Preoperative anxiety affects an estimated 60–80% of surgical patients (Shebl et al., 2025). In a prospective audit of 115 consecutive surgical patients, Carroll et al. (2012) found that 66% reported anxiety before their procedure, yet only 4% were offered anxiolytic premedication. This gap is clinically significant: a recent systematic review and meta-analysis demonstrated that preoperative anxiety is associated with increased anesthetic and analgesic drug requirements, higher odds of postoperative delirium in adults, and prolonged time to extubation and discharge readiness (Shebl et al., 2025). Unfavorable physiological responses such as tachycardia, hypertension, and increased cardiac contractility are also described in the literature (Carroll et al., 2012).
The benefits of premedication include a mitigation of measurable perioperative morbidity and an increase in patient comfort. Indications for preoperative anxiolysis include significant anxiety or distress that may impact patient safety and outcomes, particularly for patients with prior traumatic perioperative experiences and patients who are unable to cooperate because of age or developmental factors (Heikal and Stuart, 2020). There are several medications available with well-established safety profiles.
Benzodiazepines are the most familiar medications for preoperative anxiolysis. Intravenous midazolam (0.04 mg/kg) reliably reduces anxiety without causing retrograde amnesia and has been shown to halve the incidence of postoperative nausea, with a trend toward less vomiting, while improving overall patient satisfaction (Bauer et al., 2004). In children, oral or buccal midazolam remains the most widely used agent, though its bitter taste, risk of postoperative agitation, and occasional paradoxical reactions limit universal use; smaller doses appear nearly as effective as higher ones while reducing this risk (Heikal and Stuart, 2020). Notably, the association between benzodiazepine use and postoperative delirium remains contested in the broader literature (Shebl et al., 2025).
Several alternatives to benzodiazepines have emerged. The α2-adrenoceptor agonists dexmedetomidine and clonidine provide anxiolysis with analgesic benefit, though bradycardia and hypotension are potential side effects (Heikal and Stuart, 2020). A single 300 mg oral dose of pregabalin produced significant anxiolysis before minor orthopedic surgery without sedation, dizziness, or delayed discharge, while halving postoperative opioid requirements (Gonano et al., 2011).
Melatonin (5 mg) and clonidine (100 µg) given the night before and one hour before abdominal hysterectomy produced equivalent anxiolysis, and both reduced postoperative morphine consumption by more than 30% in highly anxious patients specifically, with negligible benefit in those only mildly anxious. This highlights that anxiolytic effect, not the drug class itself, drives the downstream analgesic benefit (Caumo et al., 2009).
Physicians may be reluctant to use preoperative anxiolytic medication for day surgery due to concerns that sedation will delay discharge. However, randomized trials have not consistently demonstrated such delay, and patient-reported interest in premedication is appreciable even in ambulatory cohorts (Carroll et al., 2012).
Taken together, the evidence supports routine preoperative anxiety screening using validated tools and the use of pre-medication for anxiolysis where indicated. Effective anxiolysis contributes to anesthetic efficiency, recovery time, and postoperative analgesic burden.
References
- Bauer, K.P., Dom, P.M., Ramirez, A.M. and O’Flaherty, J.E. (2004) ‘Preoperative intravenous midazolam: benefits beyond anxiolysis’, Journal of Clinical Anesthesia, 16(3), pp. 177–183. https://doi.org/10.1016/j.jclinane.2003.07.003
- Carroll, J.K., Cullinan, E., Clarke, L. and Davis, N.F. (2012) ‘The role of anxiolytic premedication in reducing preoperative anxiety’, British Journal of Nursing, 21(8), pp. 479–483. https://doi.org/10.12968/bjon.2012.21.8.479
- Caumo, W., Levandovski, R. and Hidalgo, M.P.L. (2009) ‘Preoperative anxiolytic effect of melatonin and clonidine on postoperative pain and morphine consumption in patients undergoing abdominal hysterectomy: a double-blind, randomized, placebo-controlled study’, The Journal of Pain, 10(1), pp. 100–108. https://doi.org/10.1016/j.jpain.2008.08.007
- Gonano, C., Latzke, D., Sabeti-Aschraf, M., Kettner, S.C., Chiari, A. and Gustorff, B. (2011) ‘The anxiolytic effect of pregabalin in outpatients undergoing minor orthopaedic surgery’, Journal of Psychopharmacology, 25(2), pp. 249–253. https://doi.org/10.1177/0269881109106928
- Heikal, S. and Stuart, G. (2020) ‘Anxiolytic premedication for children’, BJA Education, 20(7), pp. 220–225. https://doi.org/10.1016/j.bjae.2020.02.006
- Shebl, M.A., Toraih, E., Shebl, M., Tolba, A.M., Ahmed, P., Banga, H.S., Orz, M., Tammam, M., Saadalla, K., Elsayed, M., Kamal, M., Abdulla, M., Eldessouky, A.I., Moustafa, Y.T., Mohamed, O.A. and Aiash, H. (2025) ‘Preoperative anxiety and its impact on surgical outcomes: a systematic review and meta-analysis’, Journal of Clinical and Translational Science, 9, e33. https://doi.org/10.1017/cts.2025.6