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Anxiety
Anxiety
Anxiety in dermatologic surgery results from multiple potential factors, including concern about the risks of the procedure, separation from loved ones, unfamiliar environment, loss of control, reliance on strangers, needle phobia, cosmetic concerns, and anticipation of intraoperative and postoperative pain.9,10 Increased levels of anxiety may have a negative impact on the patientโs surgical course. The release of epinephrine into the bloodstream causes blood vessel constriction, increased heart rate, increased blood pressure and temperature, flushing, and sweating.11 These physiologic changes may result in increased intraoperative and postoperative bleeding. Anxiety has also been shown to increase postoperative pain in dermatologic surgery; Chen et al. demonstrated that higher preoperative scores on two validated questionnaires, the Pain Catastrophizing Scale (PCS) and Pain Anxiety Symptoms Scale (PASS), correlate with increased pain after MMS.12 Anxiety can also decrease patient satisfaction.13 In order to minimize patient anxiety, it is key to manage patient expectations and provide clear explanations before, during, and after surgical procedures.
Before surgery, patient anxiety can be decreased by a phone call discussing the diagnosis and what to expect on the day of the surgery, as well as reading written material or searching the Internet for information regarding the procedure.13 Calls from physicians, as opposed to nurses or other team members, have also been shown to be effective in reducing patient anxiety.13 Listening to music has been demonstrated to reduce anxiety in patients undergoing dermatologic surgery, especially those undergoing surgery for the first time.14 Eating throughout the day, watching TV, bringing a guest, and engaging in small talk with the surgeon and staff during the procedure have also been shown to subjectively decrease patientsโ anxiety.13 Other potential relaxation strategies include slower breathing, biofeedback, progressive muscular relaxation, guided imagery, hypnosis, and meditation.15
Some patients may require a preoperative oral anxiolytic such as diazepam, alprazolam, or midazolam. During MMS, midazolam has been shown to offer the benefit of amnesia, reduced alertness, and reduced blood pressure with no clinically significant adverse effects.16 In patients requiring an anxiolytic, informed consent should be obtained prior to medication administration. The patient should be accompanied to their surgical appointment and should be instructed not to operate a vehicle the day of the surgery.17 The most notable side effects of benzodiazepine use include drowsiness and respiratory depression, which require intra- and postoperative patient monitoring. It is important to note that <1% of individuals taking a benzodiazepine may paradoxically
experience agitation, restlessness, hyperactivity, and combativeness, and may require flumazenil for reversal of the medication.18