A survey of anesthetic preference and preoperative anxiety in hip and knee arthroplasty patients: the utility of the outpatient preoperative anesthesia appointment

Abstract

Purpose

The general public's perceptions of anesthesia and the risks associated with it may be skewed. The outpatient preoperative appointment with an anesthesiologist allows for patient education regarding different anesthetic options and counseling regarding anxiety related to anesthesia and surgery. This study investigates whether the preoperative appointment for hip and knee arthroplasty alters patient preference for general or spinal anesthesia and reduces patient anxiety.

Methods

Sixty-two patients undergoing hip or knee arthroplasty were administered two verbal questionnaires at the preoperative clinic. The first questionnaire was completed prior to meeting the anesthesiologist and addressed patient anesthetic preferences, previous anesthetic experiences, and perioperative anxiety and need for information using the Amsterdam Preoperative Anxiety and Information Scale (APAIS). The second questionnaire was completed immediately following the appointment and addressed the patient's anesthetic preference, reasons for any preference changes, and anxiety levels and need for information using the APAIS. The clinic anesthesiologist was blinded to the nature of the study.

Results

Following the clinic appointment, a significant decrease in patients wanting general anesthesia (from 48 to 18%, P < 0.001) and a significant increase in patients wanting spinal anesthesia (from 39 to 76%, 95%, P < 0.01) was noted. A significant decrease in overall anxiety and anxiety related to the patients' upcoming surgeries and need for information was also noted.

Conclusions

The preoperative anesthesia meeting serves an important role in educating patients regarding anesthesia, and can influence patients' choice of anesthetic while also reducing overall patient anxiety.

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Influenza : Treatment

IV. Which patients with suspected or confirmed influenza should be treated with antivirals?

18. Clinicians should start antiviral treatment as soon as possible for adults and children with documented or suspected influenza, irrespective of influenza vaccination history, who meet the following criteria:
    • Persons of any age who are hospitalized with influenza, regardless of illness duration prior to hospitalization (A-II).
    • Outpatients of any age with severe or progressive illness, regardless of illness duration (A-III).
    • Outpatients who are at high risk of complications from influenza, including those with chronic medical conditions and immunocompromised patients (A-II).
    • Children younger than 2 years and adults ≥65 years (A-III).
    • Pregnant women and those within 2 weeks postpartum (A-III).

19. Clinicians can consider antiviral treatment for adults and children who are not at high risk of influenza complications, with documented or suspected influenza, irrespective of influenza vaccination history, who are either:
    • Outpatients with illness onset ≤2 days before presentation (C-I).
    • Symptomatic outpatients who are household contacts of persons who are at high risk of developing complications from influenza, particularly those who are severely immunocompromised (C-III).
    • Symptomatic healthcare providers who care for patients who are at high risk of developing complications from influenza, particularly those who are severely immunocompromised (C-III)

V. For patients who are recommended to receive antiviral treatment for suspected or confirmed influenza, which antiviral should be prescribed, at what dosing, and for what duration?

20. Clinicians should start antiviral treatment as soon as possible with a single neuraminidase inhibitor (NAI) (either oral oseltamivir, inhaled zanamivir, or intravenous peramivir) and not use a combination of NAIs (A-I).
21. Clinicians should not routinely use higher doses of US Food and Drug Administration–approved NAI drugs for the treatment of seasonal influenza (A-II).
22. Clinicians should treat uncomplicated influenza in otherwise healthy ambulatory patients for 5 days with oral oseltamivir or inhaled zanamivir, or a single dose of intravenous peramivir (A-I).
23. Clinicians can consider longer duration of antiviral treatment for patients with a documented or suspected immunocompromising condition or patients requiring hospitalization for severe lower respiratory tract disease (especially pneumonia or acute respiratory distress syndrome [ARDS]), as influenza viral replication is often protracted (C-III).

VI. In a patient with suspected or confirmed influenza, when should bacterial coinfectoin of the upper or lower respiratory tract be considered, investigated, and treated?

24. Clinicians should investigate and empirically treat bacterial coinfection in patients with suspected or laboratory-confirmed influenza who present initially with severe disease (extensive pneumonia, respiratory failure, hypotension, and fever), in addition to antiviral treatment for influenza (A-II).
25. Clinicians should investigate and empirically treat bacterial coinfection in patients who deteriorate after initial improvement, particularly in those treated with antivirals (A-III).
26. Clinicians can consider investigating bacterial coinfection in patients who fail to improve after 3–5 days of antiviral treatment (C-III).

VII. If a patient with influenza does not demonstrate clinical improvement with antiviral treatment or demonstrates clinical deterioration during or after treatment, what additional testing and therapy should be considered?

27. Clinicians should investigate other causes besides influenza virus infection in influenza patients who fail to improve or deteriorate despite antiviral treatment (A-III).

VIII. When should testing be done for infection with an antiviral-resistant influenza virus?

28. Influenza NAI resistance testing can be considered for:
    • Patients who develop laboratory-confirmed influenza while on or immediately after NAI chemoprophylaxis (C-III).
    • Patients with an immunocompromising condition and evidence of persistent influenza viral replication (eg, after 7–10 days, demonstrated by persistently positive RT-PCR or viral culture results) and remain ill during or after NAI treatment (B-III).
    • Patients with laboratory-confirmed influenza who inadvertently received subtherapeutic NAI dosing (C-III).
    • Patients with severe influenza who do not improve with NAI treatment and have evidence of persistent influenza viral replication (eg, after 7–10 days) (C-II).

29. Clinicians should remain informed on current CDC and World Health Organization surveillance data on the frequency and geographic distribution of NAI-resistant influenza viruses during influenza season, and with the latest CDC antiviral treatment recommendations (A-III).

IX. Should adjunctive therapy be administered to patients with suspected or confirmed influenza?

30. Clinicians should not administer corticosteroid adjunctive therapy for the treatment of adults or children with suspected or confirmed seasonal influenza, influenza-associated pneumonia, respiratory failure, or ARDS, unless clinically indicated for other reasons (A-III).
31. Clinicians should not routinely administer immunomodulation using immunoglobulin preparations such as intravenous immunoglobulin for treatment of adults or children with suspected or confirmed seasonal influenza (A-III).

https://www.idsociety.org/practice-guideline/influenza/

Influenza : For patients who are recommended to receive antiviral treatment for suspected or confirmed influenza, which antiviral should be prescribed, at what dosing, and for what duration?

Clinicians should start antiviral treatment as soon as possible with a single neuraminidase inhibitor (NAI) (either oral oseltamivir, inhaled zanamivir, or intravenous peramivir) and not use a combination of NAIs (A-I).
Clinicians should not routinely use higher doses of US Food and Drug Administration–approved NAI drugs for the treatment of seasonal influenza (A-II).
Clinicians should treat uncomplicated influenza in otherwise healthy ambulatory patients for 5 days with oral oseltamivir or inhaled zanamivir, or a single dose of intravenous peramivir (A-I).
Clinicians can consider longer duration of antiviral treatment for patients with a documented or suspected immunocompromising condition or patients requiring hospitalization for severe lower respiratory tract disease (especially pneumonia or acute respiratory distress syndrome [ARDS]), as influenza viral replication is often protracted (C-III).
https://www.idsociety.org/practice-guideline/influenza/

Which patients with suspected or confirmed influenza should be treated with antivirals?

Clinicians should start antiviral treatment as soon as possible for adults and children with documented or suspected influenza, irrespective of influenza vaccination history, who meet the following criteria:
Persons of any age who are hospitalized with influenza, regardless of illness duration prior to hospitalization (A-II).
Outpatients of any age with severe or progressive illness, regardless of illness duration (A-III).
Outpatients who are at high risk of complications from influenza, including those with chronic medical conditions and immunocompromised patients (A-II).
Children younger than 2 years and adults ≥65 years (A-III).
Pregnant women and those within 2 weeks postpartum (A-III).
Clinicians can consider antiviral treatment for adults and children who are not at high risk of influenza complications, with documented or suspected influenza, irrespective of influenza vaccination history, who are either:
Outpatients with illness onset ≤2 days before presentation (C-I).
Symptomatic outpatients who are household contacts of persons who are at high risk of developing complications from influenza, particularly those who are severely immunocompromised (C-III).
Symptomatic healthcare providers who care for patients who are at high risk of developing complications from influenza, particularly those who are severely immunocompromised (C-III)
https://www.idsociety.org/practice-guideline/influenza/

What test(s) should be used to diagnose influenza?

10. Clinicians should use rapid molecular assays (ie, nucleic acid amplification tests) over rapid influenza diagnostic tests (RIDTs) in outpatients to improve detection of influenza virus infection (A-II) (see Table 6).
11. Clinicians should use reverse-transcription polymerase chain reaction (RT-PCR) or other molecular assays over other influenza tests in hospitalized patients to improve detection of influenza virus infection (A-II) (see Table 6).
12. Clinicians should use multiplex RT-PCR assays targeting a panel of respiratory pathogens, including influenza viruses, in hospitalized immunocompromised patients (A-III).
13. Clinicians can consider using multiplex RT-PCR assays targeting a panel of respiratory pathogens, including influenza viruses, in hospitalized patients who are not immunocompromised if it might influence care (eg, aid in cohorting decisions, reduce testing, or decrease antibiotic use) (B-III).
14. Clinicians should not use immunofluorescence assays for influenza virus antigen detection in hospitalized patients except when more sensitive molecular assays are not available (A-II), and follow-up testing with RT-PCR or other molecular assays should be performed to confirm negative immunofluorescence test results (A-III).
15. Clinicians should not use RIDTs in hospitalized patients except when more sensitive molecular assays are not available (A-II), and follow-up testing with RT-PCR or other molecular assays should be performed to confirm negative RIDT results (A-II).
16. Clinicians should not use viral culture for initial or primary diagnosis of influenza because results will not be available in a timely manner to inform clinical management (A-III), but viral culture can be considered to confirm negative test results from RIDTs and immunofluorescence assays, such as during an institutional outbreak, and to provide isolates for further characterization (C-II).
17. Clinicians should not use serologic testing for diagnosis of influenza because results from a single serum specimen cannot be reliably interpreted, and collection of paired (acute/convalescent) sera 2–3 weeks apart are needed for serological testing (A-III).

https://www.idsociety.org/practice-guideline/influenza/

What specimen(s) should be collected when testing patients for influenza?

5. Clinicians should collect upper respiratory tract specimens from outpatients for influenza testing as soon after illness onset as possible, preferably within 4 days of symptom onset (A-II).
   • Nasopharyngeal specimens should be collected over other upper respiratory tract specimens to increase detection of influenza viruses (A-II).
   • If nasopharyngeal specimens are not available, nasal and throat swab specimens should be collected and combined together for influenza testing over single specimens from either site (particularly over throat swabs) to increase detection of influenza viruses (A-II).
   • Mid-turbinate nasal swab specimens should be collected over throat swab specimens to increase detection of influenza viruses (A-II).
   • Flocked swab specimens should be collected over nonflocked swab specimens to improve detection of influenza viruses (A-II).

6. Clinicians should collect nasopharyngeal (optimally, as for outpatients), mid-turbinate nasal, or combined nasal–throat specimens from hospitalized patients without severe lower respiratory tract disease for influenza testing as soon as possible (A-II).
7. Clinicians should collect endotracheal aspirate or bronchoalveolar lavage fluid specimens from hospitalized patients with respiratory failure receiving mechanical ventilation, including patients with negative influenza testing results on upper respiratory tract specimens, for influenza testing as soon as possible (A-II).
8. Clinicians should not collect or routinely test specimens for influenza from nonrespiratory sites such as blood, plasma, serum, cerebrospinal fluid, urine, and stool (A-III).
9. Clinicians should not collect serum specimens, including single or paired sera, for serological diagnosis of seasonal influenza virus infection for clinical management purposes (A-III).

https://www.idsociety.org/practice-guideline/influenza/

Which patients should be tested for influenza?

Outpatients (Including Emergency Department Patients)

1. During influenza activity (defined as the circulation of seasonal influenza A and B viruses among persons in the local community) (see Figure 1):
   • Clinicians should test for influenza in high-risk patients, including immunocompromised persons who present with influenza-like illness, pneumonia, or nonspecific respiratory illness (eg, cough without fever) if the testing result will influence clinical management (A–III).
   • Clinicians should test for influenza in patients who present with acute onset of respiratory symptoms with or without fever, and either exacerbation of chronic medical conditions (eg, asthma, chronic obstructive pulmonary disease [COPD], heart failure) or known complications of influenza (eg, pneumonia) if the testing result will influence clinical management (A-III) (see Table 3).
   • Clinicians can consider influenza testing for patients not at high risk for influenza complications who present with influenza-like illness, pneumonia, or nonspecific respiratory illness (eg, cough without fever) and who are likely to be discharged home if the results might influence antiviral treatment decisions or reduce use of unnecessary antibiotics, further diagnostic testing, and time in the emergency department, or if the results might influence antiviral treatment or chemoprophylaxis decisions for high-risk household contacts (see recommendations 40–42) (C-III).
2. During low influenza activity without any link to an influenza outbreak:
   • Clinicians can consider influenza testing in patients with acute onset of respiratory symptoms with or without fever, especially for immunocompromised and high-risk patients (B-III).

Hospitalized Patients

3. During influenza activity:
   • Clinicians should test for influenza on admission in all patients requiring hospitalization with acute respiratory illness, including pneumonia, with or without fever (A-II).
   • Clinicians should test for influenza on admission in all patients with acute worsening of chronic cardiopulmonary disease (eg, COPD, asthma, coronary artery disease, or heart failure), as influenza can be associated with exacerbation of underlying conditions (A-III).
   • Clinicians should test for influenza on admission in all patients who are immunocompromised or at high risk of complications and present with acute onset of respiratory symptoms with or without fever, as the manifestations of influenza in such patients are frequently less characteristic than in immunocompetent individuals (A-III).
   • Clinicians should test for influenza in all patients who, while hospitalized, develop acute onset of respiratory symptoms, with or without fever, or respiratory distress, without a clear alternative diagnosis (A-III).

4. During periods of low influenza activity:
   • Clinicians should test for influenza on admission in all patients requiring hospitalization with acute respiratory illness, with or without fever, who have an epidemiological link to a person diagnosed with influenza, an influenza outbreak or outbreak of acute febrile respiratory illness of uncertain cause, or who recently traveled from an area with known influenza activity (A-II).
   • Clinicians can consider testing for influenza in patients with acute, febrile respiratory tract illness, especially children and adults who are immunocompromised or at high risk of complications, or if the results might influence antiviral treatment or chemoprophylaxis decisions for high-risk household contacts (see recommendations 41–43) (B-III).

https://www.idsociety.org/practice-guideline/influenza/