Efficacy of pharmacological and non-pharmacological interventions for pre-operative anxiety: a systematic review with network meta-analysis of randomised clinical trials

Abstract

Pre-operative anxiety is distressing for patients and is associated with peri-operative complications, yet the relative effectiveness of available pharmacological and non-pharmacological interventions remains unclear. We conducted a systematic review with network meta-analysis to compare anxiolytic strategies in the pre-operative setting. We searched six databases for randomised controlled trials in patients aged ≥ 16 years undergoing surgery, evaluating pharmacological or non-pharmacological anxiolytic interventions. Study selection, data extraction and risk-of-bias assessment were performed in duplicate. We performed pairwise and network meta-analysis for pre-operative anxiety and secondary outcomes (postoperative pain, patient satisfaction, pre-operative sedation and minor or major complications) and used the Grading of Recommendations Assessment, Development and Evaluation to rate certainty of evidence. A total of 350 studies were included. Data from 309 studies (27,218 patients) were analysed for the primary outcome (pre-operative anxiety). Fifteen interventions reduced pre-operative anxiety compared with placebo or sham or no intervention and usual care, including spiritual training standardised mean difference (95% CrI) −6.07 (−9.33 to −2.84), mirtazapine −3.37 (−5.55 to −1.17), binaural beats −2.99 (−5.00 to −0.97), benzodiazepines −1.27 (−1.67 to −0.86), gabapentinoids −1.13 (−1.78 to −0.48) and melatonin −0.90 (−1.65 to −0.16). Other interventions associated with lower anxiety included relaxation techniques, herbal medicines, massage, hydroxyzine, acupoint stimulation, audiovisual distraction, aromatherapy, clonidine and educational strategies. Five interventions improved peri-operative patient satisfaction compared with placebo: parecoxib, acupoint stimulation, psychological intervention, audiovisual distraction and education. No significant differences were identified between interventions for postoperative pain, pre-operative sedation or minor and major complications. Multiple pharmacological and non-pharmacological interventions reduce pre-operative anxiety and may improve peri-operative patient satisfaction. No single intervention appears clearly superior and comparative safety differences remain uncertain.