiologist can safely administer the medication. It is at this point the team can be confident there will be no voluntary changes to the plan of care and can focus on creating a level of ease for the patients as they embark on the journey back to the operating room.
As discussed, the main priority of care is to provide patients with the utmost compassion and ensure as much comfortability as possible; however, safety will always take precedence. Although we are trying to provide relief, the improper use of anxiolytics preoperatively places patients at risk and can greatly decrease patient satisfaction, and success overall. It can be extremely difficult to calculate the efficacy because of the unpredictable environment in the operating room with ever-changing and evolving daily operations. Each patient should be reviewed on a case-by-case basis prior to considering pre-medicating for anxiety to ensure that safety, efficacy and patient satisfaction can be maintained.
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